Shoulder Pain

Question 1

Epidemiology

Answer 1

Prevalence 21-34% in primary care; 3rd most common MSK complaint; in oyug pts often related to injuries (GH joint instability or overuse); in older pts more commonly rotator cuff tendinitis, tears, adhesive capsulitis, and OA

Question 2

Anatomy

Answer 2

Glenohumeral (GH), acromioclavicular (AC), and sternoclavicular (SC) joints; Rotator cuff (RC) “SITS” muscles; Supraspinatus (abduction and external rotation; most commonly injured), Infraspinatus (External rotation and abduction0, Terese minor (external rotation and abduction), & Subscapularis (Internal rotation)

Question 3

Cervical Disease

Answer 3

Pain radiating below the elbow, decrease C-spine ROM

Question 4

Labral tear

Answer 4

Fall on outstretched arm or repetitive overhead loading activities; p/w deep shoulder pain catching sensation, instability

Question 5

RC Impingement & Tendinopathies

Answer 5

Anterolateral pain worse with abduction and/or reaching, typically in context of repetitive activity at or above level of shoulder (swimming, wt lifting, tennis, throwing)

Question 6

Biceps tendinitis

Answer 6

Gradual onset anterior shoulder pain typically with heavy lifting

Question 7

RC tear

Answer 7

Pain and weakness w/lifting shoulder (ie combing hair); suspect full thickness tear if pain w/abduction 60-120 degrees (painful arc sign), weakness with external rotation and + drop arm test

Question 8

Adhesive Capsulitis

Answer 8

Progressive decrease active and passive ROM, w/pain, often at night in pts w/DM, thyroid disease, trauma, and restricted ROM (ie stroke); plain films and MRI typically nml; clinical dx.

Question 9

Osteoarthritis

Answer 9

> 50y, pain w/activity, stiffness, decrease ROM, crepitus w/arm elevation; may affect AC (pain w/elevation of arm >90 degrees) or GH joint (pain w/external/internal rotation when arm is in neutral position); radiographs necessary to distinguish from adhesive capsulitis.

Question 10

GH joint instability

Answer 10

Shoulder pain in throwing athletes

Question 11

Other etiologies of shoulder pain

Answer 11

Fracture, referred pain from C-spine herniation, nerve entrapment, MI, septic arthritis, UE DVT, PE, avascular necrosis, PMR

Question 12

Differential

Answer 12

Cervical disease
Labral tear
RC impingement and tendonopathies
Biceps tendinitis
RC tear
Adhesive capsulitis
Osteoarthritis
GH joint instability

Question 13

Exam

Answer 13

Examin C-spine, both shoulders and arms, palpate AC, SC and GH joints, biceps tendon, subacromial bursa, trapezius muscles; distinguish pain w/ active motion (muscular or tendon) from passive motion (concerning for joint involvement); distinguish rotator cuff tear from impingement or bursitis by assessing weakness w/external rotation & abduction; assess sensation, reflexes, & motor strength for nerve impingement

Question 14

Apley scratch test

Answer 14

Touch superior and inferior aspects of opposite scapula

rotator cuff injury or OA

Question 15

Drop-arm test

Answer 15

Cannot smoothly adduct arm/shoulder to waist

rotator cuff tear

Question 16

Neer test

Answer 16

Full pronate arm then place arm in full flexion

Subacromial impingement

Question 17

Hawkin test

Answer 17

Elevate arm forward to 90 degrees while forcible internally rotating the shoulder

Subacromial impingement

Question 18

External rotation

Answer 18

Flex both elbows to 90 degrees while the examiner provides resistance against external rotation

Teres minor & infraspinatus tear or impingement

Question 19

Empty can/full can test

Answer 19

90 degree elevation in the scapula plane and full internal rotation (empty can) or 45 degree external rotation (full can); examiner applies downward pressure at wrist

supraspinatus tear or impingement

Question 20

Yergasson sign

Answer 20

Elbow flexion to 70 degrees; pt forces supination against reistance

Biceps tendinitis

Question 21

Workup

Answer 21

Image if hx trauma concerning for fracture/dislocation, or exam concerning for joint involvement/RC tear, gross deformity, localized swelling/tenderness over AC or SC joint, joint instability; consider imaging in pts w/persistent shoulder pain despite w/2-3 mos of conservative RX; start with radiograph

Question 22

Radiograph

Answer 22

True AP (glenohumeral joint)
Axillary lateral
Y view (AC joint)

Question 23

MRI w/o contrast

Answer 23

95% Se and SP in RC tears; can identify abnormality in asx pts; indicated w/persistent pain, unrevealing plain films, nonspecific H&P.

Question 24

Arthrography

Answer 24

Invasive, good at identifying complete RC tears, labral tears, or capsulitis

Question 25

Ultrasound

Answer 25

Good for complete RC tears, bursitis, but operator-dependent

Question 26

CT

Answer 26

May be useful for subtle dislocation, prosthetic joints

Question 27

General treatment approach

Answer 27

For most shoulder pain in older adults without e/o joint instability, marked muscle weakness or atrophy, or infection, initial trial of NSAIDs +/- PT (if limited ROM or strength) for 2-4 weeks; if no improvement, consider nerve block or referral; if impingement, tendinitis, or bursitis, earlier injection may be useful

Question 28

Shoulder impingement treatment

Answer 28

Ice, rest, PT, glucocorticoid injection in refractory cases

Question 29

Adhesive capsulitis treatment

Answer 29

PT. APAP; glucocorticoid injection, prednisone, or surgery referral for manipulation under anesthesia or release in refractory/severe cases

Question 30

Osteoarthritis treatment

Answer 30

generally NSAIDs, PT, rest

Question 31

Rotator cuff tears treatment

Answer 31

Surgical repair of acute, complete tears; rest, ice, NSAIDs, PT, glucocorticoid injection for partial thickness and chronic full thickness tears w/surgical referral in refractory cases

Question 32

Dislocation or fracture treatment

Answer 32

Relocation and immobilization bu w/early ROM to prevent adhesive capsulitis, PT indicated

Question 33

When to refer

Answer 33

Urgent eval needed in fracture, dislocation, separation, rotator cuff tear, joint instability/infection; ortho referral if gross deformity or joint instability as joint separation may require surgery; injury in high-functioning athletes; suspect full labral tear or full thickness tear; if sx not improving w/3 mos of conservative mgmt. and PT.