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shoulder pain

Etiology: 1) history of prior trauma a) rotator cuff tear: more common in elderly b) dislocation: 90% are anterior dislocations c) fracture - clavicle - humerus - scapula (rarely) d) acromioclavicular joint injury e) sternoclavicular joint injury f) glenohumeral joint injury 2) no history of prior trauma a) rotator cuff inflammation (rotator cuff tendonitis) b) bursitis - subacromial bursitis - subdeltoid bursitis - more common in elderly c) adhesive capsulitis (frozen shoulder) more common in elderly d) biceps tendonitis or biceps rupture (long head of biceps) e) arthritis - glenohumeral arthritis - acromioclavicular arthritis - sternoclavicular arthritis f) glenohumeral instability g) neurologic disorders - cervical radiculopathy - C7 radiculopathy - brachial plexus h) neoplastic processes - primary - metastatic i) infection 3) radiation of pain to the shoulder a) diaphragm b) heart Clinical manifestations: 1) physical examination a) supraspinatus test b) biceps test c) external rotators test d) acromioclavicular joint test e) Neer's test f) Hawkin's test g) Speed's test h) Yergason's test i) Apley scratch test j) shoulder apprehension test 2) pain that occurs with abduction of the shoulder above 90 degrees suggests rotator cuff involvement 3) shoulder pain with adduction & with pain on palpation of the acromioclavicular joint suggests acromioclavicular joint degeneration [2] 4) a positive drop-arm test suggests rotator cuff tear [2] Special laboratory: - EMG to evaluate nerve root injury Radiology: 1) plain film radiographs: useful for a) fractures of clavicle, humerus, or scapula b) calcification of rotator cuff tendons: indicates chronic inflammation c) widening or calcification of acromioclavicular joint or sternoclavicular joint d) lytic or sclerotic bone lesions e) dislocation of humerus 2) magnetic resonance imaging (MRI) evaluation of rotator cuff tear or rotator cuff tendonitis - ultrasound may be more cost effective [2] 3) computed tomography (CT) test or choice for glenoid labrum tear 4) CT or MRI of cervical spine if indicated by EMG Management: 1) fractures a) clavicle - observation - figure of 8 splint - surgery rarely indicated b) humerus - sling & swath initially - physical therapy - avoid prolonged immobilization c) scapula: physical therapy 2) rotator cuff inflammation & tears, subacromial bursitis a) non steroidal anti-inflammatory agents b) physical therapy c) avoid immobilization d) corticosteroid injection of subacromial bursa if patient fails physical therapy e) arthroscopic surgery for rotator cuff tears - patient fails medical & physical therapy - not first-line treatment f) radial extracorporeal shockwave treatment inferior to physical therapy [3] 3) dislocations a) patients under 20 - 90% likelihood of reoccurrence of dislocation - surgery indicated b) patients over 40 - low risk of subsequent dislocation - physical therapy 4) acromioclavicular & sternoclavicular inflammation/injury a) symptomatic treatment for pain b) corticosteroid injection for persistent pain c) surgical resection of distal clavicle for intractable pain of the acromioclavicular joint 5) cervical or axillary nerve root compression - surgical decompression 6) lytic bone lesions: search for underlying cause

Related

adhesive capsulitis (frozen shoulder) bursitis physical examination of the shoulder rotator cuff tendonitis; impingement syndrome; painful arc syndrome; subacromial pain syndrome shoulder trauma

Specific

cervicobrachial syndrome

General

pain [odyn-]

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 738-40
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 16, American College of Physicians, Philadelphia 1998, 2006, 2012 - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  3. Engebretsen K et al Radial extracorporeal shockwave treatment compared with supervised exercises in patients with subacromial pain syndrome: single blind randomised study BMJ 2009;339:b3360 PMID: 19755551 http://www.bmj.com/cgi/content/full/339/sep15_1/b3360
  4. House J, Mooradian A. Evaluation and management of shoulder pain in primary care clinics. South Med J. 2010 Nov;103(11):1129-35 PMID: 20890250
  5. Armstrong A. Evaluation and management of adult shoulder pain: a focus on rotator cuff disorders, acromioclavicular joint arthritis, and glenohumeral arthritis. Med Clin North Am. 2014 Jul;98(4):755-75, xii. Review. PMID: 24994050
  6. Beach H, Gordon P. VIDEOS IN CLINICAL MEDICINE. Clinical Examination of the Shoulder. N Engl J Med 2016; 375:e24September 15, 2016 PMID: 27626540 http://www.nejm.org/doi/full/10.1056/NEJMvcm1212941