Shoulder Pain

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					                                                 Shoulder Pain

• 85% of shoulder pain is intrinsic to the shoulder; the remainder is referred usually from the neck
• Acute symptoms following trauma is typically due to dislocation, fracture, or rotator cuff tear
• Vary with age; <30 yo < 1% have complete rotator cuff tears; >45 y.o. Up to 35% of patients with
    shoulder pain will have complete tears

Rotator cuff injuries
              • Impingement syndrome: symptoms which result in the compression of the rotator cuff
                   tendons and the subacromial bursa between the greater tubercle of the humeral head and
                   the lateral edge of the acromion process
                             Repetitive overhead reaching, pushing, pulling and lifting with outstretched
                             arms compression
                             Impingement is the principle cause of rotator cuff tendonitis
                             On exam: Overhead reaching causes pain on outer deltoid, atrophy of the
                             muscles on top and back of the shoulder if longstanding
              • Tendonitis: inflammation of the supraspinatous (abduction) and infraspinatous (external
                   rotation) tendons
                             Pain with reaching, pushing, pulling, lifting, positioning the arm above the
                             shoulder level or lying on the shoulder
                             Pain on outside of the deltoid
                             Common shoulder tendonitis has no loss of ROM (as in frozen shoulder),
                             painful flexion (Biceps tendonitis), nor any persistent weakness (as in a rotator
                             cuff tear); ***most common diagnosis of shoulder pain (70%)
              • Tendon tear: occur as the end result of chronic subacromial impingement, tendon
                   degeneration, trauma or combination
                             Primarily involve the supraspinatus
                             On exam and by Hx: Shoulder weakness, localized pain over the upper back, a
                             popping or catching sensation when the shoulder is moved, nighttime pain
                             Acute injuries associated: falls on to outstretched arm, falls on to outer shoulder,
                             vigorous pulling of the lawn mower cable and unusual pushing and pulling
                             Small tears or parallel to the tendon pain with direct pressure, pain with active
                             reaching, lifting pushing and pulling.
                             Large tears weakness including inability to reach overhead or lift with arms
                             outstretched or impairment with pushing of pulling

Acromioclavicular injuries: second most common complaint occurs at the AC joint
       Joint is susceptible to arthritic changes and to trauma
       By Hx: anterior shoulder pain, deformity often localized to the AC joint
       Exam: pain with reaching across the chest, rotation and elevation

Frozen Shoulder: stiffened glenohumeral joint Loss of ROM
        Most common cause is rotator cuff tendonitis; 10% of patients with this disorder will develop
        frozen shoulder; those with DM, low pain threshold and poor compliance with exercise therapy
        are at greatest risk

Biceps Tendonditis/rupture: inflammation of the long head of the biceps as it passes through the grove of
the anterior humerus
         Repetitive lifting is etiology
         By Hx.: anterior shoulder pain aggravated by lifting or overhead reaching and will often localized
         to biceps grove, pain with flexion
              o If severe worsening of symptoms and weakness occurs and a lump appears above the
                  actecubital fossa tendon rupture
Subcapular bursitis: results from friction between the superior-medial angle of the scapula and the 2nd and
third rib; repetitive to and fro motions (ironing, assembly worker) common
          By Hx.: localized pain over the upper back, popping with shrugging

Glenohumeral osteoarthritis: wear and tear of the glenoid labrum and humeral head; uncommon, usually
associated with trauma (may be distant)
         By Hx.: Gradual anterior shoulder pain

Referred Pain: on exam: shoulder movement is normal and does not change pain
        Neural impingement of c-spine posterior pain
        Peripheral nerve entrapment distal to the spinal column of either the long thoracic or suprascapular
        Diaphragmatic irritation, intrathoracic tumors and distension of the hepatic capsule ipsilateral
        shoulder pain
        MI left sided shoulder pain

Exam (there are several approaches):
        The uninvolved shoulder is useful as a control
        Begin with a brief exam of the neck, scapula, shoulder, elbow and wrist
        Examine active ROM:
             1. Elevate arm as much as possible (Nl:180 degrees); NFL touchdown maneuver shows
                  active ROM and strength of abduction
             2. With elbow at patient’s side and forearm at 90 degrees anterior-posterior measure internal
                  and external rotation (nl: 40 and 55 degrees respectively); further evaluation is achieved
                  by having patient touch back
             3. Adduction can be measured by patient touching opposite shoulder
        Passive ROM: ROM in abduction and external rotation
        Resisted Exam
             1. Pt holds elbow at side with forearm at 90 degrees in anterior-posterior plane
             2. Abduction is resisted at elbow
             3. Adduction: resistance of inward motion
             4. Flexion: forward motion at elbow
             5. Extension: resisted backwards motions at the elbow
             6. External rotation: Pt presses laterally and external rotates at the elbow agt resistance
             7. Resistance to supination and flexion assesses the biceps tendon
             8. Painful Arc maneuver (abducting the glenohumeral joint while preventing shoulder
                  shrugging) assesses the subacromial impingement
        Drop arm test refers to the ability to smoothly lower arm after it is raised; a positive drop arm test
        is specific for rotator cuff tear (not sensitive)
        See chart for interpretation

• Plain films are indicated in the following situations:
            o Significant trauma
            o Suspected arthritis
            o Suspicion of neoplasm
            o Suspicion of osteonecrosis
• MRI: expensive but useful at evaluating soft tissue injuries especially in the following situations
            o Suspicion of rotator cuff tear
            o Lack of response to physical therapy
            o Significant weakness on exam

• Most patient with an acute injury will benefit from 2-3 days in a sling
• Prolonged immobilization should be avoided as it can lead to frozen shoulder and contractures
•   Pendular and wall climbing exercises as well as physical therapy can be useful in improving ROM
•   Joint injections are useful for tendonitis and bursitis
•   Special cases:
              o Rotator cuff tears: ortho should be consulted; small tears can be managed medically with
                  physical therapy and NSAIDS; larger repairs usually require surgery
              o Biceps tendon rupture surgery
              o Frozen shoulder aggressive physical therapy and joint injection
              o Dislocations (95% are anterior) prompt reduction

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