Shoulder Pain/Swelling

Shoulder Pain/Swelling: Excerpt from In a Page: Signs and Symptoms

The shoulder is a complex arrangement of the humerus held loosely in place by ten muscles acting on the scapula, clavicle, and humerus, which form three articulations (acromioclavicular, glenohumeral, and sternoclavicular). Acute injuries are generally due to trauma (e.g., forced hyperabduction) or excessive demands; most chronic cases are due to overuse. The glenohumeral joint is the most frequently dislocated joint in the body (anterior in 95% of cases).

Differential Diagnosis

• Trauma and sports related injuries
  –Acromioclavicular dislocation (“separated shoulder”)
  –Sternoclavicular dislocation
  –Glenohumeral dislocation
  –Proximal humeral fractures

• “Impingement syndrome”
  –Progressive degeneration and inflammation of the subacromial contents (rotator cuff and subacromial bursa) in part due to compression between the acromion and the head of the humerus
  –May result in rotator cuff tear

• Rotator cuff strain, tear, or rupture
  –May occur acutely (secondary to trauma) or, more commonly, due to a relatively mild (e.g., reaching overhead) insult to a chronically degenerative cuff
• Degenerative joint disease
• Tendonitis
• Subacromion and/or subcapsular bursitis
• AC joint inflammation
• Calcific tendonitis
  –Deposition of calcium crystals in the rotator cuff with resulting inflammation and severe pain
• Suprascapular nerve entrapment
• Bicipital tendonitis
• Adhesive capsulitis
  –Thickened, scarred joint capsule and “frozen shoulder” due to prolonged postinjury or postsurgery immobilization
• Cervical disc disease and radiculopathy
• Gout
• Pseudogout
• Connective tissue disease (e.g., rheumatoid arthritis, SLE)
• Brachial plexus injury
• Septic arthritis
• Referred pain from MI, cholecystitis, splenic injury
• Malignancy (e.g., apical lung)
• Lyme disease
• Fibromyalgia
• Thoracic outlet syndrome
• Reflex sympathetic dystrophy
• Rib dislocation/rib pain
• Acute axillary vein thrombosis

Workup and Diagnosis

• History and physical examination
  –Inspection for asymmetry, dislocation, or atrophy
  –Note range of motion, strength, sensory, crepitus, pain with passive and/or active motion
  –Perform a complete neurovascular exam
• Plain X-rays of shoulder; cervical spine films and chest X-ray may also be useful
• X-ray or CT scan may identify chronic, degenerative arthritis
• Shoulder MRI evaluates the anatomy of the rotator cuff and associated soft tissue; may differentiate partial from complete tears
• EMG can help discern nerve entrapments, cervical disc disease, or brachial plexus injury
• Diffuse shoulder or acromioclavicular pain may require workup for medical etiologies, including ESR, ANA, rheumatoid factor, and TSH

Treatment

• Slings may be used for comfort but early range of motion (24–48 hours) is necessary to prevent adhesive capsulitis
• Conservative therapy is beneficial for most cases of shoulder pain: Rest, ice, NSAIDs, and opioid narcotics
• Subacromial cortisone injection if other anti-inflammatory methods fail; however, multiple injections are discouraged because of possible tissue atrophy
• Physical therapy is generally the mainstay of treatment
  –Conditioning and strengthening
  –Progressive range of motion exercises for adhesive capsulitis
• Full thickness rotator cuff tears may require surgical repair
• Adhesive capsulitis may require surgical lysis of adhesions
• Prevent future injuries by promoting strength and flexibility

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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