Shoulder Pain

Question 1

Differential diagnoses of Shoulder Pain

Answer 1

1. Shoulder Pain - Polymyalgia Rheumatica *

Probability diagnosis 
Cervical spine dysfunction (referred pain)
Rotator cuff tendonopathy ± a tear
Adhesive capsulitis (glenohumeral joint)
Glenoid labral tears
Bicipital tendonopathy 

Serious disorders not to be missed
Cardiovascular:
•angina
•myocardial infarction

Neoplasia/cancer:
•Pancoast tumour
•primary or secondary in humerus

Infection:
•septic arthritis (especially children)
•osteomyelitis

Axillary vein thrombosis
Rheumatoid arthritisIntra-abdominal pathology, e.g. bleeding

Pitfalls (often missed) 
Polymyalgia rheumatica
Cervical dysfunction
Gout/pseudogout (uncommon)
Osteoarthritis of acromioclavicular joint
Winged scapula--muscular fatigue pain
Masquerades checklist 
Depression
Diabetes esp. adhesive capsulitis
Drugs, e.g. steroids, anabolic steroids
Thyroid disorder (rarely)
Spinal dysfunction 

Is the patient trying to tell me something?
Shoulder is prone to (uncommonly) psychological fixation for secondary gains, depression and conversion reaction.

Question 2

Shoulder Pain - Key History

Answer 2

Key history

A careful history should generally indicate whether the neck or the shoulder (or both) is responsible for the patient’s pain. 
Enquire about features of movement:
- stiffness and restriction
- excessive movement/instability
- weakness
- rough versus smooth.

Question 3

Shoulder Pain - Key PE

Answer 3

Key examination

•Examine the cervical spine then the affected shoulder
•Follow the protocol of inspection, palpation, movement, special tests for tendonopathies
•Look for impingement and a painful arc with adduction
•Undertake resisted movements for each tendon:
o- adduction for supraspinatus
o- internal rotation for subscapularis
o- external rotation for infraspinatus
o- elbow flexion for biceps

Question 4

Shoulder Pain - Key investigations

Answer 4

Key investigations

Consider:
•ESR (polymyalgia rheumatica)
•rheumatoid factor and anti-CCP
•ECG (if ischaemic heart disease suspected)
•imaging according to history and examination (e.g. high resolution ultrasound).

Question 5

Shoulder Pain - Diagnostic tips

Answer 5

Diagnostic tips

• Consider dysfunction of the cervical spine, especially C4–5 and C5–6 levels, as a cause of shoulder pain.
• Modern ultrasound is the investigation of choice for painful disorders of the rotator cuff.
• An older person presenting with bilateral shoulder girdle pain has polymyalgia rheumatic until proved otherwise.