Shoulder pain

Probability diagnosis

Cervical spine dysfunction (referred pain)

Rotator cuff tendonopathy ± a tear

Adhesive capsulitis (glenohumeral joint)

Glenoid labral tears

Bicipital tendonopathy

Serious disorders not to be missed

Cardiovascular:

• angina

• myocardial infarction

Neoplasia/cancer:

• Pancoast tumour

• primary or secondary in humerus

Infection:

• septic arthritis (especially children)

• osteomyelitis

Axillary vein thrombosis

Rheumatoid arthritis

Intra-abdominal pathology, e.g. bleeding

Pitfalls (often missed)

Polymyalgia rheumatica

Cervical dysfunction

Gout/pseudogout (uncommon)

Osteoarthritis of acromioclavicular joint

Winged scapula--muscular fatigue pain

Masquerades checklist

Depression

Diabetes esp. adhesive capsulitis

Drugs, e.g. steroids, anabolic steroids

Thyroid disorder (rarely)

Spinal dysfunction

Is the patient trying to tell me something?

Shoulder is prone to (uncommonly) psychological fixation for secondary gains, depression and conversion reaction.

Key history

A careful history should generally indicate whether the neck or the shoulder (or both) is responsible for the patient’s pain. Enquire about features of movement:

• stiffness and restriction

• excessive movement/instability

• weakness

• rough versus smooth.

Key examination

• Examine the cervical spine then the affected shoulder

• Follow the protocol of inspection, palpation, movement, special tests for tendonopathies

• Look for impingement and a painful arc with adduction

• Undertake resisted movements for each tendon:

  • - adduction for supraspinatus

  • - internal rotation for subscapularis

  • - external rotation for infraspinatus

  • - elbow flexion for biceps

Key investigations

Consider:

• ESR (polymyalgia rheumatica)

• rheumatoid factor and anti-CCP

• ECG (if ischaemic heart disease suspected)

• imaging according to history and examination (e.g. high resolution ultrasound).

Diagnostic tips

• Consider dysfunction of the cervical spine, especially C4--5 and C5--6 levels, as a cause of shoulder pain.

• Modern ultrasound is the investigation of choice for painful disorders of the rotator cuff.

• An older person presenting with bilateral shoulder girdle pain has polymyalgia rheumatic until proved otherwise.