shoulder pain

Etiology

• history of prior trauma
  • rotator cuff tear: more common in elderly
  • dislocation: 90% are anterior dislocations
  • fracture
    • clavicle
    • humerus
    • scapula (rarely)
  • acromioclavicular joint injury
  • sternoclavicular joint injury
  • glenohumeral joint injury
• no history of prior trauma
  • rotator cuff inflammation (rotator cuff tendonitis)
  • bursitis
    • subacromial bursitis
    • subdeltoid bursitis
    • more common in elderly
  • adhesive capsulitis (frozen shoulder) more common in elderly
  • biceps tendonitis or biceps rupture (long head of biceps)
  • arthritis
    • glenohumeral arthritis
    • acromioclavicular arthritis
    • sternoclavicular arthritis
  • glenohumeral instability
  • neurologic disorders
    • cervical radiculopathy
      • C7 radiculopathy
    • brachial plexus
  • neoplastic processes
    • primary
    • metastatic
  • infection
• radiation of pain to the shoulder
  • diaphragm
  • heart

Clinical manifestations

• physical examination
  • supraspinatus test
  • biceps test
  • external rotators test
  • acromioclavicular joint test
  • Neer's test
  • Hawkin's test
  • Speed's test
  • Yergason's test
  • Apley scratch test
  • shoulder apprehension test
• pain that occurs with abduction of the shoulder above 90 degrees suggests rotator cuff involvement
• shoulder pain with adduction & with pain on palpation of the acromioclavicular joint suggests acromioclavicular joint degeneration
• a positive drop-arm test suggests rotator cuff tear

Diagnostic procedures

• EMG to evaluate nerve root injury

Radiology

• plain film radiographs: useful for
  • fractures of clavicle, humerus, or scapula
  • calcification of rotator cuff tendons: indicates chronic inflammation
  • widening or calcification of acromioclavicular joint or sternoclavicular joint
  • lytic or sclerotic bone lesions
  • dislocation of humerus
• magnetic resonance imaging (MRI) evaluation of rotator cuff tear or rotator cuff tendonitis
  • ultrasound may be more cost effective
• computed tomography (CT) test or choice for glenoid labrum tear
• CT or MRI of cervical spine if indicated by EMG

Management

• fractures
  • clavicle
    • observation
    • figure of 8 splint
    • surgery rarely indicated
  • humerus
    • sling & swath initially
    • physical therapy
    • avoid prolonged immobilization
  • scapula: physical therapy
• rotator cuff inflammation & tears, subacromial bursitis
  • non steroidal anti-inflammatory agents
  • physical therapy
  • avoid immobilization
  • corticosteroid injection of subacromial bursa if patient fails physical therapy
  • arthroscopic surgery for rotator cuff tears
    • patient fails medical & physical therapy
    • not first-line treatment
  • radial extracorporeal shockwave treatment inferior to physical therapy
• dislocations
  • patients under 20
    • 90% likelihood of reoccurrence of dislocation
    • surgery indicated
  • patients over 40
    • low risk of subsequent dislocation
    • physical therapy
• acromioclavicular & sternoclavicular inflammation/injury
  • symptomatic treatment for pain
  • corticosteroid injection for persistent pain
  • surgical resection of distal clavicle for intractable pain of the acromioclavicular joint
• cervical or axillary nerve root compression
  • surgical decompression
• lytic bone lesions: search for underlying cause

More general terms

• pain [odyn-]

More specific terms

• cervicobrachial syndrome

Additional terms

• adhesive capsulitis (frozen shoulder)
• bursitis
• physical examination of the shoulder
• rotator cuff tendonitis; impingement syndrome; painful arc syndrome; subacromial pain syndrome
• shoulder trauma