Shoulder Pain

Shoulder Pain – Joseph Nowatzke

Background

  • Bones:Clavicle, Scapula (Acromion and Coracoid process) and ProximalHumerus  
  • Rotator Cuff: Supraspinatus, Infraspinatus, Teres minor, subscapularis
  • Neurovascular: anterior and posterior circumflex humeral arteries, branching off axillary artery; Innervated by axillary, suprascapular, subscapular nerve offbrachial plexus  
  • Labrum is a cup-shaped rim of cartilage lining and reinforces the shoulder joint by surrounding the glenoid fossa, allowing extra support to the head of the humerus 

 

Presentation

  • Brachial Plexus Palsies 
  • Vascular Pathology (e.g. thoracic outlet syndrome, thrombus, atherosclerosis, vasculitis) 
    • Typical symptoms are tightness, heaviness, cramping, or weakness in arm 
  • Rotator Cuff Injuries:  
    • Impingement Syndrome: supraspinatus is most susceptible
    • Tendinopathy: develops after repetitive motions; pain worsens with active movement
    • Tendon Tear: develop as a progression of tendinopathy; develops weakness
  • Labral Tear & SLAP (superior labral tear from anterior to posterior): develop in repetitive overhead motions (swimming, baseball, tennis); often described as a “catching” sensation 
  • Adhesive capsulitis: “frozen shoulder” stiffened glenohumeral joint, loss of both active and passive RoM. Increased frequency in diabetics 
  • AC (acromioclavicular) joint pain: joint often affected by OA, RA and common cause for anterior shoulder pain shoulder separations and osteoarthritis  
  • Glenohumeral OA: degeneration of articular cartilage and subchondral bone with narrowing of the glenohumeral joint. Presents in older adults with progressively worsening anterior shoulder pain and stiffness in both passive and active ROM
  • Biceps Tendinopathy: localized anterior shoulder pain, worsened with overhead lifting; when rupture develops, will often have a “lump” and acute worsening of symptoms 
  • Posterior shoulder pain often related to cervical radiculopathy 

 

Evaluation

  • Physical Exam: 
    • Inspection: Symmetry, erythema, ecchymosis, swelling, deformity, muscle atrophy (deltoid, infraspinatus), scapular winging 
    • Palpation: warmth, landmarks, tenderness: SC joint, clavicle, AC joint, acromion, spine of scapula, bicipital groove, biceps tendon, greater tuberosity of humerus, common myofascial trigger points (trapezius, levator scapulae, rhomboids, supraspinatus) 
    • Passive ROM: performed by the examiner without patient assistance
      • Helps to distinguish motion limitations caused by a structural constraint (adhesive capsulitis) vs. motion limitations caused by pain 
    • Active ROM: performed by the pt on their own. Loss of active motion usually indicates weakness due to either muscular (tears) or nerve injury 
    • C-spine: evaluate the C-spine as the origin of pain that may be referred to the shoulder 
    • Provocation tests: see Below
  • Imaging:  
    • Not as useful as a thorough physical exam, especially if non-traumatic pain 
    • XR: AP (Internal Rotation, External Rotation), Lateral, Scapular and axillary views 
    • CT: often reserved for traumatic fracture and artificial joint assessment 
    • MRI w/out contrast: used to evaluate soft tissues, tendons, muscle and bursae
    • Ultrasound: becoming more useful for initial evaluation of rotator cuff

 

Test

Isolates

Action

Positive if

Empty Can Test

Supraspinatus

Place arms at 80 abduction, 30 forward flexion and pronate hand with thumbs down; exert downward force at elbows

Pain -> tendinopathy

Weakness + pain -> tear

Neer sign

Subacromial impingement

Passively flex arm with hand pronated (similar to empty can)

If pain -> subacromial impingement

External Rotation

Infraspinatus, teres minor

Arms at side, flex 90 elbow, exert medial force to distal forearm

Weakness, pain

Lag sign & Lift-Off test

Subscapularis

Place dorsum of hand on lumbar area of back and actively and passively move hand off of back

Pain or failure to perform indicates subscapularis pathology

Cross arm test

AC joint

Active abduction of arm across torso

Pain -> AC joint dysfunction

Speed’s Test

Biceps Tendon

Have pt extend arm in full supination with the shoulder flexed. Ask pt to elevate arm while applying downward force

Pain in the anterior shoulder

 Biceps tendon pathology

  

 

Management

  • Fractures: require assessment by orthopedics for reduction and surgical intervention
  • Soft Tissue Injuries, Arthritis 
  • Conservative management: referral to physical therapy for muscle strengthening, flexibility, and postural improvement.  
  • Consider short course of NSAIDs, 7-10 days (meloxicam, diclofenac) for pain relief
  • Injections can often be diagnostic and therapeutic – refer to ortho 
  • Sports Medicine referral for surgical evaluation if pt fails conservative therapy