Shoulder pain

Question 1

What is the classification of shoulder pain?

Answer 1

Intrinsic shoulder pain

Extrinsic shoulder pain

Question 2

What are the causes of intrinsic shoulder pain?

Answer 2

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.

Question 3

What are the causes of rotator cuff disorders?

Answer 3

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.

Question 4

What are the causes of extrinsic shoulder pain?

Answer 4

Referred pain: neck pain, myocardial ischaemia, referred diaphragmatic pain (eg, gallbladder disease, subphrenic abscess).

Polymyalgia rheumatica.

Malignancy: apical lung cancers, metastases.

Question 5

At which age do rotator cuff disorders present?

Answer 5

35-75 years

Question 6

What is the most common source of shoulder pain?

Answer 6

Subacrominal impingement

Question 7

How does subacromial impingement present?

Answer 7

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.

Question 8

How does a rotator cuff tear present?

Answer 8

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.

Question 9

Which test is used to detect a massive rotator cuff tear?

Answer 9

The drop arm test may be used to detect a massive tear.

Question 10

What is a major complication of rotator cuff tears?

Answer 10

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.

Question 11

What is calcific tendonitis?

Answer 11

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.

Question 12

At what age do adhesive capsulitis present?

Answer 12

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.

Question 13

How does adhesive capsulitis present?

Answer 13

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.

Question 14

How do acromioclavicular disorders present?

Answer 14

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.

Question 15

How does referred neck pain present?

Answer 15

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.

Question 16

Which questions should you always ask in a px presenting with shoulder pain?

Answer 16

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?

Question 17

Which questions should you ask in the hx of a px presenting with shoulder pain?

Answer 17

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.

Question 18

What should be included in the examination of a px presenting with shoulder pain?

Answer 18

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.

Question 19

What is the drop arm test?

Answer 19

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.

Question 20

What is the scarf test?

Answer 20

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.

Question 21

What are the red flag symptoms/signs of shoulder pain?

Answer 21

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.

Question 22

What are the investigations used to assess shoulder pain?

Answer 22

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.

Question 23

Why are plain x-rays in assessing shoulder pain?

Answer 23

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.

Question 24

Why is USS the preferred imaging for shoulder pain?

Answer 24

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.

Question 25

What is the management of rotator cuff disorders?

Answer 25

Advise modification of activities, including reducing precipitating movements (e.g., reaching overhead).

Offer analgesia; paracetamol with or without codeine, or an oral non-steroidal anti-inflammatory drug (NSAID).

Refer to physiotherapy with the goal of optimising shoulder function, using an evidence-based rehabilitation protocol.

Consider a subacromial corticosteroid injection if the person has limited function because of pain and is therefore unable to perform strengthening and stabilising exercises. They may be of short-term benefit when used alone.

Question 26

What are the risks of corticosteroid injections?

Answer 26

Risks of corticosteroid injection include failure to work, infection, pain, worsening of symptoms temporarily, bruising, bleeding and skin dimpling.

Question 27

When are steroid injections contraindicated for rotator cuff disorders?

Answer 27

The person has previously received a corticosteroid injection from an experienced practitioner with minimal or no benefit.

The person has already had three or more injections in the same shoulder in the previous year.

There is a suspected significant rotator cuff tear.

There is any contra-indication to corticosteroid injection (eg, infection, osteomyelitis).

Question 28

Can you have shoulder surgery after having steroid injections?

Answer 28

Injection with steroid precludes surgical intervention with implants (prosthesis or in this case bone anchors) for a period of 3 months minimum due to the risk of infection hence you need to be clear that you definitely don’t want to pursue a surgical option in the near future prior to administering an injection.

Question 29

What is the management of rotator cuff tears?

Answer 29

Physiotherapy and steroid injections may be helpful for minor tears.

Suspected large tears that are symptomatic may benefit from early referral for orthopaedic input.

Surgical treatment usually involves arthroscopic rotator cuff tendon repair.

Arthroplasty may be required in the combined instance of cuff tear and arthritis i.e. cuff arthropathy, the best course of treatment would be with a shoulder replacement.

Question 30

How does calcific tendonitis present?

Answer 30

When calcific tendonitis is symptomatic, it may present as chronic, relatively mild pain in the shoulder, with sporadic episodes of severe, acute pain radiating down the arm or to the neck.

The calcium deposits cause a chemical irritant inflammatory reaction. There is also an increase in pressure in the tendon, which is turn leads to malfunction of the rotator cuff and subacromial pain.

Question 31

What is the treatment for calcific tendonitis?

Answer 31

Treatment for calcific tendonitis includes NSAIDs, corticosteroids, physiotherapy, aspiration or lavage. For patients refractory to these treatments, open or arthroscopic shoulder surgery may be offered to excise the deposit.

Extracorporeal shock wave lithotripsy is no longer recommended by the National Institute for Health and Care Excellence (NICE).

Question 32

What is the treatment for glenohumeral disorders?

Answer 32

Glucocorticoid injection appears to be more effective in the short term than physiotherapy and exercises.

Question 33

What is the treatment for acromioclavicular disease?

Answer 33

Acromioclavicular injury usually responds to rest and simple analgesia, unless there is a significant disruption of the joint, in which case orthopaedic referral is necessary.

Consider providing a sling for 5-7 days if an acromioclavicular joint injury is suspected.

Consider referring to physiotherapy after 4-6 weeks if the person responds poorly to rest and analgesia.

Question 34

What is the treatment for the degeneration of the humeral head?

Answer 34

The humeral head may degenerate as a result of a range of conditions - e.g., osteoarthritis, rheumatoid arthritis or avascular necrosis. The whole or only part of the articular surface of the humeral head may be affected.

Conservative treatment includes physiotherapy, pain relief, topical or oral NSAIDs and corticosteroid injections.

Patients who do not respond to conservative treatments may need surgery, which involves either shoulder arthroplasty using a stemmed humeral head prosthesis, or fusion of the joint.

Shoulder resurfacing arthroplasty replaces only the damaged joint surfaces, with minimal bone resection and is recommended by NICE as a surgical option.

Question 35

When should you refer a px with shoulder pain to secondary care?

Answer 35

Consider referral for specialist review for people who present with shoulder pain in the following circumstances:

• Acute trauma with elevation limited to less than 120°.
• A significant rotator cuff tear is suspected.
• Pain and significant disability for 3-6 months, despite appropriate conservative management.
• History of recurrent joint instability.
• Referral should also be considered in those groups in whom their shoulder problem is especially disabling due to the nature of their work or sport

Question 36

What is the prognosis of shoulder disorders?

Answer 36

The prognosis of chronic shoulder pain depends on the underlying cause.

Increasing age, female sex, symptoms of gradual onset, prolonged symptoms, severe or recurrent symptoms and associated neck pain are associated with a worse outcome.

Recovery in shoulder pain is generally slow. Studies have shown complete recovery at one month in 23% of patients and at 18 months in 59% of patients.