Shoulder Pain

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Author / Curator: Christopher Steele, MD MPH MS

Faculty Advisor:

GUIDELINES:
The format of each page are recommended guidelines. They should be fluid as each topic will have a unique flow.

(1) Be concise.

(2) Be evidence-based. (Everything should have a reputable citation and resource)

(3) Be clinically relevant. (Avoid unnecessary discussion of pathophysiology and epidemiology if it does not help clinical decision-making).


Learning Objectives

  • Understand the anatomy that makes up the shoulder.
  • Develop an organized approach to forming a differential on shoulder pain.
  • Become familiar with the shoulder exam, including specialized maneuvers.
  • Understand how to manage common shoulder pathology, including when to refer to a specialist.
  • Know when it is appropriate to order imaging for the shoulder.

Top Teaching Points

  • Shoulder pain is present in nearly 16% of all people, making it the 3rd most common musculoskeletal concern seen in primary care and about 1% of all visits. [1]
  • The shoulder is the only joint in the body where the tendons (rotator cuff) pass along a moving joint making it more likely to be injured.[2]
  • Shoulder pain is chronic once a patient has pain lasting over 6 months.[3]
  • Despite localizing shoulder pathology, most shoulder pain is treated similarly with conservative therapy such as ice, rest, physical therapy, strength training, sling or NSAIDs and/or Tylenol.[4]
  • Steroid injections have been shown to be superior to NSAIDs for rotator cuff tendinopathy for a 9 month period. Physical therapy and exercise is shown to be superior than no activity.[5] [6]
  • Refer to an orthopedic surgeon if conservative therapy fails after 3 months, it is felt that surgical treatment is needed such as a rotator cuff tear and or if a practitioner does not feel comfortable with steroid injections.[4]
Basic anatomy of tendons and muscles of shoulder

Background

Shoulder pain is present in nearly 16% of all people, making it the 3rd most common musculoskeletal concern seen in primary care and about 1% of all visits.[1] Like any joint, a thorough understanding of the anatomy is crucial to diagnose shoulder pain properly.

Anatomy

Basic anatomy of the shoulder
The shoulder is one of the most complex joints in the body. It is the only joint where the tendons (rotator cuff) pass along a moving joint making it more likely to be injured.[2] This is a joint that is best understood by breaking it apart layer by layer. First we will discuss the 3 joints of the shoulder then build up anatomically from the joint to more externally. The two images to your right should be used to better illustrate these points.

There are actually 3 joints that make up the shoulder, they are the glenohumeral (GH), acromioclavicular (AC), and sternoclavicular (SC) joints.[7] For now, we will focus on the GH joint. The GH joint is a ball and socket joint composed of four bones which are the humeral head, glenoid of the scapula, acromion and clavicle.[7] Of those two bones, the glenoid and humeral head are the two that come in contact to form the ball and socket joint. Tissue surrounds where the humeral head and glenoid meet called a capsule. The glenoid itself has a structure called the labrum which can be thought of fibrocartilage that helps give depth to the socket joint.[7]

Surrounding the GH joint are 4 tendons known as the rotator cuff. The four tendons are the supraspinatus, infraspinatus, teres minor and subscapularis. The acronym SITS is frequently used to remember the tendons that help stabilize the humeral head to the glenoid.[8] These tendons can be as mild as a tendinopathy (irritation without tear) to partial and complete tears. To complicate things further, the two tendon heads of the bicep also attach in this area, with the long head attaching to the glenoid fossa and the short head attaching to the scapula. Biceps tendinitis is a frequent cause of shoulder pain as discussed below. The most superior component of the shoulder is the deltoid. Anteriorly, the deltoid muscle has three heads labeled by anatomical positioned called the anterior, medial and posterior heads of the deltoid. Other muscles aid in shoulder movement such as the pectoralis, triceps, trapezius and latissimus dorsi muscles. [7]

Another common concern is AC joint which itself can be a form of discomfort in the shoulder, just under the ac joint lies the most effected bursa known as the sub-acromial bursa which provides cushioning between the acromion and rotator cuff. Both the AC and GH joints are also effected by osteoarthritis. Finally, another major cause of shoulder pain is referred pain from either the cervical spine or other organs such as the heart or pancreas.

Diagnosis

Differential Diagnosis

For practitioners, the best way to form a differential diagnosis is from a modified Cyriax Approach where we will use the basic anatomy to localize pathology.[2] Although not perfect, there are other forms of shoulder pain that do not neatly fit into this category such as dislocations and referred pain which will also be discussed.

Although there are many exams for the shoulder, many of these tests if positive may signify pathology for multiple joints as summarized in the table below.The following table summarizes the pathology that can result in shoulder pain by anatomical consideration when appropriate.

Differential diagnosis of shoulder pain based on anatomical position when appropriate[1] [2] [3] [4]
Diagnosis Typical Presentation Physical Exam Findings
GH Joint Pathology Adhesive Capsulitis Typically seen other comorbid conditions such as diabetes, cardiovascular and thyroid disease, with worse symptoms at night with normal x-rays.[9] [10] Decreased range of passive and active motion on exam.
Labrum Tear

"SLAP"

Superior labrum anterior and posterior[11]

Pain with overhead movement. Shoulder itself is not usually painful unless patient is raising their hand above their head. May report a clicking sensation. [12] Clicking sensation when arm raised above head

Speed's Test

Anterior Apprehension Test

O'Brien's Test

Yergason's Sign[13]

Osteoarthritis Variable Apley Scratch Test

The three most specific findings for OA are palpated bony enlargements, genu varum and stiffness lasting less than 30 minutes.[2]

Rotator Cuff pathology Generalized rotator cuff tear + tendiopathy Usually a pain localized to the rotator cuff region that feels like a muscle-like ache. Tears varry upon location of the tear but usually severe pain.[14] Apley Scratch Test

Drop arm test

Supraspinatus tear or tendonopathy Tenderness over the greater tuberosity and the anterior shoulder.[15] Empty Can Test
Infraspinatus tear or tendonopathy Usually non-specific Resistance with external rotation (can also diagnose teres minor tears)
Biceps Biceps tendonitis Patient reports anterior shoulder pain brought on by holding or lifting things (e.g. mother with new born) Yergason Sign*

Speed's Test[16] Pain on palpation of the biceps groove.[17]

Impingement Subacromial pain syndrome (SAPS) Patients are usually over 40 a clear history for cause. With the arm raised parallel to the floor, patients report a painful sensation with arm elevation or depression of a 30 degree angle from that position.[18] Neer Sign

Hawkin's Sign

Painful Arc Test

Bursa Subacromial bursitis Pain in the anterior to lateral region after one traumatic event. More common after 30 in females.[19] Speed's Test
AC Joint Pathology AC Joint Pain Tenderness across the AC joint, usually no clear story and may manifest as neck or shoulder pain.[20] Cross Arm Test
Referred Pain Cervical Disease Pain, numbness or tingling that shoots down ones arm with certain neck positions. Spurling Sign
Conditions such as pancreatitis, heart attacks, pancreatitis Variable Varied
Dislocation[21] Anterior Dislocation Most common of the two, usually from hyperlax joints. Arm is usually abducted and externally rotated.
Posterior Dislocation Classically, patient experienced an anterior blow to the shoulder caused by a seizure or a fall with an outstretched arm. Arm is usually adducted and internally rotated. [22]
Systemic Disease Polymyalgia Rheumatica, fibromyalgia Variable Varied

*Signifies the superior test to diagnose that condition.

** Bolded terms are the tests we recommend primary care providers be familiar at performing.

Physical Exam

The physical exam for the shoulder is similar to any other joint. First, the practitioner should inspect and palpate both shoulders. Next, the practitioner should assess for range of motion. Finally, the practitioner should do specialized physical exam techniques to localize the pathology of the shoulder further.

Inspection[3]

  • Start by examining symmetry of both shoulder looking for difference and atrophy.
  • Examine the c-spine, and both arms up to at least the elbow, bilaterally.

Palpation[3]

  • Palpate the three joints of the AC, GH and SC joints.
  • Palpate the c-spine.
  • Palpate the medial and lateral epicondyle of the elbows, bilaterally.

Range of Motion[3]

  • Test the Range of motion of the neck, shoulder and elbow first with passive then active motion in all directions.
  • Apley Scratch Test - Helps determine range of motion.
  • Passive: With the unaffected knee, first bend and extend the knee. Repeat the same with the affected knee.
  • Active: After passive motion is tested, have the patient bend and extend their knee joint with both legs.

Specialized Physical Exam Maneuvers

Unlike the knee exam, the exams of the shoulder are less specific and frequently need multiple exams to rule in/out pathology.

This section will highlight common exam techniques a practitioner should know to diagnose different knee pathology. The following videos are posted with permission from Eric Sorenson, the original creator and from Physiopedia and the University of Michigan Family Medicine Residency Program from a Creative Commons Attribution . Please Eric's YouTube channel for more in depth videos on joint exams: https://m.youtube.com/channel/UCiTSxBvnGI8LmsGkFRKDcGg

The 4 specialized physical exams a practitioner should know

It is overwhelming to know all the exams for the shoulder. Practitioners should first start out knowing 4 exams very well and expanding their differential depending on findings.

1) Empty Can Test

Tests for supraspinatus tears or tendinopathy

Technique: With arm raised parallel to the floor, have the patient rotate their hand with their thumb pointing towards the ground. The practitioner then places their hands on the patients wrists and applies pressure downward.

Positive: Pain on palpation.

This test is the superior test to look at supraspinatus tears, the most common tendon to be torn in rotator cuff.

2) Hawkin's Sign

Test for sub-acromial impingement.

Technique: The patient flexes their arm in the shape of a hawk's wing parallel to the floor (arm bent 90 degrees). The practitioner then applies pressure upwards on the elbow while downwards on the wrist.

Positive: Pain with movement.

3) Neer's Test

Test for subacromial impingement.

Technique: First, have the patient pronated. Then the practitioner should raise their arm in front of them until their hand is reaching for the sky.

Positive: If cannot perform due to pain.

4) O'Brien's Test

This test is good for SLAP or labrum pathology/tears.

Technique: While sitting, the patient raises their arm parallel to the floor and angles their arm towards opposite knee. The patient will pronate their arm similar to the empty can test. The practitioner will apply pressure and ask the patient to make an external rotation motion. Next, the patient will supinate their arm and the practitioner will again apply pressure.

Positive: If a click is heard during pronation and not heard during supination.

The other tests below are exams that are recommended to further help differentiate shoulder pathology further arranged by alphabetical order.

Apley Scratch Test

This test is good to test range of motion of the joint and helps rule in pathology such as osteoarthritis and generalized rotator cuff pathology.

Apprehension Test

Test for overall stability of the GH joint.

Cross Arm Test

This is a good test for AC joint pathology.

Painful Arc Syndrome

This is a good test for subacromial impingement pathology.

Resistance Against External Rotation

Can diagnose infraspinatus tears.

Speed's Test

This test can be used to diagnose bicep tendinitis, subacromial bursitis or labrum tears.

Spurling's Test

Best test to rule out cervical disease.

Yergason's Test

This test is the superior test to rule out bicep tears.

Management

Diagnostic Imaging

  • Routine imaging should not be ordered unless the patient meets criteria listed below.
  • X-ray is usually the initial screening modality for shoulder pain and can rule in things like fractures, dislocations and osteoarthritis. [23]
  • MRI is the imaging modality of choice to evaluate the shoulder, however, should only be reserved in the acute setting for acute fractures or rotator cuff tears. If the pathology is less severe (e.g. rotator cuff tendinopathy) then the practitioner can wait around 3 months after failure of conservative therapy.[23]

Medication and Therapies

  • Despite localizing shoulder pathology, most shoulder pain is treated similarly with conservative therapy such as ice, rest, physical therapy, strength training, sling or NSAIDs and/or Tylenol.[4]
  • Physical therapy is shown to be superior to those who do not exercise and should be offered to patients. NSAIDs and steroid injections are superior to placebo.[5]
  • Steroid injections in a 7 study meta-analysis is shown to be superior to NSAID therapy for rotator cuff tendinopathy for a 9 month period.[6]
  • Refer to an orthopedic surgeon if conservative therapy fails after 3 months, it is felt that surgical treatment is needed such as a rotator cuff tear and or if a practitioner does not feel comfortable with steroid injections.[4]

Trial Summaries

.Additions pending

Ongoing controversies / New updates

Additions pending

Teaching Resources

References

  1. 1.0 1.1 1.2 Mitchell C et al. Shoulder pain: diagnosis and management in primary care. BMJ. 2005 Nov 12; 331(7525): 1124–1128.
  2. 2.0 2.1 2.2 2.3 2.4 McGee, S. Chapter 57: Examination of the musculoskeletal exam. Evidence-Based Physical Diagnosis. 4th ed. Elsevier; Philadelphia, PA: 2018.
  3. 3.0 3.1 3.2 3.3 3.4 Burbank KM et al. Chronic Shoulder Pain: Part I. Evaluation and Diagnosis. Am Fam Physician. 2008 Feb 15;77(4):453-460.
  4. 4.0 4.1 4.2 4.3 4.4 Burbank KM et al. Chronic Shoulder Pain: Part II. Treatment. Am Fam Physician. 2008 Feb 15;77(4):493-497.
  5. 5.0 5.1 Steuri R et al. Effectiveness of conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: a systematic review and meta-analysis of RCTs.Br J Sports Med. 2017 Sep;51(18):1340-1347.
  6. 6.0 6.1 Arroll et al. Corticosteroid injections for painful shoulder: a meta-analysis. Br J Gen Pract. 2005 Mar 1; 55(512): 224–228. 
  7. 7.0 7.1 7.2 7.3 Kent BE. Functional anatomy of the shoulder complex. A review. Phys Ther. 1971 Aug;51(8):947.
  8. N. Yamamoto, A review of biomechanics of the shoulder and biomechanical concepts of rotator cuff repair. Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology. Volume 2, Issue 1, January 2015, Pages 27–30.
  9. D’Orsi GM et al. Treatment of adhesive capsulitis: a review. Muscles Ligaments Tendons J. 2012 Apr-Jun; 2(2): 70–78.
  10. Tighe CB, Oakley WS Jr. The prevalence of a diabetic condition and adhesive capsulitis of the shoulder. South Med J. 2008 Jun;101(6):591-5.
  11. ANDREWS JR et al., Glenoid labrum tears related to the long head of biceps. Am J Sports Med., 1985;13:337–341
  12. WILK K.E. et al, The recognition and treatment of superior labral (SLAP) lesions in the overhead athlete. Int. J. Sports Phys. Ther., 2013; 8(5): 579-600
  13. Physiopedia SLAP lesions. Accessed on 4 March 2018:https://www.physio-pedia.com/SLAP_Lesion#cite_note-2
  14. Physiopedia Rotator Cuff Tendiopathy. Accessed on March 4 2018:https://www.physio-pedia.com/Rotator_Cuff_Tendinopathy
  15. Physiopedia Rotator Cuff Tears. Accessed on 4 March 2018:https://www.physio-pedia.com/Rotator_Cuff_Tears
  16. Holtby, R., Razmjou, H. (2004). Accuracy of the Speed's and Yergason's test in detecting bicpes pathology and SLAP lesions: comparison with arthroscopic findings. Arthroscopy: The Journal of Arthroscopic and Related Surgery, 20(3), 231-236.
  17. Athrens PM et al. The long head of biceps and associated tendinopathy; The journal of bone and joint surgery. 2007;89:1001-9.
  18. Physiopedia Subarcomial Pain Syndrome. Accessed on 4 March 2018. https://www.physio-pedia.com/Subacromial_Pain_Syndrome#cite_note-:1-16
  19. Physiopedia Shoulder Bursitis. Accessed on 4 March 2018. https://www.physio-pedia.com/Shoulder_Bursitis
  20. https://www.physio-pedia.com/Acromioclavicular_Joint_Disorders
  21. Physiopedia Shoulder Dislocations. Accessed on 4 March 2018:https://www.physio-pedia.com/Shoulder_Dislocation
  22. Life in the fast lane on Posterior Shoulder Dislocations. Accessed on 4 March 2018. https://lifeinthefastlane.com/posterior-shoulder-dislocation/
  23. 23.0 23.1 Wise JN et al. ACR appropriateness criteria on acute shoulder pain. J Am Coll Radiol 2011;8:602-609.
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Contributors

Alexey, Christopher Steele