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Shoulder pain

Shoulder pain is very common with an annual population prevalence of up to 46.7 % and lifetime prevalence of up to 66.7 % It is the 3rd most common cause of musculoskeletal condition in primary care and about 1 % of all adults consult a GP with new shoulder pain annually Four shoulder conditions account for most cases of shoulder pain and disability in primary care
○ rotator cuff disorders 
○ glenohumeral disorders
○ acromioclavicular joint disease
○ referred neck pain Study in Southern Australia has shown that shoulder symptoms are common affecting 22 % of adults UK data shows that the prevalence increases linearly with age – peaks around 50 yrs then remains static at around 2 % A 3 year f/u study in UK revealed that
○ 22.4 % were referred to secondary care
○30.8 % were issued NSAIDs
○ 10 % received injections

 

High societal costs and patient burden Impaired QoL , increased psychological distress and reduced capacity to work and maintain employment It is estimated that in the year 200 the directs costs for the treatment of shoulder dysfunction in the US totaled $ 7 billions Shoulder complaints may have an unfavorable outcome with only about 50 % of all new episodes showing a complete recovery in 6 months and this proportion increases to 60 % after 1 year This impacts the elderly more persistently and in them most types of shoulder disorders still cause problem 3 yrs after the 1st presentation

 

Exclude referred pain Enquire about 
○ onset , character , duration , trauma
○ site of maximal pain
○ relationship to movement , rest , night pain
○ additional symptoms Functional impairment Systemic features Previous MSK problems elsewhere Sig comorbidity Occupation

 

Examine both shoulders Inspect the skin and soft tissue contours Ask to place the palms of their hands at the base of the neck with elbows pointing laterally 
then to put arms down and try to put the back of the hands between shoulder blades Inspect front , side and behind for muscle wasting , swelling and deformity , bruising Palpate the shoulder bones
♦ clavicle ♦ proximal humerus ♦ scapula and joints
♦ sternoclavicular
♦ acromioclavicular
♦ glenohumeral Check active and passive range of movements check strength in all directions Look for painful arc ( between 7–120 degrees of active abduction) ○ if present suspect impingement and proceed to Hawkins test Cervical spine Special shoulder tests ( more than 180 physical examination tests of the shoulder have been described ) can be used to affirm an expected diagnosis in a differential manner after conclusion of all other portions of the examination has been completed ( the diagnostic utility of these tests is doubtful )

 

Tumour 
○ previous h/o cancer ♦ symptoms and signs suggestive of cancer 
♦ unexplained deformity ♦ mass or swelling ♦ lymphadenopathy Red skin , fever , systemically unwell ? infection ( septic arthritis is rare in shoulder < 0.1 % ) Unreduced dislocation ♦ trauma ♦ epileptic fit
♦ electric shock ♦ loss of rotation ♦ abnormal shape Acute rotator cuff tear
♦ recent trauma ♦ acute disabling pain and sig weakness ♦ + ve drop arm test →inability to hold affected arm in 90 degrees of abduction then lower it slowly to side Neurological lesion – unexplained wasting , sig sensory or motor deficit Inflammatory arthropathy Visceral disease – shoulder pain can be caused by any condition that irritates the mediastinal pleura , pericardium or diaphragm ( e.g acute MI )

 

Most common source of shoulder problems Often presents age 35-37 yrs Significant overlap of presenting symptoms and signs Midrange ( about 90° ) catching sensation / arc of pain with active elevation They can occur in athletes , workers with repetitive overhead activities and elderly

 

Impingement Subacromial/ Infraspinatus bursitis Tendinopathy Painful arc syndrome Tears ( Partial , full thickness and massive ) Long head of biceps tendinosis or rupture Calcific tendinitis

 

Impingement Subacromial bursitis Calcific tendinitis Biceps tendinitis Cuff degeneration Supraspinatus or rotator cuff tendinopathy Partial rotator cuff tear

Tendons of rotator cuff and the subacromial bursa become irritated and painful

Most common cause of shoulder pain in primary
 care ( up to 70 % )

Lateral shoulder pain localised to acromion – gets worse by lifting arm (eg lifting heavy kettle or overhead movements )
Can be associated with night pain

 

Age 45-65 yrs Women affected slightly ↑ than men ↑ in diabetics , often ↑ in non dominant arm Global ROM reduction X ray normal Reduced external rotation Night pain can radiate below elbow Cannot sleep lying on affected side Pain intense and constant (especially initial stages ) Inflammatory fibrosing process →affects articular capsule and causes it to contract over the jt ↓ mobility Painful inflammatory phase →gradual development of diffuse , severe pain , ↑ at night , inability to lie on affected side ( 2-9 months ) Stiff Phase → less severe pain at the end of ROM , global stiffness and severe loss of shoulder movement ( 4-12 months ) Recovery → gradual return of movement over

 

Secondary to from wear and tear of articular cartilage of glenoid , labrum and humeral head Less common than in hip ( non weight bearing jt ) Usually clear predisposing factor 
( eg previous injury / dis , avascular necrosis of humeral
head or age ) Pain in shoulder and down the arm More joints usually involved

 

Younger Contact sports Injury → fall on shoulder Localised pain → over AC jt and tenderness Cross chest test painful

 

Tenderness directly over the joint Pain ↑ with adduction overhead activity AC joint OA may also cause subacromial impingement steroid injection frequently helpful

 

Age < 40 yrs History of dislocation / subluxation Excessive glenohumeral accessory motions in multiple directions Overhead work/ sports Vague pain referred to deltoid Catching pain on activity Dead arm after repeated motion + ve apprehension ↑ ed laxity and pain on testing

 

Cervical spine disorders Myocardial ischaemia Nerve disorders
N root irritation
Compression/ entrapment
Brachial plexus injury
Neuralgic amyotrophic
 Inflammatory disorders
Rh arthritis
PMR Fibromyalgia Basal pleurisy Cholecystitis ( referred pain rt shoulder ) Subphrenic abscess Complex regional pain syndrome Myofascial pain syndrome Visceral disorders Malignancy ( Apical lung cancers Pancoast , Malignancy )

References

  1. Ackerman, Ilana N et al. “Exploring the personal burden of shoulder pain among younger people in Australia: protocol for a multicentre cohort study.” BMJ open vol. 8,7 e021859. 19 Jul. 2018, doi:10.1136/bmjopen-2018-021859 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6059320/
  2. L. Linsell, J. Dawson, K. Zondervan, P. Rose, T. Randall, R. Fitzpatrick, A. Carr, Prevalence and incidence of adults consulting for shoulder conditions in UK primary care; patterns of diagnosis and referral, Rheumatology, Volume 45, Issue 2, February 2006, Pages 215–221, https://doi.org/10.1093/rheumatology/kei139
  3. Shoulder pain Scott Masters , Simon Burley https://www.racgp.org.au/afpbackissues/2007/200706/200706masters.pdf
  4. Meislin RJ, Sperling JW, Stitik TP. Persistent shoulder pain: epidemiology, pathophysiology, and diagnosis. American Journal of Orthopedics (Belle Mead, N.J.). 2005 Dec;34(12 Suppl):5-9 ( Abstract )
  5. Mitchell, Caroline et al. “Shoulder pain: diagnosis and management in primary care.” BMJ (Clinical research ed.) vol. 331,7525 (2005): 1124-8. doi:10.1136/bmj.331.7525.1124 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1283277/
  6. When moving hurts Global year against musculoskeletal pain October 2009-10 via https://s3.amazonaws.com/rdcms-iasp/files/production/public/Content/ContentFolders/GlobalYearAgainstPain2/MusculoskeletalPainFactSheets/ShoulderPain_Final.pdf
  7. Artus Mvan der Windt DAAfolabi EK, et al
    Management of shoulder pain by UK general practitioners (GPs): a national survey
  8. Biederwolf, Nicklaus E. “A proposed evidence-based shoulder special testing examination algorithm: clinical utility based on a systematic review of the literature.” International journal of sports physical therapy vol. 8,4 (2013): 427-40.
  9. Gismervik, Sigmund Ø et al. “Physical examination tests of the shoulder: a systematic review and meta-analysis of diagnostic test performance.” BMC musculoskeletal disorders vol. 18,1 41. 25 Jan. 2017, doi:10.1186/s12891-017-1400-0
  10. CKS NHS Shoulder pain accessed via http://cks.nice.org.uk/shoulder-pain
  11. The painful shoulder : an update on assessment , treatment and referral Br J Gen Pract 2014 ;64 ( 626 ) : e595
  12. Shoulder pain- Arthritis research
  13. The Painful Shoulder : Part 1. Clinical Evaluation Am Fam Physician . 2000 May 15;61 (10 ) : 3079-3088
  14. Shoulder problems in general practice . Reports on the Rheumatic Diseases Series 4 Arthritis Research Campaign 2005
  15. Assessment of shoulder pain for non-specialists BMJ 2016 ; 355:i5783
  16. Subacromial shoulder pain BESS/BOA
  17. Patient Care Pathway Rohit Kulkarni et al Shoulder & Elbow 0(0) 1-9 2015

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