Shoulder pain Flashcards
What is the classification of shoulder pain?
Intrinsic shoulder pain
Extrinsic shoulder pain
What are the causes of intrinsic shoulder pain?
Rotator cuff disorders
Glenohumeral disorders: adhesive capsulitis (‘frozen shoulder’), arthritis.
Acromioclavicular disorders.
Biceps tendonitis.
Infection (rare).
Shoulder instability - associated with hypermobility including subluxation or dislocation.
What are the causes of rotator cuff disorders?
Rotator cuff tears.
‘Subacromial pain’, which may be due to impingement if the humeral head is not depressed sufficiently to slide under the acromion on elevation of the arm. It is also sometimes referred to as subacromial bursitis, tendonitis or tendinopathy.
Calcific tendonitis.
What are the causes of extrinsic shoulder pain?
Referred pain: neck pain, myocardial ischaemia, referred diaphragmatic pain (eg, gallbladder disease, subphrenic abscess).
Polymyalgia rheumatica.
Malignancy: apical lung cancers, metastases.
At which age do rotator cuff disorders present?
35-75 years
What is the most common source of shoulder pain?
Subacrominal impingement
How does subacromial impingement present?
There may be a history of heavy lifting or repetitive movements, especially above shoulder level. However, it often occurs in the non-dominant arm and in non-manual workers.
On examination there may be muscle wasting with pain on movements and a partial restriction of active movements (passive movements are full but painful).
A painful arc (between 70-120° of active abduction) is not specific or sensitive but increases the likelihood of a rotator cuff disorder.
How does a rotator cuff tear present?
Usually follows trauma in young people. It is usually atraumatic in elderly people and caused by attrition from bony spurs on the under surface of the acromion or intrinsic degeneration of the cuff, possibly.
Pain and weakness are the predominant features.
Partial tears may be difficult to differentiate from rotator cuff tendinopathy on examination.
Which test is used to detect a massive rotator cuff tear?
The drop arm test may be used to detect a massive tear.
What is a major complication of rotator cuff tears?
Rotator cuff tear can lead to secondary impingement with superior migration of the humeral head as the supraspinatus is involved in maintaining the humeral head in the glenoid.
What is calcific tendonitis?
Crystalline calcium phosphate is deposited in the rotator cuff tendon.
The cause is not known. It is more common in women (70% of cases) and affects people aged 30-60.
It is a self-limiting condition as the calcium will eventually resorb but may take many years.
At what age do adhesive capsulitis present?
Adhesive capsulitis most often presents between the ages of 40 to 65 years, whereas osteoarthritis is most common in those aged 60 years or older.
How does adhesive capsulitis present?
Adhesive capsulitis (frozen shoulder) and arthritis often present with a history of non-adhesive capsulitis symptoms, cause deep joint pain and restrict activities such as putting on a jacket - because of impaired external rotation.
Patients tend to have pain, then stiffness and pain and longer term just stiffness with the pain settling.
Adhesive capsulitis is more common in people with diabetes and may also occur after prolonged immobilization.
There is usually generalised shoulder pain and a restriction of passive and active movements.
How do acromioclavicular disorders present?
They are usually caused by trauma or osteoarthritis.
Pain and tenderness are localised to the acromioclavicular joint and there is a restriction of passive, horizontal movement of the arm across the body when the elbow is extended.
Obvious deformity after injury suggests a significant tear of the acromioclavicular ligament.
Acromioclavicular osteoarthritis may cause subacromial impingement.
How does referred neck pain present?
Typically, this presents with pain and tenderness of the lower neck and suprascapular area, with pain referred to the shoulder and upper arm.
There may be a restriction of shoulder movement and movement of the neck and shoulder may reproduce more generalised upper back, neck and shoulder pain.
There may also be upper limb paraesthesia.
Which questions should you always ask in a px presenting with shoulder pain?
Is the pain arising from the shoulder, neck or elsewhere?
Are there any ‘red flag’ symptoms/signs?
Is the pain localised to the acromioclavicular joint: the ‘pointing sign’? If yes, there is acromioclavicular joint disease.
Is there global pain and restriction of all active and passive movements? If yes, this suggests glenohumeral joint disorder (either ‘frozen shoulder’ or arthritis).
Does the patient show a broad area of pain: the ‘grasping sign’ suggestive of subacromial pain?
Which questions should you ask in the hx of a px presenting with shoulder pain?
How the pain started.
Any specific injury.
Whether it is acute or chronic.
Any impact on function/activities of daily living.
Whether the pain is on the side of the dominant hand.
Whether there is pain at rest or on movement.
Whether there is night pain that affects sleep.
Any associated pain - for example, neck, chest or other upper limb or joint pain.
Any history of shoulder pain/instability/dislocation.
The patient’s occupation.
The patient’s sporting activities.
Any signs or symptoms of systemic illness.
Past medical history (particularly any history of diabetes, coronary heart disease, cancer).
Drug history and adverse drug reactions.
What should be included in the examination of a px presenting with shoulder pain?
Examine the neck, axilla and chest wall.
Examine the cervical spine and assess range of movement.
Inspect from the front, side, and behind for muscle wasting, swelling and deformity, or for bruising.
Palpate the sternoclavicular, acromioclavicular and glenohumeral joints. Look for tenderness, swelling, warmth and crepitus.
As an initial screening test, ask the person to place the palms of their hands at the base of the neck with elbows pointing laterally and then to put their arms down and try to put the back of the hands between the shoulder blades. However, be aware that this also involves joints other than the shoulder (i.e. elbow, wrist).
Assess the power, stability and range of movement (active, passive and resisted) in both shoulders.
Look for a painful arc (pain between 70-120° of abduction)- subacromial pain.
Test passive external rotation (reduced in ‘frozen shoulder’). With the elbow held into the side, turn the arm outwards as far as possible.
Perform the ‘drop arm test’:
Perform the ‘cross-arm test or scarf test’
Other special tests include the Hawkins-Kennedy test, empty can test and lift-off test.
What is the drop arm test?
Passively abduct the patient’s shoulder. Then ask the patient to lower the abducted arm slowly to the waist.
This can identify a massive rotator cuff tear. They may be able to lower the arm slowly to 90° because this uses mostly the deltoid muscle but, below 90°, the arm will drop to the side.
What is the scarf test?
This isolates the acromioclavicular joint. Ask the patient to raise the arm to 90° straight in front of them. Then ask the patient to adduct the arm across the chest. If there is an acromioclavicular joint problem, there will be pain in the area of the joint.
What are the red flag symptoms/signs of shoulder pain?
History of malignancy or symptoms/signs consistent with neoplasia - e.g., weight loss, deformity, mass or swelling, abdominal discomfort/swelling.
Overlying skin erythema may suggest tumour or infection.
Symptoms/signs of systemic illness: ask specifically about symptoms that may indicate polymyalgia rheumatica/giant cell arteritis.
Fever can suggest malignancy or infection.
History of trauma or recent convulsion/electric shock may suggest an unreduced dislocation.
Change in shoulder contour with loss of rotation suggests dislocation.
The presence of a significant sensory or motor deficit suggests a neurological lesion.
What are the investigations used to assess shoulder pain?
Blood tests including FBC, ESR/CRP and radiology such as CXR are generally only necessary if there are ‘red flag’ symptoms/signs.
Ultrasonography is the preferred imaging technique for the shoulder.
Plain X-rays rarely help except to confirm shoulder dislocation and shoulder arthritis.
Magnetic resonance arthrogram is useful in shoulder instability.
If referred neck pain is suspected then cervical spine X-rays may be helpful but the diagnosis is usually clinical.
Why are plain x-rays in assessing shoulder pain?
All patients presenting with joint pain to orthopaedic clinic should have basic radiological imaging.
Every department will have picked up a metastatic or primary bone lesion by doing so. In addition it provides invaluable information about the joint surface in terms of arthritis and anatomy.
Clinically frozen shoulder and osteoarthritis can be difficult to differentiate however plain XR will demonstrate typical changes of OA in arthritis and not in frozen shoulder.
Why is USS the preferred imaging for shoulder pain?
Not first line, but a cheap (if highly operator dependant) investigation which would demonstrate rotator cuff tear, burisitis / fluid in the subacromial space and of benefit is that this test is dynamic i.e. the patient can move and be imaged during the movement. You can demonstrate the impingement.
