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One of the most common musculoskeletal complaints that clinicians encounter in primary care is shoulder pain. In the United States, it is the third most common musculoskeletal disorder in the general population and accounts for 5 percent of all general practice musculoskeletal-related visits. The incidence in primary care practice is estimated at 6.6 to 25 cases per 1,000 patients per year and peaks in the fourth through the sixth decades of life. Shoulder pain is the second most common musculoskeletal disorder that clinicians refer for orthopedic and sports medicine consultation.1 In regard to possible arthritis involvement in the shoulder, consider the following two tests. Apprehension and relocation sign. To perform this test, have the patient seated or in the supine position, and externally rotate the shoulder. If the patient resists the activity because he or she fears the shoulder will dislocate, the patient will often state that the shoulder is “coming out.” Reassure the patient and take the maneuver one step further. Apply pressure over the humeral head to prevent dislocation and explain this to the patient. Then extend the patient’s arm further back and release the pressure on the joint. The patient will become anxious and internally rotate the shoulder. This is known as a positive relocation sign. This is suggestive of anterior glenohumeral instability.
When it comes to shoulder pain, there are numerous associated risk factors such as occupational and leisure activities that involve heavy lifting and awkward positions, especially overhead postures. In addition to other risk factors, repetitive motions and exposure to excessive vibration carry a high risk for acute and chronic shoulder problems and pain. Athletes who participate in sports that involve throwing, high impact contact activities and repetitive arm movements are prone to shoulder pain.
The shoulder is a complex structure that involves the thorax, the humerus, clavicle, acromion and glenoid bones, surrounding soft tissue and approximately 30 regional muscles. In order for the shoulder to maintain functional integrity, five bony articulations (the acromioclavicular (AC), sternoclavicular (SC), glenohumeral (GH), scapulothoracic (ST), coracoclavicular (CC)) and three gliding surfaces (the subacromial bursa, the rotator cuff and the long head of the biceps) must function properly.
Shoulder pain is often associated with functional impairment and the symptoms are commonly persistent and recurrent. The most commonly affected structure in the shoulder is the rotator cuff. However, shoulder pain may arise from numerous disorders or trauma to articular musculoskeletal and soft tissue. Shoulder pain could also be a symptom of systemic rheumatic disease (i.e. gout, rheumatoid arthritis, septic arthritis, polymyalgia rheumatica).
When evaluating the shoulder, clinicians should be aware of the possibility of other pathology as pain can be referred from the hand (i.e. carpal tunnel syndrome), the neck (radicular symptoms), the chest (angina), the abdomen (gallbladder disease and other sources of diaphragmatic irritation) or the elbow (tendonitis).
Indeed, evaluating shoulder pain is a complex process that requires a detailed patient history and a thorough physical examination in order to accurately diagnose the problem and provide appropriate therapeutic intervention.
What You Should Focus On In The Patient History
The patient history should focus on the patient’s age, dominant hand, his or her occupation and any sports and hobbies. One may also want to ask about the patient’s ability to perform normal daily activities and if there is any recent or remote history of trauma.
One should assess any limitations of activity and function. In addition to evaluating pain quality, duration and aggravating/alleviating factors, clinicians must assess for stiffness, instability, decreased range of motion, swelling and sensations such as locking or catching.
The age of the patient is an important consideration as specific shoulder problems tend to occur in specific age groups. Instability syndromes are the most common shoulder problems in individuals under 30 years of age. Impingement syndromes occur most often in adults between the ages of 20 to 30 but can occur throughout one’s life. In the 30- to 45-year-old age group, impingement, subacromial bursitis, partial rotator cuff tears and degenerative joint disease become more common although instability remains problematic for some patients. Adhesive capsulitis and calcific tendonitis are particularly common in the 30- to 60 year-old age group. In older adults, degenerative joint disease, subacromial bursitis and adhesive capsulitis are common. Keep in mind that impingement syndrome in the older adult can progress to rotator cuff tears, including full-thickness tears.
Once the baseline history is complete, it may be necessary to determine the possibility of referred pain from non-shoulder sources. Clinicians should ask patients about any associated numbness, tingling or muscle weakness. One should have a higher index of suspicion for cervical neck disorders if pain or numbness radiates below the elbow. If the patient has any history of peptic ulcer disease, gall bladder disease, cardiac ischemia or pneumonia, clinicians may consider these conditions as possible sources of referred pain. If there is a history of malignancy, one should evaluate the patient for metastatic disease.
Key Considerations With The Physical Exam
Physical examination of the shoulder involves meticulous inspection and palpation as well as the assessment of passive and active range of motion. One may employ additional maneuvers including provocative tests to assess for specific disorders.
Visual inspection begins with the patient’s neck, shoulders and scapulae. In addition, other visual inspections should include the upper thorax being fully exposed as well as anterior, posterior and lateral postures. Working downward from the neck, look for asymmetry between contralateral bony prominences and surrounding soft tissue, any obvious deformity or atrophy, and the attitude or how the patient is holding the shoulder. Given the great mobility of the shoulder, passive and active range of motion (ROM) may provide important diagnostic clues. One should perform both active and passive ROM, and assess painful maneuvers last. 5,6
Palpation can often give important clues to localizing the source of shoulder pain. Clinicians frequently encounter localized tenderness and deformity with fractures. Locating the specific site of tenderness facilitates formulating a management plan or orthopedic referral.
One should palpate both shoulders and compare them for tenderness, warmth, crepitus and deformity. The examiner should start anteriorly over the biceps tendon and move laterally over the subdeltoid bursa and rotator cuff. Palpate the acromioclavicular, sternoclavicular and glenohumeral joints, the coracoid process, acromion, scapula and the biceps tendon. Clinicians should also palpate the cervical spine and pararvertebral muscles for any tenderness and deformity.
Assessing Range Of Motion: What You Should Look For
The shoulder has a wide range of motion, which can reach up to 180 degrees in multiple planes. One should assess active range of motion first. When comparing the affected and unaffected shoulders, you should evaluate against corresponding normal values.
A useful maneuver is to have patients put their hands on top of their head and then put their hands behind their back as if they are tying an apron. If the patient is able to perform these movements without restriction or pain, the shoulder’s functional capacity is not compromised. Additionally, one should observe the patient performing horizontal adduction and abduction with the arms extended to the height of the shoulders and across the front of the torso.
Clinicians can also assess active range of motion movements through a combination of maneuvers. The Apley Scratch test is one method of observing combined movements of the shoulder. This maneuver combines internal rotation with adduction on one arm and external rotation with abduction on the opposite arm. In order to perform this test, the patient reaches overhead behind the back toward the opposite shoulder blade with one arm while concurrently reaching downward behind the back with the opposite arm to the opposite shoulder blade. Astute observation is required to recognize which movements are restricted when a patient performs this maneuver.
Assessing for the “painful arc” is a critical component of active range of motion evaluation. Ask the patient to lift the arm (with the palm down) very slowly out to the side until the arm is above the head. Instruct the patient to stop if there is pain and then have him or her continue the motion to see if the pain ceases. A painful arc indicates pain in the mid-range of the arc (from 45 to 120 degrees) and no pain at the top or bottom of the arc. When one elicits pain during this test, it generally indicates subacromial bursitis, tendinitis of the rotator cuff or impingement syndrome due to impinging tissue on the acromial arch and the coracoacromial ligament.
If the patient complains of a persistent click during certain phases of range of motion, it is possible that he or she has torn the glenoid labrum or glenohumeral capsule. Having the patient guard or overcompensate for the scapula in relation to the humerus during active abduction enables one to evaluate scapulohumeral rhythm. The usual movement of the humerus relative to the scapula is a 2:1 ratio. When you see excess movement at the scapula in comparison to the glenohumeral joint, this may indicte adhesive capsulitis or rotator cuff tear.
For the best evaluation of passive range of motion, one should have the patient lie on his or her back or sitting upright, and be as relaxed as possible. The examiner should keep the fingers of one hand on the supraspinatus during the passive range of motion evaluation. Clinicians should assess abduction, adduction, forward elevation, internal rotation and external rotation for pain. Other signs to look for are restricted movements and alterations in the end feel of the motion or excessive motion. Excessive motion or hypermobility may be a sign of glenohumeral instability. One can simultaneously test strength with passive range of motion and observe differences between the affected and non-affected extremity.
Generally, patients who exhibit limitations of both active and passive range of motion are likely to have adhesive capsulitis, a fracture or chronic bursitis. Rotator cuff tears may present as limited active range of motion with full passive range of motion. In individuals who have full active and passive range of motion but complain of pain with one resisted movement, the problem is likely tendonitis.
When You Suspect Impingement Or Rotator Cuff Injuries
After the shoulder inspection, palpation and range of motion assessment, one should perform provocative and special testing as the examiner should now have a fairly good idea of which shoulder structures are involved. Provocative tests can provide important diagnostic clues when evaluating the painful shoulder and guide further diagnostic studies and management. In addition to the aforementioned Apley Scratch Test, several other special maneuvers are essential to evaluating the painful shoulder. With this in mind, let us take a closer look at several common tests that clinicians can utilize to help detect suspected impingement and rotaor cuff injuries.
If you suspect shoulder impingement, consider the following tests.
Jobe’s test. Have the patient hold the affected arm in the scapular plane approximately 30 degrees from full extension. Tell the patient not to hold the arm directly in front of the chest or out to the side but at a comfortable angle as if he or she is pouring a cup of coffee. If this position is painful, the greater tuberosity of the humerus is being pushed up against the acromion. This is a positive Jobe’s test for impingement.
Simultaneously, push down on the arm to test for any weakness since this is a position of strength.
Hawkin’s test. With the arm in the throwing position and shoulder flexed forward about 90 degrees, forcibly internally rotate the humerus. The elbow should also be flexed approximately 90 degrees. If you are able to elicit pain, this is a positive Hawkin’s test due to impingement of the supraspinatus tendon against the coracoacromial ligament. An additional finding may be crepitus at the subacromial bursa.
Neer’s sign. The patient has subacromial impingement if you elicit pain when pinching the patient’s rotator cuff tendons under the coracoacromial arch. To perform this maneuver, place the patient’s affected arm in forced flexion with the arm fully pronated. Be sure to stabilize the scapula on the affected extremity to prevent scapulothoracic movement.
Consider these exams when evaluating for a possible rotator cuff injury.
Infraspinatus strength. Infraspinatus strength is responsible for 90 percent of the shoulder’s external rotation function. To test the strength of the infraspinatus, have the patient flex both elbows to 90 degrees as you exert resistance against external rotation of the shoulder. Loss of strength of the infraspinatus is closely related to the size of a rotator cuff tear.
Supraspinatus strength. Have the patient hold his or her arms in the scapular plane as if he or she is pouring out of a can. Have the patient forward elevate the arms as you exert resistance. Assess for weakness. The patient then attempts to elevate the arms against examiner resistance. This maneuver is also referred to as the “empty can test.”
Subscapularis strength. The subscapularis, along with the supraspinatus and infraspinatus tendons, is a portion of the rotator cuff. One can test subscapularis strength by the “lift-off test.” Ask the patient to hold his or her hand behind the back at waist level with the palm facing out. Then have the patient move the arm away from the body against your resistance. Pain and inability to move the arm away from the body suggests subscapularis muscle injury or dysfunction.
Drop arm test. Perform this maneuver by passively adducting the patient’s shoulder. Then observe the patient slowly lower the arm to the waist. It is common to observe the patient’s arm drop to his or her side in the presence of rotator cuff tears and supraspinatus dysfunction. Since this movement is largely a function of the deltoid muscle, some individuals will be able to lower the arm slowly to 90 degrees but will be unable to complete the motion all the way to the waist.
Essential Insights On Detecting Signs Of Instability In The Shoulder
Instability is one of the most difficult dysfunctions of the shoulder to assess due to considerable overlap between instability and impingement. Here are some tests to consider.
Sulcus sign. One can test this sign by having the patient hold the affected arm in a resting position at their side. The examiner gently pulls the arm downward from the elbow or wrist while observing and palpating for a depression below the shoulder. The presence of a depression is considered a positive sulcus sign suggestive of inferior glenohumeral instability.
How To Detect And Treat
Cross arm test. One would perform this test to assess the acromioclavicular joint. Have the patient internally rotate the shoulders by crossing his or her arms over the chest (cross body adduction). Individuals with osteoarthritis will have tenderness over the acromioclavicular joint and pain with this maneuver. Generally, these individuals will also have a positive O’Brion’s test.
O’Brion’s test. This involves the patient adducting the arm across the chest, pronating the hand as if he or she was emptying out a can and then performing forward elevation against resistance. If the patient experiences pain at the top of the acromioclavicular joint with the hand pronated but has no pain if the hand is supinated, this is a positive O’Brion’s test.
Treatment of arthritic shoulder conditions varies dependent on the involved structures and etiology.
Acromioclavicular joint arthritis generally presents as pain and swelling at the joint and is usually associated with some degree of impingement. Plain radiographs will often exhibit joint space narrowing, hypertrophy and spurs. Initial treatment includes ice or moist/deep heat, NSAIDs and exercise including water exercise. Steroid injections may be beneficial for some patients with severe disease. However, these injections are very difficult and are best performed by an orthopedist. Surgery is sometimes needed if conservative treatment fails to resect the distal clavicle.
Glenohumeral arthritis is associated with chronic pain, decreased range of motion, crepitus and disuse atrophy. Radiographs will show characteristic joint space narrowing and changes in the humeral head. Conservative treatment consists of NSAIDs and physical therapy. For conservative therapy failures and advanced disease, orthopedic referral is warranted for consideration of arthroplasty.
Septic arthritis generally presents as acute, painful limited range of motion accompanied by fever and chills. Initial diagnostic tests should include, at a minimum, complete blood count, erythrocyte sedimentation rate and plain radiographs. One should also obtain synovial fluid for white cell count and culture. Patients with septic arthritis require prompt infectious disease and/or orthopedic referral for intravenous antibiotics and possible surgical irrigation.
Systemic arthritis, including gout, polymyalgia rheumatica and rheumatoid arthritis, can also affect the shoulder. Although primary care providers can treat all of these conditions, it is prudent to consider a rheumatology consult. In individuals with gouty arthritis, several pharmacologic therapies are available and they include NSAIDs, colchicines, allopurinol and probenecid. The goal of treatment is keeping the serum uric acid within low to moderate normal ranges. Polymyalgia rheumatica requires treatment with relatively high-dose corticosteroids for several weeks to months.
Additional precautions include monitoring serum blood sugar and preventive osteoporosis therapy. In regard to rheumatoid arthritis, one may treat this with several different pharmacotherapies including NSAIDs, disease modifying antirheumatologic drugs and steroid injections.
Yergason test. Commonly, inflammation of the biceps tendon presents in patients suffering from rotator cuff tendonitis. To evaluate the biceps tendon, the patient’s elbow should be flexed 90 degrees with the thumb pointing upward. The examiner grasps the wrist and resists attempts by the patient to actively supinate the arm and flex the elbow. Pain with this maneuver indicates biceps tendonitis.
Clunk sign. With the patient lying supine, one can assess for evidence of glenoid labral tears by rotating the patient’s arm while applying force (loading) from extension through to forward flexion. A “clunk” or clicking sensation may indicate a labral tear even in the absence of instability.
Ludington’s test. The patient clasps both hands on top of the head, allowing the interlocking fingers to support the weight of the upper limbs. This allows maximum relaxation of biceps tendon. The patient then alternately contracts and relaxes the biceps muscle while the examiner palpates the biceps tendon. If the test is positive, the examiner will not be able to feel the tendon and this indicates a rupture of the biceps tendon.
Other Tests You Should Consider To Identify The Cause Of Shoulder Pain
Adson maneuver. In order to test for thoracic outlet syndrome, have the patient rotate his or her head toward the affected shoulder. The patient then extends the head while the examiner laterally rotates and extends the shoulder. Proceed to palpate the radial pulse of the affected extremity and instruct the patient to take a deep breath and hold it. If the pulse disappears, the test is positive for thoracic outlet syndrome.
Spurling’s test. In a patient with shoulder and neck pain or pain that radiates below the elbow, a useful maneuver to further evaluate the cervical spine is Spurling’s test. Place the patient’s neck in extension and rotate the head toward the affected shoulder while exerting pressure on the head (axial load on spine). If this maneuver reproduces the patient’s shoulder or arm pain, further evaluation of the cervical spine is necessary to rule out nerve root compression.
A Few Thoughts On The Value Of Diagnostic Imaging
Depending on the outcome of the history and physical examination, imaging studies are sometimes warranted to establish or confirm a diagnosis. Other indications for diagnostic imaging include severe trauma, uncontrolled pain, failure of conservative therapy and inability to return to previous activity considerations.
By narrowing your assessment, you have a good idea of what shoulder structures are involved and can select the study that will provide the best accuracy. Imaging studies that clinicians commonly use to evaluate the shoulder are plain radiographs, arthrograms, ultrasound, computed tomography and magnetic resonance imaging (MRI).
Prior to using MRI, clinicians frequently used arthrograms to examine complex shoulder structures. When selecting diagnostic imaging studies, keep in mind that plain radiographs and computed tomography facilitate the best identification of bony pathology whereas ultrasound and MRI are best for identifying soft tissue disorders.
A Primer On Helpful Therapeutic Interventions
Therapeutic management of shoulder pain is dependent on the structures involved and patient preferences. Patients presenting to primary care providers usually have less severe or chronic shoulder disorders as opposed to those one sees in emergency departments with acute, severe trauma. When any patient presents with a suspected fracture or severe trauma, one should immobilize the joint and promptly refer the patient for radiographs and orthopedic evaluation.
Only experienced health care providers should attempt to reduce dislocations. Initially, primary care providers can treat the majority of shoulder pain syndromes conservatively. When it comes to treating impingement disorders, including bursitis, adhesive capsulitis and tendonitis, one would generally start with ice or moist heat applications and instruct the patient to avoid activities that reproduce the shoulder pain.
Nonsteroidal antiinflammatory drugs (NSAIDs) offer good relief as most pain associated with bursitis is mild to moderate. One should consider a physical therapy or sports medicine referral for range of motion and strengthening exercises. If this approach fails to relieve the pain and dysfunction after three to four weeks, performing a corticosteroid injection into the subacromial space may offer significant relief. However, only health care providers adept in these procedures should perform the injection. Otherwise, one may want to pursue an orthopedic referral. Orthopedic referral is indicated if conservative measures fail after three months as decompression may be needed to relieve the impingement.
Rotator cuff tears do not always require surgery. Depending on the degree of the tear and the associated pain and dysfunction, conservative treatment may offer sufficient relief. Conservative treatment involves rest and refraining from activities that cause pain, NSAIDs and physical therapy. Physical therapy may include a wide range of modalities including ice, heat, ultrasound, electrical stimulation and massage.
However, the mainstay of physical rehabilitation for rotator cuff disease is exercise and muscle reeducation. Patients who fail to improve with conservative therapy may benefit from judicious use of corticosteroid injection therapy in the bursa above the tendon. However, this should only be attempted by a very skilled clinician and often requires orthopedic or sports medicine referral. Current guidelines recommend no more than three steroid injections per shoulder as overuse of steroid injections could lead to tendon weakening or even rupture.
Surgical intervention is recommended for individuals with advanced rotator cuff disease, significant tears, conservative therapy failure and when the quality of life is severely impacted by the dysfunction.
Other Pertinent Treatment Pearls
Management options for instability disorders of the shoulder vary widely depending on the extent of the problem and the involved structures. One can often treat mild to moderate dysfunction with physical rehabilitation for strengthening of the joint structures. In the presence of more advanced dysfunction and disorders including labral tears, hypermobility disorders and ruptured tendons, orthopedic or sports medicine consultation is recommended.
Thoracic outlet syndrome may require invasive vascular diagnostic procedures and should be referred for surgical evaluation. Cervical radiculopathy may present as degenerative changes on plain radiographs or compressive radiculopathy such as herniated nucleus pulposus on MRI. Conservatively, one can treat cervical radiculopathy with NSAIDs or oral corticosteroids and physical therapy. Treatment failures and individuals with severe disease require surgical evaluation for possible decompression.
In Conclusion
The aforementioned treatment strategies discussed here are general guidelines only. Management of specific shoulder disorders requires accurate diagnosis and therapeutic interventions that consider the patient’s desires and limitations.
Shoulder pain is a common problem in primary care that can adversely affect functional capabilities and the quality of life for patients. Obtaining an attentive patient history and emphasizing a thorough physical examination may lead to an accurate diagnosis. Most patients do not require either imaging or referral initially and can be managed successfully in the primary care setting. For those patients with more complex and acute shoulder disorders, or those who fail conservative treatment, referral to the appropriate specialty provided is indicated.
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