Shoulder pain

Data gathering

  • Red flags – night pain, wt loss, fever, numbness, PMH malignancy,
  • Others – neck pain, right handed, cancer, occupation, trauma, impact
  • Examine – shoulder/neck

 

Clinical management

  • Investigations
    • Xray
    • USS
  • Acromioclavicular joint
    • Younger patient, manual worker, sportsman, pain on top of shoulder, painful to lie on that side, tender over ACJ
    • Tx: activity modification, NSAIDs, physiotherapy, steroid injection, surgery
  • Subacromial space
    • Subacromial bursa
    • Rotator cuff
      • Rotator cuff tendinopathy
        • often caused by repetitive movements – painful arc, dull throbbing over deltoid, impingement signs (positive Hawkin’s test)
        • Tx: activity modification, NSAIDs, steroid injections, physiotherapy, surgery
      • Rotator cuff tear
        • Tear usually due to trauma, >40yo – pain and weakness in shoulder – unable to raise arm over head
        • Tx: NSAIDs, rest, orthopaedic referral if acute tear
      • Acute calcific tendonitis
        • crescendo severe pain
        • Tx: Xray, steroid injection, surgery
  • Gleno-Humeral joint
    • Capsule (Adhesive capsulitis i.e. frozen shoulder)
      • 40+yo, diabetes – three phases: (1) pain (2) pain + stiffness (3) gradual improvement. Marked reduction in external rotation – inflammation of surrounding tissues making them stiff
      • Tx: usually resolves over 18-24 months, analgesia, steroid injection, physiotherapy, surgery
    • Osteoarthritits
      • wear and tear of joint – older age, gradual onset of pain, reduced ROM, crepitus
      • tx: Xray, analgesia, steroid injection, physiotherapy, surgery
    • Labral injuries (instability)
      • traumatic – younger patient following dislocation
      • capsular laxity – hypermobility, check Beighton score
      • Ix: Apprehension test
      • Tx: surgery (if young), physiotherapy (if hypermobility)

 

Notes

  • Shoulder exercises examples
    • pendulum swing, door press
  • Xray shoulder
    • OA
    • Calcific tendonitis
  • USS shoulder
    • Good for full thickness tears, calcific tendonitis
    • Cant diagnose impingement
    • Can be wrong
  • Special tests on examination
    •  Supraspinatus
      • Empty beer can test
    • Infraspinatus
      • Weak external rotation (elbow tucked in)
    • Subscapularis
      • Napoleon’s Belly press (hand on belly, move elbow forward)