Shoulder Pain
Differential Overview
❑ Rotator cuff tendinitis
❑ Bicipital tendinitis
❑ Acromioclavicular joint inflammation
❑ Acromioclavicular joint separation
❑ Cervical spondylosis
❑ Impingement syndrome
❑ Rotator cuff tear
❑ Adhesive capsulitis
❑ Glenohumeral joint instability
❑ Referred pain
❑ Shoulder dislocation
❑ Humeral neck fracture
❑ Glenohumeral joint arthritis
❑ Reflex sympathetic dystrophy
❑ Aseptic necrosis of the humeral head
Diagnostic Approach
Beware referred pain, which can be the seemingly innocuous presentation of a life-threatening condition. The patient will often try to link the pain to a musculoskeletal explanation, inadvertently providing false clues leading away from the correct diagnosis. Consider this explanation if there is no pain with movement of the shoulder.
Pain aggrevated with reaching is due to rotator cuff tendinitis or impingement in 80%, most commonly supraspinatus tendinitis. Pain with motion usually signifies periarticular pathology. Pain with isometric resistence in midarc abduction and external rotation of the shoulder is found in supraspinatus tendinitis, whereas with impingement this manuver is not painful. Pain with resisted external rotation occurs with infraspinatus and teres minor inflammation, and pain with resisted internal rotation occurs with subscapularis inflammation.
Apprehension test: With the shoulder at 90 degrees abduction, and the elbow at 90 degrees flexion, the examiner applies forward pressure to the posterior aspect of the humerus. A positive test occurs if the patient expresses pain or apprehension. Relocation test: With the arm in the same position and the patient lying supine, the examiner applies backwards pressure on the anterior aspect of the humerus and the patient expresses relief. Anterior release: After performing the relocation test, the examiner releases pressure, and the patient expresses apprehension or pain. Biceps load: With the patient supine, and the elbow at 90 degrees and maximally externally rotated, the shoulder is placed at 90 degrees of abduction (biceps load I). While the examiner pulls laterally on the forearm, the patient resists. A positive test is indicated by increased pain. The biceps load II test is performed at 120 degrees.
Clinical Findings
Rotator cuff tendinitis Most often this results from supraspinatus tendinitis, the patient describing the pain diffusely over the deltoid (C5 distribution). There is usually no major precipitating event other than repetitive motion (e.g., painting or doing carpentry work). Pain is increased with abduction and elevation of the shoulder, demonstrated by extension of both arms with the thumbs pointed downward (the “empty beer can” test), finding weakness on pressing down on the involved arm.
Bicipital tendinitis The patient describes anterior shoulder pain, pointing with one finger to the bicipital groove. Elbow flexion and forearm supination against resistance with the elbow held at the side will reproduce the pain. Tenderness is found over the long head of the biceps in the bicipital groove in the anterior aspect of the shoulder. Since 85% of the strength of elbow flexion is produced by the brachioradialis and the short head of the biceps, a tear of the long head of the biceps will not produce detectable weakness.
Acromioclavicular joint inflammation This is found in patients who do heavy labor or play contact sports. Pain is reproduced by reaching above and in front of the body. Pain and tenderness localize over the acromioclavicular joint in the superior shoulder at the distal end of the clavicle.
Acromioclavicular joint separation Acute shoulder injury produces an elevation and springboarding effect of the distal clavicle. The superior acromioclavicular joint will be very tender.
Cervical spondylosis Pain is neuritic in character (numb, burning), unaffected by shoulder position, and elicited on neck motion to the side of the pain. Pain usually projects to the shoulder and lateral arm.
Impingement syndrome A “catch” or increase in subacromial pain occurs when the arm is elevated forward while the shoulder girdle is depressed. There is a painful arc on passive motion at 60 to 120 degrees as the thickened supraspinatus tendon is trapped between the acromion and greater tuberosity.
Rotator cuff tear Tearing typically occurs with a “snap” with a fall onto an outstretched arm or direct blunt trauma. The patient is unable to reach overhead or lift with the arm outstretched. The “drop-arm” sign is positive: the arm drops to the side when released at 90 degree passive abduction. There will be full passive range of motion but little voluntary abduction, even after lidocaine anesthesia. On palpation, there is fine crepitance and a depression over the tendon.
Adhesive capsulitis A “frozen shoulder” occurs after a period of immobilization, causing generalized shoulder pain that is often worse at night. Active and passive range of motion is limited to a small pain-free arc. It may be associated with reflex sympathetic dystrophy.
Glenohumeral joint instability Subsequent to a capsular tear, the shoulder “gives out” repeatedly. When the arm is gently abducted and externally rotated, a feeling of joint instability and insecurity will be elicited.
Referred pain Myocardial ischemia radiates from the chest to the left shoulder. Aortic dissection of the ascending arch produces right neck and shoulder pain, and dissection of the transverse and descending arch produce left back and shoulder pain. Inflammation of the underside of the diaphragm produces pain in the posterosuperior shoulder, accentuated with deep breaths. A superior sulcus (Pancoast) lung cancer can produce shoulder pain in conjunction with brachial plexus findings.
Shoulder dislocation Usually resulting from trauma while the shoulder is hyperextended, dislocation is most often anterior and characterized by loss of the shoulder’s lateral rounded appearance and prominent swelling. The rounded end of the humerus can be palpated anteriorly. Assess for axillary nerve damage, radial pulse, supraspinatus tendon rupture, and humeral fracture.
Humeral neck fracture There is a history of trauma (usually a fall onto the outstretched hand), with findings of severe pain and tenderness with ecchymosis over the proximal upper arm.
Glenohumeral joint arthritis A low-grade ache increases with activity. Muscle atrophy, crepitation, and diminished motion are noted on examination.
Reflex sympathetic dystrophy Classic findings include persistent burning pain, diffuse tenderness, immobilization of the shoulder, swelling of the arm, trophic changes (atrophy, hyperpigmentation, nail thickening, hyperhidrosis), and vasomotor instability in the hand.
Aseptic necrosis of the humeral head The typical history is stiffness with intermittent pain of the shoulder, in the setting of predisposing medical conditions including steroids, sickle cell anemia, lupus, or dialysis.
Pictures
Book Source Details
- Book Title: Field Guide to Bedside Diagnosis
- Author(s): David S. Smith
- Year of Publication: 2007
- Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Shoulder symptoms
Read excerpts from these other book chapters related to Shoulder symptoms:
Medical Books Excerpts
- Shoulder Pain
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.
More About Causes of Shoulder symptoms
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More About This Book:
Title: Field Guide to Bedside Diagnosis
Authors: David S. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 0-78178-165-5
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» Next page: Retractions, costal and sternal (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
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