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Shoulder Pain Cheat Sheet (DRAFT) by

Shoulder Pain Diagnosis + Exam

This is a draft cheat sheet. It is a work in progress and is not finished yet.

Causes of Shoulder Pain

- Myofascial pain syndrome
- Cx Dysfun­ction with referred pain
- Cx Radicu­lopathy
- Supras­pinatus Tendinosis
- Adhesive Capsulitis
- Subacr­omial imping­ement syndrome
- Supras­pinatus tendon tear/r­upture
- Acute Bursitis
- Calcific Tendinitis
- GH Arthrosis
- TOS
- AC joint osteoa­rth­rosis
- Bicep Tendinitis
- Visceral Referred Pain

Serious Disorders

- Malignancy
- Septic Infection
- Carcinoma of the lung
- MI

Pitfalls

- Referred sources of shoulder pain: Cx spondy­losis, Cx arthritis, Cx disc disease, MI, CRPS, Diaphr­agmatic irrita­tion, TOS, Gallbl­adder Disease
- PMR ( >60 yo, bilateral, inflam­matory shoulder girdle pain)
- Posterior disloc­ation of the shoulder joint
- Recurrent sublux­ation of shoulder joint
- AVN of humeral head
- Rotator cuff tear/d­ege­ner­ation

Referral

- Persisting night pain with shoulder joint stiffness
- Persisting supras­pinatus teninitis - Rotator cuff tear/d­ege­ner­ation
- Confir­med­/su­spected shoulder disloc­ation
- Confir­med­/su­spected recurrent sublux­ati­on/AVN
- Children with shoulder instab­ility

Hx

- Duration
- Onset - Night pain when leaning + Hx of trauma, >65 yo = rotator cuff tear
- Activi­ty/­mec­hanism at the time of onset - Overhead work = imping­ement syndrome (60-120 degrees)
- Activities that reliev­e/e­xac­erbate
- Patient's age - <30 = biomec­han­ica­l/i­nfl­amm­atory (atrau­matic instab­ility, tendinosis and arthro­pat­hies)
>45 = Complete rotator cuff tears
- Past Hx of trauma­/injury
- Past Hx of should­er/arm surgery
- Treatment attempted - not getting better
- Other medical conditions (Diabetes, Thyroid disease, Coronary Artery disease, Alcohol abuse + use of cortic­ost­eroids)

Hx

Age
<­40yo: Instab­ility, rotator cuff tendin­opathy
>­40yo: Rotator Cuff tears, Adhesive Capsul­itis, GH OA
Diab­ete­s/T­hyroid disord­ers
Adhesive capsulitis
Hx of trauma
<40 yo: Shoulder Disloc­ati­on/­sub­lux­ation
>40 yo: rotator cuff tears
Loss of ROM
Adhesive Capsul­itis, GH OA
Night Pain
Rotator Cuff Disorders, adhesive capsulitis
Para­est­hesia and arm pain past elbow
Cx Spine
Pain Location
Anterior- Superior shoulder pain = AC joint
Diffuse shoulder pain in deltoid = rotator cuff, adhesive capsul­itis, GH OA
Pain with overhead activity
Imping­ement, rotator cuff disorders
Sports
Instab­ility - overhead sports and collision sports
Weak­ness
Rotator Cuff disorders, GH OA

Further Questions

Injury - even very minor when the pain started?
Does the pain keep you up at night?
Pain/S­tif­fness in neck?
Pain/r­est­riction when clippi­ng/­han­dling your bra or touching you shoulder blades (limited internal rotation)
Trouble with combing hair? (External rotation)
Pain on walkin­g/some stressful activity?
Pain worse when waking in the morning?
Is it both sides? Do you have it in your hips too?
Pain associated with sporting activity, housework, dressing?

Invest­iga­tions

- ESR/CRP (PMR, Infection, Inflam­matory)
- RF
- Serum Uric acid (Gout)
- X-ray
- Bone Scan
- US
- MRI

In children

- Septic Arthri­tis­/os­teo­mye­litis
- Swimmer's Shoulder

In Elderly

- PMR
- Supras­pinatus Tear+ Persistent tendinitis
- Other Rotator Cuff Disorder
- Stiff Shoulder due to Adhesive Capsulitis
- OA of AC + GH joints
- Cx manipu­lable lesion with referred pain
- AVN of the humeral Head

Adhesive Capsulitis

Caus­es:
Diabetes
Thyroid Disease
Pulmonary disorders - TB, carcinoma
Cardiac Disease (MI)
Cerebr­ova­scular accident
Shoulder Trauma
Recent surgery under anaest­hetic

S&S

Onset usually >40 yo, mean age 60yo
F > M
Unilateral (But can be bilateral - rare)
Increasing pain and stiffness
3 Phases:
Painful phase: Insidious onset - shoulder pain + ache on movement in upper traps. Increasing during the night
Adhe­sive: After several months - pain becomes less severe, but pain during movement remains. Shoulder movement more restricted
Reso­lut­ion: Pain less severe , restri­ction is worse. ROM slowly improved
- To differ­ent­iation between rotator cuff tenditis, Adhesive capsulitis has global restri­ction of passive movment , traps tenderness and early movement of scapula on abduction

Management

3 times a week (inten­sive) - No manipu­lation at initial stage
Rest
Pendular Exercises
NSAID advice - pharma­cists
Cryoth­erapy
US, IF
Trigger points­/bands of the shoulder girdle - upper traps
Spencer Technique
When acute episode is better, restore function - active exercises
Mobili­sat­ion­/ma­nip­ulation
PIR
Resisted streng­thening exercises - isometric (press against wall) in pain free range to isotonic (moving shoulders with weights)
DOES NOT RECUR IN THE SAME SHOULDER WHEN BETTER
Spencer: 7 stages
1. GH Flexion + elbow extension
2. GH Extension + elbow flexion
3. Circum­duction + traction
4. Circum­duction + compre­ssion
5. Externally rotate + adduct (combing hair)
6. Internally rotate + abduction and extension (wiping bum)
7. Milking - scoop up
4-5 repeti­tions on every step. Slow movements

Subacr­omial Bursitis

- Caused by inflam­mation of supras­pintus and/or other structures around the bursa
- Pain and swelling = imping­ement
- Pain on active + passive ROM of the shoulder
- Focal warmth, swelling
- Pt shrugs shoulder to initiate abduction
- Ultrasound

Management

- Cryoth­erapy
- Sling (48-72 hours) - decreases tension on supras­pinatus tendon
- Mobility exercises
- NSAIDs
- Mobili­sat­ion­/ma­nip­ulation of GH, AC, SC and Scapular abnorm­alities

Calcific Tendinitis

- HADD = Hydrox­yap­atite Deposition Disease
- Caused by trauma­/ov­eruse
- Intense pain in the shoulder, radiates down upper arm - starts suddenly and rapidly becomes worse
- Pain worse with ANY shoulder movements and restricted in ALL directions
- Clinical features + X-ray (soft tissue calcif­ica­tions)

Management

- Rest - may need a sling for several days
- Cryoth­erapy
- NSAIDs
- GP for cortic­ost­eroid injections
- Can improve within 4-5 days of conser­vative care

GH Disloc­ation

- Usually anterior
- Forced abduction + external rotation
- Severe pain, patient holds arm tightly against body
- Shoulder appears flattened laterally + prominent anteri­orly. AC more prominent too
- X-rays in AP and Lateral scapul­a/a­xillary
- Posterior disloc­ation - axial loading of adducted, internally rotated arm. Seizure should be consid­ered!

GH Instab­ility

Types: Anterior inferior (common), Posterior, Multid­ire­ctional - congenital
- Trauma related - direct­/ov­eruse (overhead activi­ties), intent­ional, atraumatic - congen­ital, bilateral, joint laxity
Hx: General shoulder pain, worse with activi­ty/­certain arm positions
Relieved by rest/heat
Hx of catchi­ng/­locking with motion
Painful arc of motion (impin­gement)
Exam: Sulcus sign/r­edness
Trigger points + myospasm of rotator cuff
AROM/PROM shows repeatable clunk/­app­reh­ension with abduction + external rotation
+ve Load and shift
Anteri­or/­pos­terior appreh­ension sign.
DDx: Labral Tear/GH OA
Biceps Tendin­opathy
Rotator cuff tear
Shoulder Imping­ement
Subacr­omial Bursitis
Mana­gem­ent: Correction of faulty movement patterns - streng­thening of rotator cuffs + correction of muscle imbalances (PFROM then to mild resistance exerci­ses), if not getting better, consider referral to GP for surgery

Imping­ement Syndrome

- Not a condition on it's own
- Caused by:
Subacr­omial Bone spurs/­bursal hypert­rophy
AC Joint arthro­sis­/bone spurs
Rotator cuff disease
Superior labral injury
GIRD
GH Instab­ility
biceps tendin­opathy
Scapular dyskinesis
Cx radicu­lopathy
- Hx: Dull, achy shoulder - worse with shoulder abduction , overhead activi­ty/­exc­essive use
Sudden onset of sharp pain in shoulder with tearing = rotator cuff tear
Exam: Pain on top of shoulder = AC joint arthritis
Pain over bicipital groove = bicipital tendonitis
Pain over lateral shoulder = supras­pinatus tendin­opathy
AROM = pain with shoulder abduct­ion­/fl­exion 8-120 degrees + shoulder hiking
PROM: WNL unless tendon is involved
RROM: Muscle weakness due to pain
SMR = WNL - rule out Cx radicu­lop­ath­y/n­eur­olo­gical
+ve imping­ement sign
+ve neer's sign
+ve Hawkins Kennedy
+ve Drops arm, Empty Can
DDx: Biceps tendon­itis, rotator cuff injuries, Adhesive capsul­itis, AC joint pathology, Glenoid Labral Tear, Subacr­omial Bursitis
Mana­gem­ent: Education + reassu­rance , avoidance of aggrav­ating activity, PRICE + NSAIDs, MF release, Manipu­lation of SC, AC, Cx,Tx, TENs, US
Rehab: Ice and rest shoulder after
PRFROM + Pendulum arm swings, stretching then PFAROM + mild resistance exercises

Labral Tear

Classi­fic­ations