Evaluation of Shoulder pain

Christopher Betts PGY-IIFamily Medicine

Sports Medicine Presentation

History taking

• Is it acute or chronic?

• Chronic when present for greater than six months.

History taking

Etiologies associated with chronic shoulder pain: Rotator cuff disordersAdhesive capsulitisShoulder instabilityShoulder arthritis

Other chronic pain issues

History taking

Etiologies associated with chronic shoulder pain: • Rotator cuff disorders

– Tendinopathy– Partial tears– Complete tears– Calcific tendinitis

• Adhesive capsulitis• Shoulder instability• Shoulder arthritis

– Acromioclavicular– Glenohumeral

• Other chronic pain issues– Non-shoulder problems

History taking

• Patients younger than 40 present more commonly with c/o shoulder instability or mild rotator cuff disease (impingement, tendinopathy).

• Patients greater than 40 years of age have higher risk for advanced chronic rotator cuff disease, adhesive capsulitis, or glenohumeral osteoarthritis.

History taking• Onset• Location• Duration• Characters• Agitated by• Alleviated by• Radiation• Timing (duration,

frequency)• Severity

• Age• Past treatments• Past medical history• Social Hx

– Occupational activities– Recreational activities

History taking

• Onset–Overhead activity = rotator cuff

disorders–Hx of trauma

• Younger than 40 yrs old = shoulder dislocation/subluxation

• Older than 40 yrs old = rotator cuff tears

History taking

• Location– Anterior-superior shoulder pain

• Acromioclavicular joint pathology– Diffuse or lateral shoulder pain in deltoid

region• Rotator cuff disorders• Adhesive capsulitis• Glenohumeral osteoarthritis

History taking

• Characters– Numbness/tingling = cervical etiology– Dull, achy night pain = rotator cuff tears or

severe glenohumeral osteoarthritis

History taking

• Agitated by– Overhead activity = rotator cuff disorders– Sleeping on affected side at night = rotator cuff

tears– Painful arc, noted by pain w/ overhead activity =

mild rotator cuff disease and tendinopathy as well as rotator cuff tears

History taking

• Radiation– Pain radiating past the elbow = cervical etiology (not

related to shoulder pathology)– It is not uncommon to have pain that radiates into the

neck because the trapezius muscle often spasms in patients with underlying chronic shoulder pathology.

• Timing (duration, frequency)– Worse at night = adhesive capsulitis, rotator cuff

disorders

History taking

• Severity– Loss of range of motion = adhesive capsulitis,

glenohumeral osteoarthritis

History taking

• Past medical history– Diabetes mellitus, thyroid disease = adhesive capsulitis– Previous trauma to shoulder = dislocation/subluxation

(<40 yrs of age), rotator cuff tears (>40 yrs of age)– Previous shoulder surgery = adhesive capsulitis,

glenohumeral osteoarthritis (as early or late complications)

– Autoimmune disease and inflammatory arthritis = glenohumeral osteoarthritis (from erosions and wear-and-tear)

History taking

• Occupational activity & Recreational interests:– Hx of collision sports or weigh-lifting = instability or

AC osteoarthritis– Overhead activity = rotator cuff disorders

Physical exam

• Inspection & Observation• Observation of Range of motion (ROM)

– Evaluate in flexion, abduction, internal rotation, and external rotation.

• Palpation• Provocative tests

• If the patient has a full active ROM, a passive ROM need not be assessed.

Physical exam

• Inspection• Look for side-to-side symmetry, atrophy,

scars, deformity, and swelling.– Supraspinatus or infraspinatus atrophy =

chronic rotator cuff tear– Large anterior bulge = anterior dislocation of

humeral head– Scars = previous surgery or trauma

Physical exam

• Palpation– Clavicular tenderness = fracture or dislocation– AC tenderness = AC joint osteoarthritis or chronic

sprain– Tender between lesser and greater trochanter =

biceps tendonitis – Subacromial tenderness = rotator cuff pathology– Multiple trigger points around shoulder = non-

shoulder pathology (e.g. fibromyalgia)

Physical exam

Observation of ROM• Forward flexion• Abduction• External rotation• Internal rotation

• Look for any limitation of motion or pain with motion.

Physical exam

Passive range of motionRestricted movement with passive ROM is indicative of adhesive capsulitis

Passive ROM is usually preserved in rotator cuff disorder.

Active range of motionLimitation or pain with active ROM is seen with either rotator cuff disorder or adhesive capsulitis.

Physical exam

• Provocative tests– Hawkins’ impingement – Drop-arm– Empty-can– Lift-off– External rotation/infraspinatus strength– Painful Arc of motion– Cross-body adduction– Apprehension– Relocation

Physical Exam – Provocative Tests

Testing for ImpingementHawkins’ testForward flex the arm to 90 degrees with the elbow bent to 90 degrees. The arm is then internally rotated. A positive test, noted by pain on internal rotation, may signify subacromial impingement including rotator cuff tendinopathy or tear.

Physical Exam – Provocative Tests

Rotator Cuff pathologyDrop-arm testThe arm is passively raised to 160 degrees. The patient is then asked to slowly lower the arm to the side. A positive test, noted by an inability to control the lowering phase and a dropping or giving way of the arm, may indicate a large rotator cuff tear.

Physical Exam – Provocative Tests

Rotator Cuff pathology Empty-can test Tests the supraspinatus. The arms are abducted to 90 degrees and forward flexed 30 degrees. With the thumbs turned downward, the patient actively resists a downward force applied by the examiner. A positive test is indicated by weakness compared with the contralateral side and may indicate rotator cuff pathology, including supraspinatus tendinopathy or tear.

Physical Exam – Provocative Tests

Rotator Cuff pathologyLift-off test Tests the subscapularis. With the arm internally rotated behind the patient's lower back, the patient internally rotates against the examiner's hand. A positive test is indicated by the inability to lift the hand off of the back and may indicate subscapularis tendinopathy or tear.

Physical Exam – Provocative Tests

Rotator Cuff pathologyExternal rotation testThe patient's arms are held at their sides with the elbows flexed to 90 degrees. The patient actively externally rotates against resistance. A positive test is indicated by weakness compared with the contralateral side and may be associated with infraspinatus or teres minor tendinopathy or tear.

Physical Exam – Provocative Tests

Rotator Cuff pathologyPainful arc of motionThe patient’s tested arm is held abducted and externally rotated at 60-100 degrees. At this angle of external rotation, the patient is asked to abduct against the examiner’s resistance. Positive finding is weakness and pain can be seen in rotator cuff tendinopathy, as well as in adhesive capsulitis and glenohumeral osteoarthritis.

Physical Exam – Provocative Tests

Acromioclavicular joint Cross-body adduction testThe arm is passively adducted across the patient's body toward the contralateral shoulder. Pain may indicate acromioclavicular joint pathology, including chronic sprain or osteoarthritis.

Physical Exam – Provocative Tests

Shoulder instability Apprehension & Relocation testsWith the patient supine, the patient's arm is abducted to 90 degrees and the elbow is flexed to 90 degrees. Pain and a sense of instability with further external rotation may indicate shoulder instability. Relief of these symptoms with a posteriorly directed force on the proximal humerus is a positive relocation test and further supports diagnosis of shoulder instability.

Imaging

• Plain radiographs• CT scans• MRI • Ultrasound

Imaging – Radiographs

• Common to use in helping diagnose massive rotator cuff tears, shoulder instability, and shoulder arthritis

• Standard series includes anteroposterior, scapular Y, and axillary views

• Can also diagnose calcific tendinitis

Imaging – CT

• Computed Tomography scan is used in such indications:-Bony disorders of the shoulder-Shoulder arthritis and erosion- Instability with significant bone loss of humeral head or the glenoid

-Tumors-Occult fractures

Imaging – MRI

• Common to use in diagnosing rotator cuff disorders (tendinopathy, partial tears, complete tears)

• For shoulder instability, magnetic resonance imaging arthrogram is preferred over MRI.

• Preferred test for diagnosing rotator cuff disorders assesses rotator cuff tendinopathy, partial tears, and complete tears.

Imaging – Ultrasound

• Also preferred for use in diagnosing rotator cuff disorders.

• Emerging as a cost-effective alternative to MRI• Better patient tolerance• Dynamic assessment • Improved resolution in the face of previous

surgery• Technician-dependent

Treatment

• Activity modification and analgesic medications comprise the initial treatment in most cases.

• If this does not lead to improvement or if the initial presentation is of sufficient severity then a trial of PT is done to focus on the specific diagnosis indicated. With this, combined steroid and local anesthetic injections can be used as an adjuvant; they can also be used as therapy alone without PT.

• Symptoms that persist or worsen after 6-12 weeks of directed treatment should be referred to an orthopedic specialist.

• In a recent Cochrane review: Due to the lack of well-designed clinical trials, there is little evidence for or against the most common treatments of chronic shoulder disorders.

Treatment

• Activity modification– Rotator cuff pathology and adhesive capsulitis

• Reduction or avoidance of overhead activity – Glenohumeral osteoarthritis

• Avoiding heavy lifting and loading of the shoulder– Unstable shoulder

• Avoiding overhead activities such as bench pressing, kayaking, overhand throwing

– Acromioclavicular osteoarthritis • Avoiding motions that mimic cross-body shoulder adduction, e.g.

golf swinging or weight lifting.

Treatment

• Medications– NSAIDs– Acetaminophen– Short-term opiate medication

• There is no conclusive support for the use of NSAIDs over simple analgesia in the treatment of chronic shoulder pain. Therefore, the risks and benefits of each class should be considered before use.

Treatment

• Physical therapy– Large range of treatments– Therapeutic modalities designed to alleviate pain

directly (heat & ice, U/S, hyperthermia)– Stretching exercises used to relieve pain– The type and focus of the PT depends on the

underlying etiology.

Treatment

Injections• Indicated for those with poor response to initial treatment.• Directed toward the affected area (subacromial space,

acromioclavicular joint, glenohumeral joint)• Patients with adhesive capsulitis have been shown to respond to

intra-articular injections with decreased pain and increased function, particularly in combination with physical therapy for stretching.

• Subacromial injections for rotator cuff disease is a treatment option currently supported by the American Academy of Orthopedic Surgeons (AAOS). Two systematic reviews found little evidence to support or refute the use of subacromial injection; two systematic reviews found it to be beneficial for rotator cuff tendinitis and shoulder pain; and another review suggested a possible small benefit.

Treatment

Surgical Referral• Although most chronic shoulder problems can be treated

conservatively with activity modification, oral medications, physical therapy, and possible corticosteroid injections, there are cases where surgical intervention is required.

• Patients may require referral if they do not respond to conservative measures despite adequate time with the appropriate treatment. Patients with continued instability or disabling pain that is not responsive to initial conservative measures may require earlier surgical referral.

• Surgical or specialty referral also should be considered when the diagnosis is unknown.

Key Recommendations for Practice• All patients should receive radiographs as part of the initial work-up for chronic

shoulder pain (C). • Further testing of chronic shoulder pain, using imaging* should be performed when

the diagnosis remains unclear or the outcome would change management (C).• If acromioclavicular osteoarthritis is suspected, the acromioclavicular joint should be

assessed for tenderness, and a cross-body adduction test should be performed to help confirm the diagnosis (C).

• When rotator cuff injury is suspected, asses for night pain and pain with overhead activity (C).

• When the patient has a painful shoulder with severely limited active and passive ranges of motion, a diagnosis of adhesive capsulitis should be considered (C).

– *imaging options include MRI, arthrography CT scan, and US– C evidence rating is consensus, disease-oriented evidence, usual practice, expert opinion, or

case series.

Key Recommendations for Practice• Most patients with chronic shoulder pain improve with non-operative treatment. Worse

outcomes are associated with severe pain, prolonged symptoms or gradual onset (B).

• There is little evidence for or against the use of medication for chronic shoulder pain (B).

• Physical therapy can provide improved short-term recovery and long-term function for rotator cuff disorders (B).

• Although subacromial corticosteroid injections for rotator cuff disorders are very common in clinical practice there is little evidence to support or refute its use (B).

• Glenohumeral joint injection has been shown to hasten the resolution of symptoms in patients with adhesive capsulitis, but most patients resolve without intervention and interventions have not been shown to improve long-term outcomes (B).

Rotator cuff disorders- Types: partial tear, complete tear, tendinitis, tendinosis, and calcific

tendinitis- History

- Pain with overhead activity and worse pain at night, especially when laying on the affected shoulder

- Common in patients older than 40 years of age- Pain in the lateral aspect of the arm with radiation no farther than the elbow

- Physical exam- weakness on empty can test- Weakness with external rotation resistance- Positive impingement sign

Provocative tests:- Drop-arm test- Empty-can test (supraspinatus) - Lift-off test (subscapularis) - External rotation test

Rotator cuff disorders

A prospective analysis of 400 patients found that the triad of weakness found with the empty-can supraspinatus and external rotation tests, along with a positive impingement test (e.g., Hawkins' impingement test), had a 98 percent probability of being a rotator cuff tear (partial or complete).

Patients older than 60 years who had two out of three findings also had a 98 percent probability of a rotator cuff tear.

Adhesive Capsulitis

Treatment• Long-term follow up studies found that it resolves spontaneously over one to two

years without intervention.• Treatment goal: decrease duration of symptoms• Activity modification• Anti-inflammatory or analgesic medication • PT for stretching done recommended at home• Six weeks of therapy with no improvement intra-articular steroid injection with

lidocaine; it has shown short-term benefit in decreasing pain and disability. Patient should reinitiate the stretching exercises one week after the injection.

• Surgery is rare but is warranted if there is no improvement after six months of non-operative treatment. It usually involves manipulation under anesthesia or arthroscopic capsular releases.

Adhesive Capsulitis

• History– Diffuse shoulder pain that is worse at night– Pain with active or passive movements– Gradual onset of pain and stiffness– Loss of motion in all planes w/ increased pain at the extremes

of motion– Hx of diabetes or thyroid disease

• Physical – Loss of active and passive ROM is the hallmark of adhesive

capsulitis, but this can also be seen in moderate to severe glenohumeral osteoarthritis.

Shoulder (Glenohumeral) Instability

• Disorders affecting the capsulolabral complex, including dislocation and subluxation.

• History– Hx of dislocation or subluxation, especially in those <40 years of age– Hx of collision or overhead sports– Complaints of a “dead arm”– Numbness over lateral deltoid

• Physical– Positive apprehension test– Positive relocation test

• Imaging: Radiographs– Dislocation– Inferior glenoid avulsion fracture

• Treatment– Activity modification and aggressive stretching program– Surgical referral

Glenohumeral osteoarthritis

• History– Gradual pain– Age over 50 years– Gradual loss of motion– History of arthritis– Previous shoulder surgeries

• Physical– Crepitus on palpation– Decreased active ROM, but passive ROM is preserved

• Imaging: three view shoulder radiograph• Treatment

– The goal is to maintain overall function with adequate pain control.– Initial attempts: anti-inflammatory and analgesic medications– PT may warrant and be helpful but should be undertaken w/ caution.

Acromioclavicular osteoarthritis• History

– Superiorly located shoulder pain– Hx of injury to joint (shoulder separation)– Heavy weight lifting

• Physical – Tenderness to palpation over AC joint– Pain w/ cross-body adduction test– Pain w/ extreme internal rotation– Pain w/ forward flexion

• Imaging (Radiographs)– Distal clavicular lysis or an elevated distal clavicle.

• Treatment– Pain control: NSAIDS (mild stages), steroid injection (severe stages)– Activity modification

DIAGNOSISFINDINGS CONSISTENT WITH DIAGNOSIS

FINDINGS INCONSISTENT WITH DIAGNOSIS IMAGING

Acromioclavicular joint osteoarthritis

Pain at acromioclavicular joint; positive cross-body adduction test; may have history of trauma

No pain with palpation at acromioclavicular joint; negative cross-body adduction

Radiography shows osteoarthritis at acromioclavicular joint, some evidence of acromioclavicular separation

Adhesive capsulitis Age older than 40 years; decreased active and passive range of motion; history of diabetes or thyroid disease

Full passive range of motion; no pain with movements

Radiography usually normal

Glenohumeral instability Age usually younger than 40 years; history of subluxation or dislocation, or generalized ligamentous laxity; positive apprehension test

Negative apprehension test Radiography usually normal

Glenohumeral osteoarthritis Age older than 50 years; progressive pain; crepitus with range of motion

Age younger than 50 years; normal radiography

Radiography shows narrowing of joint space, spurring, and osteophytes

Rotator cuff pathology Age usually older than 40 years; pain with overhead activity; night pain; weakness; positive Hawkins' impingement test; and rotator cuff weakness

No pain with overhead activities; no arm pain; no weakness with lift-off, external rotation, or empty-can tests

Radiography may show humeral head sclerosis or cyst, loss of acromial-humeral interval; acromial spur

Diagnosing Causes of Chronic Shoulder Pain

Hawkins exam Links

• https://www.youtube.com/watch?v=c6E51EAGnwM

• https://www.youtube.com/watch?v=R5fKMRHdggA

References

1. Chronic shoulder pain: Part I – Evaluation and diagnosis. Am Fam Physician. 2008 Feb 15;77(4):453-460.

2. Chronic shoulder pain: part II – treatment. Am Fam Physician. 2008 Feb 15;77(4):493-497

3. Weir, Jamie; Abrahams, Peter H.; Spratt, Jonathan D.; Salkowski, Lonie R (2010-03-02). Imaging Atlas of Human Anatomy. ISBN: 978-0-7234-3457-3

4. Physical Examination of the Shoulder in the Primary Care Setting. McShane, J. Prim Care Clin Office Pract 31 (2004) 783–788