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Shoulder Pain

Joseph Nowatzke

Background

  • Bones: Clavicle, Scapula (Acromion and Coracoid process) and Proximal Humerus  

  • Rotator Cuff: Supraspinatus, Infraspinatus, Teres minor, subscapularis

  • Neurovascular: anterior and posterior circumflex humeral arteries, branching off axillary artery; Innervated by axillary, suprascapular, subscapular nerve off brachial plexus  

  • Labrum is a cup-shaped rim of cartilage lining and reinforces the shoulder joint by surrounding the glenoid fossa, allowing extra support to the head of the humerus

Presentation

  • Brachial Plexus Palsies 

  • Vascular Pathology (e.g. thoracic outlet syndrome, thrombus, atherosclerosis, vasculitis) 

    • Typical symptoms are tightness, heaviness, cramping, or weakness in arm 

  • Rotator Cuff Injuries:  

    • Impingement Syndrome: supraspinatus is most susceptible

    • Tendinopathy: develops after repetitive motions; pain worsens with active movement

    • Tendon Tear: develop as a progression of tendinopathy; develops weakness

  • Labral Tear & SLAP (superior labral tear from anterior to posterior): develop in repetitive overhead motions (swimming, baseball, tennis); often described as a “catching” sensation 

  • Adhesive capsulitis: “frozen shoulder” stiffened glenohumeral joint, loss of both active and passive RoM. Increased frequency in diabetics 

  • AC (acromioclavicular) joint pain: joint often affected by OA, RA and common cause for anterior shoulder pain shoulder separations and osteoarthritis  

  • 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: 

    • Inspection: Symmetry, erythema, ecchymosis, swelling, deformity, muscle atrophy (deltoid, infraspinatus), scapular winging 

    • Palpation: warmth, landmarks, tenderness: SC joint, clavicle, AC joint, acromion, spine of scapula, bicipital groove, biceps tendon, greater tuberosity of humerus, common myofascial trigger points (trapezius, levator scapulae, rhomboids, supraspinatus) 

    • Passive ROM: performed by the examiner without patient assistance

      • Helps to distinguish motion limitations caused by a structural constraint (adhesive capsulitis) vs. motion limitations caused by pain 

    • Active ROM: performed by the pt on their own. Loss of active motion usually indicates weakness due to either muscular (tears) or nerve injury 

    • C-spine: evaluate the C-spine as the origin of pain that may be referred to the shoulder 

    • Provocation tests: see Below

  • Imaging:  

    • Not as useful as a thorough physical exam, especially if non-traumatic pain 

    • XR: 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

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 (similar to empty can) If pain subacromial impingement
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
Cross arm test AC joint Active abduction of arm across torso Pain 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

Management

  • Fractures: require assessment by orthopedics for reduction and surgical intervention

  • Soft Tissue Injuries, Arthritis 

    • Conservative management: referral 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 ortho 

    • Sports Medicine referral for surgical evaluation if pt fails conservative therapy