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Shoulder Pain

I. Extrinsic conditions

A. Cervical spine

B. Thoracic outlet

C. Postural disorders

D. Cardiac and thoracic disorders

II. Intrinsic conditions

A. Pain arising from the glenohumeral joint.

1. Glenohumeral instability

2. Glenohumeral osteoarthritis rotator cuff tear

B. Pain arising from the acromioclavicular joint

C. Pain arising from soft tissue structures.

1. Subacromial bursa

2. Rotator cuff tendons

3. Biceps tendon

4. Joint capsule

III. Extrinsic conditions

A. Cervical spine

1. Important to remember that disorders of the neck can refer pain to the shoulder. The neck must be examined in every patient who presents with complaints of shoulder pain. This includes examination of the neck and neurological examination of the upper extremities. Often shoulder pain will be produced during neck extension testing and on extremes of rotation. Spurling test may be positive. X-rays may be required. Although shoulder function usually is normal, there may be glenohumeral joint stiffness in-patients who have had pain for some time and attempted to protect the arm by not using it (frozen shoulder).

2. Treatment is conservative with physical therapy including local heat, intermittent traction and anti-inflammatories.

B. Thoracic outlet

1. Thoracic outlet syndrome can be due to a cervical rib, fibrous bands, aberrant muscles. Adson's test and the abduction external rotation test of Roos can help in the diagnosis.

2. Pancoast's tumor causes constant pain unrelieved by rest.

C. Postural

1. The patient complains of pain near the base of the neck or superomedial aspect of the scapula. The pain tends to be worse toward the end of the day. Examination reveals point tenderness over the superomedial aspect of the scapula.

2. Treatment includes trigger point injections, physical therapy and correct ergonomic advice as to positioning and height of desk and chair.

D. Cardiac and thoracic disorders

1. Keep this in mind as a referred source of pain

IV. Intrinsic conditions

A. Pain arising from the glenohumeral joint.

1. Glenohumeral instability

a. The patient under 40 with a painful shoulder most likely has an underlying instability.

b. This can be subtle with an impingement syndrome or obvious with recurrent dislocations or subluxations and positive apprehension sign.

c. Four questions need to be answered.

1) Traumatic or atraumatic?

2) Voluntary or involuntary?

3) Degree of instability (whether subluxation or full dislocation?)

4) Direction of the instability (anterior, posterior or multidirectional?)

d. Treatment

1) Strengthening the rotator cuff muscles to stabilize the joint ie, physical therapy

a) Strengthening, etc.

b) refer if no improvement after 6 weeks or recurrent instability

2. Glenohumeral osteoarthritis

a. This is uncommon and presents with gradually increasing pain with restricted range of motion.

b. Examination reveals crepitus and pain at the extremes of range of motion.

c. X-rays are diagnostic.

d. Treatment

1) Maintenance of range of motion

2) NSAID for pain control.

3) Joint replacement surgery is usually successful particularly for pain relief but not to re-establish overhead use.

B. Pain arising from the acromioclavicular (AC) joint.

1. AC joint arthritis is common and develops much earlier than that of the glenohumeral joint

2. Can even present in the teens. When this joint is symptomatic, tenderness is localized over its superior and anterior aspects and the horizontal adduction test causes pain. X-rays with the arm abducted to 100 degrees and externally rotated best visualize the joint. A local anesthetic and steroid injection is diagnostic if complete pain relief is obtained and it the symptoms recur, a resection arthroplasty can be considered.

C. Pain from soft tissue structures.

1. "The impingement syndrome"

a. Subacromial bursitis, bicipital tendinitis and rotator cuff tendinitis rarely present as isolated distinct entities.

b. Rather each is part of the impingement syndrome, in which one element or the other is predominantly symptomatic.

2. Diagnosis:

a. Night pain

b. Painful arc- catching sensation between 60 and 120 degrees of abduction.

c. Impingement sign- scapular rotation prevented by one hand and other hand raises the arm in forward elevation between flexion and abduction causing the greater tuberosity to impinge against the acromion which will cause pain.

d. Impingement test - an injection of local anesthetic beneath the anterior acromion results in pain relief.

3. Treatment:

a. Rest

b. Cold for acute period

c. Heat for chronic symptoms

d. Subacromial injection of a cortisone preparation

e. Rotator cuff exercise program

4. Refer if:

a. No or minimal response to treatment in six weeks

b. Obvious weakness

c. Muscle atrophy

D. "Frozen shoulder"

1. The process involves primarily the capsule which is adherent to the humeral head and to itself in the axillary fold.

2. Essentially any condition that causes the patient to keep the arm at the side in a dependent position for an extended period can result in adhesive capsulitis.

3. There is a cycle of disuse with the following phases:

a. Increasing pain and increasing stiffness.

b. Decreasing pain with persistent stiffness,

c. Painless return of almost full movement.

d. Each phase lasts 4 to 8 months.

4. Diagnosis

a. Restricted active and passive range of motion in all directions

b. Pain in all ranges

c. Normal X-rays

5. Treatment

a. Physical Therapy

b. home exercise program

c. NSAID

d. Injections into the subacromial space and into the shoulder joint

e. Avoid manipulation

6. Refer if

a. No improvement

7. Indications for MRI

a. Patient over 40 with impingement syndrome that has been unresponsive to conservative treatment for 3 months.

b. An "injury^" regardless of how trivial with sudden marked weakness of the shoulder.

c. A rupture of the long head of the biceps associated with shoulder symptoms.

d. Unstable glenohumeral dislocation or a dislocation followed by shoulder symptoms in a patient greater than 40 years old.