Shoulder Pain

Shoulder Pain
Charles De Mesa, DO, MPH
Brian A. Davis, MD, FACSM
Misty Humphries, MD, MAS, RPVI, FACS
FAST FACTS
  • Shoulder pain usually arises from the shoulder joint itself and can be due to bursitis, tendinopathy or tear, instability arthritis, or fractures.
  • It can be due to referred pain from the neck, thorax, or abdomen.
  • Shoulder pain may be divided into four categories: musculoskeletal, neurologic, vascular, and referred visceral-somatic pain.
  • A systematic approach is essential for effective management of shoulder pain.
INTRODUCTION
Shoulder pain is the third most common pain complaint in the primary care setting and accounts for approximately 16% of all musculoskeletal complaints.1 The shoulder is a complex structure. Therefore, it is important to define the shoulder by region to better identify the location of perceived pain, as it may originate from somewhere else. This chapter will identify shoulder girdle pain as the perception of pain located within the bones which connects the arm to the axial skeleton on each side, namely, the clavicle, scapula, humerus and the joints, tendons ligaments, muscles, subcutaneous tissue, and skin subserving this location. Shoulder pain may be divided into four categories: musculoskeletal, neurologic, vascular, and referred visceral-somatic pain (see Tables 16-1, 16-2, 16-3, 16-4).2
In contrast, the “neck pain chapter” will identify neck pain as the region bounded superiorly by the superior nuchal line, laterally by the lateral margins of the neck, and inferiorly by an imaginary transverse line through the T1 spinous process.3
HISTORY
Physicians make a correct diagnosis about 80% of the time based on history and physical examination alone.4 The pain history requires a detailed interview which includes the chief complaint, mechanism of injury, accompanying symptoms, prior treatments, and impact on function and quality of life. The character, quality, and location of the pain including perceived level of pain are also important. Ways of conveying this information may include a numeric rating pain score with 0 being no pain and 10 being the worst possible pain. Ascertaining the pain score for current pain, average pain for the last week, lowest and worst pain in the last 24 hours allow for characterization of the pain leading up to the office visit. A pain diagram illustrating the location is useful in communicating the pattern of pain and for interval assessment following treatment.
MECHANISM OF INJURY
Acute versus chronic injuries are important considerations in the assessment of shoulder pain (Table 16-5). Trauma from a motor vehicle collision or accidental fall may imply acute pain while overuse or repetitive activities are indicative of chronic microtrauma leading to pain. It is important to identify the acute presentation of neuropathic pain as a result of trauma. For example, falls in the elderly may result in cervical extension injury leading to shoulder pain referred from the neck.
TABLE 16-1 Musculoskeletal Shoulder Pain1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22

DIAGNOSIS

PHYSICAL EXAMINATION

WORK-UP

TREATMENT

WHEN TO REFER

Rotator cuff tendinitis (RCT) with or without calcification

Shoulder external rotation (ER) usually weaker than internal rotation (IR)

Hawkins-Kennedy test, the infraspinatus muscle test, and the painful arc sign

Cervical spine examination to rule out spine pathology

X-rays (anterior-posterior [AP], axillary, and supraspinatus outlet) assess for alignment and degenerative changes

Ultrasound (dynamic study to assess injury although operator dependent)

MRI (magnetic resonance image) shoulder

MR (magnetic resonance) arthrogram for clinical suspicion of a full thickness rotator cuff and/or a labral tear or postoperative complications

Activity modification, physical therapy (PT), analgesics, subacromial corticosteroid injection

For calcifications:

  • ultrasound-guided percutaneous lavage (UGPL)

  • extracorporeal shock wave therapy

If refractory rotator cuff tendinitis with calcification, refer to physical medicine and rehabiliation, sports, or pain medicine for UGPL

RCT, partial

Shoulder ER usually weaker than IR

Special tests: External rotation lag sign (ERLS), the dropping sign, the hornblower’s sign, and the internal rotation lag sign (IRLS)

Cervical spine examination to rule out spine pathology

X-rays (AP, axillary, and supraspinatus outlet) assess for alignment and degenerative changes

Ultrasound (dynamic although operator dependent)

MRI shoulder

MR arthrogram for clinical suspicion of a full thickness RCT and/or a labral tear or postoperative complications.

Activity modification, PT, analgesics, subacromial corticosteroid injection

No improvement after 3-6 mo of therapy, surgical consultation

RCT, complete

Shoulder ER usually weaker than IR

Special tests: External rotation lag sign, the dropping sign, the hornblower’s sign, and IRLS

Cervical spine examination to rule out spine pathology

X-ray

Ultrasound

MR arthrogram for clinical suspicion of a full thickness RCT and/or a labral tear or postoperative complications

Activity modification, PT, analgesics, surgery, (subacromial corticosteroid injection)

Acute, full thickness, with minimal amount of fatty infiltration—orthopedic surgical referral

Acromioclavicular (AC) joint arthritis

Painful palpation at AC joint

Special tests: Horizontal cross arm adduction test localizes pain over the AC joint

X-ray AP and lateral

Note: acromion morphology:

  • Flat

  • Curved

  • Hooked

AC joint morphology:

  • Flat

  • Curved

  • Horizontal

Hooked acromion and horizontal AC joints may have risk of developing localized impingement symptoms requiring surgery

PT, analgesics, acromioclavicular joint corticosteroid injection

If no improvement after 3-6 mo of therapy, analgesics and corticosteroid injection, then referral to orthopedic surgery for excision of the isolated painful joint or localized impingement region affecting functional quality of life

Glenohumeral arthritis

  • Local glenohumeral joint line tenderness and swelling anteriorly

  • Reduced range of motion (ROM), external rotation, and abduction

  • Atrophy of the rotator cuff muscles over the scapula

  • Crepitation

X-ray AP and lateral external rotation, Y-outlet, and axillary views

PT, nonsteroidal anti-inflammatory drugs (NSAIDs), and occasionally intra-articular injection

Failure of conservative treatment, continued impairment in shoulder function affecting daily activities and associated with intractable pain should be referred to orthopedic surgery for prosthetic replacement (except in patients younger than 50 y in whom arthroscopic debridement and removal of osteophytes might be attempted to delay the need for prosthetic replacement)

Adhesive capsulitis

Stiffness, decreased ROM ER and abduction

X-ray (rule out other diagnoses)

Ultrasound evaluation to rule out rotator cuff pathology

MR arthrogram axillary recess may show thickening ≥1.3 cm

PT, occupational therapy (OT), gentle ROM exercises (e.g., pendulum swings) provided they do not cause undue discomfort As pain allows, patients can add stretching and strengthening exercises

Intra-articular corticosteroid injection

Ultrasound-guided intra-articular dilation (distension)

Refer to sports or pain medicine for intra-articular dilation

For refractory adhesive capsulitis affecting function and quality of life, referral for arthroscopic surgical release (e.g. bipolar radiofrequency controlled capsular release)

Bicipital tenosynovitis

Painful palpation to the proximal aspect of the long head of the biceps (LHB), pain with activities that require eccentric deceleration of the upper extremity (such as throwing or swinging an object), and pain with muscular loading of the biceps (especially during shoulder flexion and arm supination)

X-ray (rules out fractures/dislocations)

Ultrasound (dynamic diagnostic evaluation can exclude subluxation)

MRI evaluation of the superior labral complex and biceps tendon

Analgesia with NSAIDs, acetaminophen (to avoid side effects from NSAIDs), ice, rest from overhead activity, or physical therapy. Biceps tendon sheath corticosteroid injection and/or needle tenotomy

Physical Medicine and Rehabilitation, sports referral for ultrasound-guided injections

Orthopedic referral if no improvement after conservative measures for consideration of surgical debridement, tenodesis, or tenotomy

Biceps tendon tear

Tenderness with palpation over biceps groove worse with arm internally rotated 10 degrees

“Popeye” deformity indicates rupture

  • Ultrasound: can show thickened tendon within bicipital groove

  • MRI: can demonstrate thickening and tenosynovitis of proximal biceps tendon increased T2 signal around biceps tendon

  • Nonoperative

    • NSAIDS

    • PT

    • steroid tendon sheath injections

  • Operative

    • arthroscopic tenodesis

    • tenotomy

Referral for orthopedic surgery if no improvement after conservative therapy for evaluation of surgical debridement, tenodesis, or tenotomy

External impingement (with accompanying subacromial bursitis)

Shoulder ER usually weaker than IR.

Hawkins-Kennedy test, the infraspinatus muscle test, and the painful arc sign

Cervical spine examination to rule out spine pathology.

X-ray orthogonal views

Ultrasound

MRI shoulder

Activity modification, PT, and analgesic medications. Subacromial corticosteroid injection

Orthopedic surgical referral if no improvement after 3-6 mo of nonsurgical management

Internal impingement

Shoulder IR usually weaker than ER

Muscular asymmetry with deep posterior pain with 90°-110° of abduction, slight extension, and maximal external rotation with scapula stabilized

X-ray orthogonal views

Ultrasound

MRI arthrogram to evaluate damage to the labrum or to assess capsular laxity and in those with prior surgery

Activity modification, PT and analgesic medications.

Subacromial corticosteroid injection

Orthopedic surgical referral if no improvement after 3-6 mo of nonsurgical management

Proximal humerus fracture (PHF)

Inspection: ecchymosis of chest, arm, and forearm neurovascular examination: 45% incidence of nerve injury (axillary most common)

X-ray complete trauma series

  • true AP

  • scapular Y

  • axillary

CT scan to characterize injury and for preoperative planning

Majority of nondisplaced fractures are Neer one-part fractures. PHFs are considered nondisplaced if no segment is displaced more than 1 cm or angulated more than 45°

For complex fractures with significant displacement and/or if nerve injury is suspected, a surgical referral is indicated

Glenohumeral instability or dislocation

Shoulder IR usually weaker than ER

Special attention to muscle tone, symmetry, and deformity. Passive ROM no more than 90° in any direction (risks redislocating)

Apprehension and anterior release tests

X-ray shoulder, AP (external rotation), and scapula, lateral (Y view)

MRI shoulder (if weakness persists after 4 wk of PT)

Pre- and postreduction X-rays to assess for humeral head location. Pre and post neurovascular examination. Sling immobilization following reduction (avoid NSAIDS may impair bony healing)

PT/OT first 1-2 wk after dislocation, gentle ROM to minimize capsular contraction

Reevaluation at 2 and 4 wk. If weakness persists at 4-wk, consider advanced imaging

Restrictions for the first 4-6 wk include no abduction and ER at 90° to prevent redislocation

Scapular strengthening introduced at 6-wk; continue strengthening dynamic/static stabilizers

Refer to surgery under following circumstances: >50% rotator cuff tear, glenoid osseous defect >25%, humeral head articular surface osseous defect >25%, PHF requiring surgery, irreducible dislocation, failed trial of rehabilitation, inability to tolerate shoulder restrictions, and inability to perform sport-specific drills without instability

Acromioclavicular separation

AC joint “step-off” on observation

X-ray AP bilateral for comparison and lateral additional projections include zanca view

Sling, cold packs, and medications can often help manage the pain.

Orthopedic surgical referral indicated for grade 3 Rockwood classification (AC and coracoclavicular [CC] ligaments are torn) with the CC distance is 25%-100% of the other side

Rheumatoid arthritis

Local glenohumeral joint line tenderness and swelling, atrophy, accompanying

Metacarpophalangeal and proximal interphalangeal joint arthritis

Laboratory tests:

  • erythrocyte sedimentation rate (ESR)

  • C-reactive protein (CRP)

  • rheumatoid factor (RF)

  • anti-cyclic citrullinated peptide (CCP) antibodies

  • antinuclear antibodies (ANA)

Arthrocentesis: if there is diagnostic uncertainty

DMARD (e.g., methotrexate), NSAIDs, or glucocorticoids

Rheumatology referral to start DMARD therapy, prevent progressive joint injury and associated functional decline

Infectious (septic) arthritis

Monoarticular joint pain, swelling, warmth, and restricted movement

Synovial fluid aspiration performed (prior to administration of antibiotics); fluid should be sent for Gram stain and culture, leukocyte count with differential, and assessment for crystals.

Antimicrobial regimen based on coverage of the most likely organisms to cause infection

More than 80% of septic arthritis cases are caused by S. aureus and other gram-positive organisms

Refer to infectious disease if poor response to therapy, coexistent renal or cardiac disease, and immunosuppression

Surgical referral for refractory antibiotic treatment

Myofascial pain

Hyperirritable nodules within taut skeletal muscle bands when palpated produce a muscle twitch and reproduction of the patient’s referred pain

Laboratory tests:

  • complete blood count (CBC), urinalysis

  • renal and liver function, serum calcium, albumin, phosphate, TSH, CK, 25-hydroxyvitamin D

Not routinely ordered but maybe helpful for myalgia.

Trigger point injections or dry needling (dry needling uses an acupuncture needle without introducing an injectate).

Consider referral to rheumatology if suspected polymyalgia rheumatica Consider physical medicine and rehabilitation referral for ongoing management

TABLE 16-2 Neurologic Shoulder Pain1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,19

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Mar 10, 2020 | Posted by in PAIN MEDICINE | Comments Off on Shoulder Pain

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