Shoulder Pain

Joseph Nowatzke and Devon Shannon

Presentation 

  • Brachial plexopathy: varied in presentation but usually some component of pain, weakness, or paresthesias
  • Brachial neuritis (Parsonage-Turner): sudden unilateral shoulder pain with subsequent weakness and/or muscle atrophy
  • Vascular pathology (e.g. thoracic outlet syndrome, thrombus, atherosclerosis, vasculitis): Typical symptoms include tightness, heaviness, cramping, or arm weakness with or without activity.
  • Rotator cuff injuries:
    • Impingement syndrome: pain with abduction and internal rotation; supraspinatus is most susceptible
    • Tendinopathy: develops after repetitive motions; pain worsens with active movement
    • Tendont tear: develops as a progression of tendinopathy; develops weakness and pain
  • Labral tear and SLAP (superior labral tear from anterior to posterior): develops in repetitive overhead motions (swimming, baseball, tennis); often described as a “catching” sensation
  • Adhesive capsulitis “frozen shoulder”: stiffened glenohumeral joint, diminished active and passive ROM; increased frequency in diabetics
  • AC (acromioclavicular) joint pain: usually secondary to trauma or fall on outstretched arm; anterior shoulder pain with AC tenderness; can develop OA
  • Glenohumeral OA: Degeneration of articular cartilage and subchondral bone with narrowing of the glenohumeral joint. Presents in older adults with progressively worsening anterior shoulder pain and stiffness in both passive and active ROM
  • Biceps tendinopathy: Localized anterior shoulder pain, worsened with overhead lifting. When rupture develops, will often have a “lump” and acute worsening of symptoms
  • Posterior shoulder pain often related to cervical radiculopathy

Evaluation 

  • Physical exam
    • IPASS. Be sure to palpate SC joint, AC joint, biceps groove, acromion, spine of scapula, greater tuberosity of humerus
    • C -pine: Evaluate C-spine as origin of pain that may be referred to the shoulder
    • Palpate common myofascial trigger points: trapezius, levator scapulae
  • Imaging:
    • Not as useful as a thorough physical exam, especially if non-traumatic pain
    • X-ray: AP (internal rotation, external rotation), lateral, scapular and axillary views
    • CT: Often reserved for traumatic fracture and artificial joint assessment
    • MRI w/out contrast: used to evaluate soft tissues, tendons, muscle and bursae
    • Ultrasound: becoming more useful for initial evaluation of rotator cuff and bicepts tendon

Test

Isolates

Action

Positive if
Empty Can Test Supraspinatus Place arms at 80⁰ abduction, 30⁰ forward flexion and pronate hand with thumbs down; exert downward force at elbows Pain = tendinopathy; Weakness + pain = tear
Neer sign Subacromial impingement Passively flex arm with hand pronated (simila r to empty can) Pain at subacromial region
Hawkins sign Subacromial impingement Flex arm to 90⁰, bend elbow to 90⁰, and internally rotate to 90⁰ Pain at subacromial region
External Rotation Infraspinatus, teres minor Arms at side, flex 90⁰ elbow, exert medial force to distal forearm Weakness, pain
Lag sign & Lift-Off test Subscapularis Place dorsum of hand on lumbar area of back and actively and passively move hand off of back Pain or failure to perform indicates subscapularis pathology
O’Briens SLAP tear Flex shoulder to 90⁰ with full elbow extension and adduct 15⁰. With shoulder IR (thumb down), apply downward pressure distally. With shoulder ER (palm up) apply same pressure Pain and clicking with shoulder IR but not with ER
Cross arm test AC joint Active abduction of arm across torso Pain à AC joint dysfunction
Speed’s Test Biceps tendon Have pt extend arm in full supination with the shoulder flexed. Ask pt to elevate arm while applying downward force Pain in the anterior shoulder; Biceps tendon pathology
Yergason test Biceps tendon Elbow at 90⁰ and resist supination Pain in anterior shoulder
Apprehension test GHJ With pt supine, place arm in 90⁰ shoulder abduction, elbow flexion and ER Feeling of instability anteriorly. Will not all full ER

Management 

  • Fractures: require assessment by Orthopedics for reduction and surgical intervention
  • Brachial plexopathy: Send for EMG, evaluation by PM&R
  • Tendon/ligament injuries, arthritis
    • Conservative management: Refer to PT for muscle strengthening, flexibility, and postural improvement
    • Consider short course of NSAIDs, 7-10 days (meloxicam, diclofenac) for pain relief
    • Injections can often be diagnostic and therapeutic – refer to PM&R or Orthopedics
    • Refer to Orthopedics for interventional/surgical evaluation if pt fails conservative therapy
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