Shoulder Pain

DDx

Non-Shoulder

• Cardiac

• Diaphragm

• Cervical radiculopathy

  • Numbness, tingling, pain radiating past elbow

• Trapezius muscle

  • Often spasms with underlying chronic shoulder pathology

• Thoracic outlet syndrome

• Fibromyalgia

Acute

• Acromioclavicular joint injuries

  • Direct trauma (fall on shoulder with arm adducted)

• Clavicle fracture

  • Fall onto top of shoulder

• Proximal humerus fracures

  • Elderly with low-energy fall

    • True AP glenoid, scapular Y view, axillary view

• Glenohumeral dislocations

  • Abduction, extension, external rotation causes anterior shoulder dislocation (90%)

  • Posterior force on flexed shoulder (eg. from electric shock/seizure) causes posterior dislocations

    • Standard X-ray views may look normal, or possible "light bulb" sign (symmetrical humeral head)

  • Suspect dislocation if gross deformity, and cannot externally rotate after trauma

• Rotator cuff tears

  • Difficulty with overhead activity

• Labral tear

  • Associated with dislocation or repetitive overhead movements

  • May have instability, clicking/catching sensation

• Biceps injury

Chronic >6 months

• Rotator Cuff tendinopathy/tears

  • Pain with overhead activity, weakness on empty can and extenral rotation tests, positive impingement

• Adhesive Capsulitis

  • Associated with diabetes/thyroid disorders

  • Diffuse shoulder pain, restricted passive ROM

• Shoulder instability

  • Young <40yo, with history of dislocation, subluxation

  • Positive apprehension and relocation

• Shoulder arthritis

  • AC osteoarthritis

    • Superior shoulder pain, AC tenderness, painful cross-body adduction test

  • Glenohumeral OA

    • Gradual pain and loss of ROM in >50yo

History

• Acute vs. Chronic

• Trauma vs. Atraumatic vs. Overuse

  • Trigger, activities (sports, employment)

• Pain OPQRST

• Prior injury

• Associated

  • Stiffness

  • Instability

  • Paresthesia

  • Weakness

  • Neck pain

  • Chest pain

  • Abdominal pain

  • Other joints

Physical Exam

• Appearance

  • Deformity from displaced clavicle

  • Bony prominences

    • Prominent acromion, loss of rounded shoulder, and shoulder held abducted/externally rotated is a classic appearance of an anterior shoulder dislocation

    • Prominent coracoid, shoulder held adducted/internally rotated can suggest posterior shoulder dislocation

  • Muscle atrophy

  • Scapula winging (long thoracic nerve)

• Palpation (Compare to unaffected shoulder, as certain structures can be painful on palpation in health shoulder)

  • AC tenderness

  • Subacromial tenderness (rotator cuff)

  • Biceps

  • Bones (Clavicle, humerus)

• Neurovascular

  • Rarely a clavicle can injure brachial plexus

  • Axillary nerve injury (lateral shoulder sensation) in glenohumeral dislocations

• ROM and Strength

  • Flexion/extension

  • Abduction/adduction

  • Internal/external rotation

• Sensation

• Joint above and below (neck/elbow)

Special Tests

• AC

  • Cross-body adduction test

• Rotator Cuff

  • Lag sign with external rotation [LR 7.2] (infraspinatus)

    • Can be performed with arm abducted 90 degrees

  • Lag sign with internal rotation [LR 5.6] (subscapularis)

  • Empty-can / Jobe's [LR 1.3] (supraspinatus)

    • 45 degree flexion and abduction, positive if pain when resisted flexion in thumbs down position

  • Drop-arm [LR 3.3] (supraspinatus)

    • Passively bring arm to 90 degrees abduction - positive if unable to hold arm as the examiner lets go

  • Painful arc test [LR 3.7] (subacromial impingement)

    • Pain with overhead activity (60-100 degrees)

• Impingement

  • Hawkins

    • Passively flex shoulder and elbow to 90 degrees, internally rotate head of humerus against rotator cuff

  • Neer's

    • Passively flex shoulder overhead

• Biceps

  • Speeds

    • Pain at bicipital groove with resistance on supinated sraightarms in forward flexion

• Labral Tear

  • Obrien's

    • 90 degree flexion and 10 degree adduction with thumb pointing down, pain with resistance to flexion

• Glenohumeral instability

  • Apprehension test [LR 8.3]

    • Patient lying supine, abduct and externally rotate shoulder with one hand while applying pressure anteriorly to humerus with other hand

      • Positive is pain or fear

  • Relocation test [LR 6.5]

    • Can continue apprehension test by applying downward pressure posteriorly to humerus to relieve pain/fear

  • Sulcus sign and Load/Shift test

    • Can grasp head of humerus and pull downwards, or translate forwards/backwards assessing for inferior, anterior or posterior instability

Management

• X-ray

  • AP in internal rotation

  • AP in external rotation

  • Scapular Y-view

  • Axillary view can be added to evaluate for dislocation

• Ultrasound

• MRI

  • MR arthrography for labral and chronic shoulder instablity

• Physiotherapy

Dislocation

• Intra-articular injection with 20mL lidocaine 1%

  • Posterior approach: 1.5 cm distal and 1.5cm medial to posteriolateral corner of acromion

  • Directly laterally in the glenoid void where the humeral head dislocated from

• Reduction

  • Stimson

    • Prone with dislocated arm over edge of stretcher with 4x 1L saline bags in a stocking [15lbs], typically takes 20mins

  • External Rotation

  • FARES

    • Patient supine, abduct arm with in-line traction, oscillate A-P, until 90 degrees, externally rotate, and continue slowly (typically reduces as 120 degrees)

  • Traction-Counter traction needed for posterior shoulder dislocation

• Sling for one week

• Passive ROM and progressive strengthening

Referral Orthopedics

• Consideration of surgical treatment of acute middle one-third clavicular fractures

• Young athletes with shoulder dislocations (especially if Bony Bankart lesion)

• Open fracture or fractures causing tenting