Shoulder Pain
Shoulder Pain: Excerpt from The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
Gowri Anandarajah
Shoulder pain is the second most frequent orthopedic complaint seen in the primary care setting (1). The joint’s complex anatomy, versatile range of motion, and central location make accurate diagnosis a challenge.
Approach
The major categories of shoulder pain are summarized in Table 12.11 (1).
History
A. Characteristics of the pain. What is the onset, location, radiation, severity, and duration of the pain? Is there any instability, weakness, stiffness, or locking? Are there exacerbating or alleviating maneuvers? Has there been any associated trauma? What was the mechanism of injury? Any associated neurologic or systemic symptoms? Is there a history of prior shoulder problems? Are other joints involved?
Physical examination
Observe the shoulder for symmetry, motion, and signs of injury. Palpate all bony structures [including the acromioclavicular (AC) joint and bicipital groove]; check cervical spine range of motion (ROM) and the neurovascular status of the affected arm. If fracture is suspected, obtain an x-ray study. If finding on the x-ray is negative, proceed with passive and active ROM testing of the shoulder. Assess muscle strength and perform provocative tests for specific suspected pathology (Table 12.12) (1).
Testing
A. Laboratory tests. A complete blood count (CBC) and analysis of synovial or bursal aspirate for cell count, Gram’s stain, and culture are obtained for suspected infectious arthritis or bursitis. Obtain an erythrocyte sedimentation rate (ESR), rheumatoid factor, antinuclear antibody, and aspirate for crystals for inflammatory arthritis.
B. Radiographic study. Routine shoulder views are obtained for a history of acute trauma or chronic injury not responsive to conservative management. Special axillary or scapular Y views are needed if posterior dislocation is suspected. Views with and without weights may better assess for AC joint separation.
C. Diagnostic injection. Anesthetic infiltration of the involved area may relieve symptoms and establish the diagnosis. Injection sites include the subacromial and intraarticular spaces, AC joint, and biceps tendon sheath (2).
D. Other imaging studies. Computed tomography (CT) scan, magnetic resonance imaging (MRI), ultrasound, arthrography, fluoroscopy, and bone scan can be used when diagnosis is unclear or surgery is considered. MRI is superior for soft tissue pathology. Arthrography is useful for rotator cuff tears if MRI is unavailable or the patient is claustrophobic. A CT scan is useful to evaluate bony structures. Ultrasonography can identify moderate and full-thickness tears, but accuracy is operator-dependent. Bone scan can identify areas of bone remodeling (e.g., metastatic tumors, nonunion of fractures). Fluoroscopy allows dynamic assessment of fracture stability and can detect loose bodies or impingement (1).
Diagnostic assessment (3,4)
A. Nonshoulder origin. Painless ROM without localized tenderness suggests referred pain. Muscular sprain or strain presents with pain on active, but not passive, ROM and muscle tenderness or spasm; cervical disc herniation with radicular symptoms, neurologic findings, and an abnormal CT or MRI scan. Thoracic outlet symptoms include pain and numbness in the shoulder or arm (especially with head turning) and a positive Adson test.
B. Shoulder origin, nontraumatic. Both inflammatory and infectious arthritis may present with a joint effusion and inflammatory signs on examination. Serologic testing may be positive in the former; joint aspirate analysis and culture will help differentiate the two. An x-ray study or bone scan can help to rule out osteomyelitis. Tumor presents with localized pain and a positive imaging study.
C. Shoulder origin, acute traumatic
1. Fractures and contusions have point tenderness on examination. An associated pneumothorax should be ruled out with a clavicular fracture. Scapular fractures are infrequent, and usually occur with other severe thoracic injury. Contusions present with point tenderness on examination, but have no evidence of ligament injury and an x-ray study is negative.
2. Shoulder separation is more common at the AC joint. An AC dislocation may occur secondary to a fall on an outstretched hand or the lateral shoulder. Pain and swelling are seen at the joint, and a crossover test is positive. An x-ray study can be negative. Sternoclavicular separation is usually associated with other severe injuries.
3. Glenohumeral instability can develop with trauma. In anterior dislocation, the patient uses the other hand to hold the injured arm in abduction and external rotation. Visually, the acromion will be prominent. In the less-common posterior dislocation, the arm is held across the chest. Only an axillary or scapular x-ray view may show the displaced head.
D. Shoulder origin, chronic traumatic
1. An AC joint sprain is usually caused by overuse, degenerative joint disease, or incorrect weightlifting. On examination, tenderness is found over the AC joint.
2. Chronic glenohumeral instability occurs when recurrent trauma causes small labral or capsular tears. The patient presents with chronic or subacute pain and may report that the shoulder “pops” in and out. On examination, mild instability signs may be seen (Table 12.12).
3. Impingement syndrome is a common cause of shoulder pain.
a. Rotator cuff tendinitis most often involves the supraspinatus tendon and is secondary to overuse of the joint. It presents with diffuse pain in the anterior or lateral shoulder. The patient cannot sleep on the affected side. The shoulder is tender in the upper deltoid region or below the acromion. Seen are decreased ROM and pain, especially between 70° and 120° abduction; impingement signs are positive. The x-ray study is normal or shows calcific tendinitis or a prominent acromial spur.
b. Subacromial bursitis is usually secondary to tendinitis and presents with the same findings. Inflammatory, infectious, or crystalline causes may need to be ruled out by joint fluid aspiration.
c. A rotator cuff tear develops with overuse or trauma in the presence of an underlying abnormality. On examination, supraspinatus weakness and positive impingement signs may be seen.
d. Bicipital tendinitis is another overuse injury. Pain in the anterior shoulder radiates to the biceps and forearm. Examination findings include limited abduction, positive impingement signs, biceps tendon tenderness, and pain on resisted elbow flexion or wrist supination.
4. Adhesive capsulitis presents with chronic pain and stiffness, often following a period of prolonged immobility. It is especially common in elders. Decreased active and passive ROM occurs in all planes.
References
1. Howard TM, O’Connor FG. The injured shoulder: primary care assessment. Arch Fam Med 1997;6:376–384.
2. Larson HM, O’Connor FG, Nirschl RP. Shoulder pain: the role of diagnostic injections. Am Fam Phys 1996;53:1637–1643.
3. Glockner SM. Shoulder pain: a diagnostic dilemma. Am Fam Phys 1995;51:1677–1687.
4. Diagneault J, Cooney LM. Shoulder pain in older people. J Am Geriatr Soc 1998;46:
1144–1151.
Pictures
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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