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Shoulder Pain Etiology · 85% of shoulder pain is intrinsic to the shoulder; the remainder is referred usually from the neck · Acute symptoms following trauma is typically due to dislocation, fracture, or rotator cuff tear · Vary with age; <30 yo < 1% have complete rotator cuff tears; >45 y.o. Up to 35% of patients with shoulder pain will have complete tears Rotator cuff injuries · Impingement syndrome: symptoms which result in the compression of the rotator cuff tendons and the subacromial bursa between the greater tubercle of the humeral head and the lateral edge of the acromion process Repetitive overhead reaching, pushing, pulling and lifting with outstretched arms compression Impingement is the principle cause of rotator cuff tendonitis On exam: Overhead reaching causes pain on outer deltoid, atrophy of the muscles on top and back of the shoulder if longstanding · Tendonitis: inflammation of the supraspinatous (abduction) and infraspinatous (external rotation) tendons Pain with reaching, pushing, pulling, lifting, positioning the arm above the shoulder level or lying on the shoulder Pain on outside of the deltoid Common shoulder tendonitis has no loss of ROM (as in frozen shoulder), painful flexion (Biceps tendonitis), nor any persistent weakness (as in a rotator cuff tear); ***most common diagnosis of shoulder pain (70%) · Tendon tear: occur as the end result of chronic subacromial impingement, tendon degeneration, trauma or combination Primarily involve the supraspinatus On exam and by Hx: Shoulder weakness, localized pain over the upper back, a popping or catching sensation when the shoulder is moved, nighttime pain Acute injuries associated: falls on to outstretched arm, falls on to outer shoulder, vigorous pulling of the lawn mower cable and unusual pushing and pulling Small tears or parallel to the tendon pain with direct pressure, pain with active reaching, lifting pushing and pulling. Large tears weakness including inability to reach overhead or lift with arms outstretched or impairment with pushing of pulling Acromioclavicular injuries: second most common complaint occurs at the AC joint Joint is susceptible to arthritic changes and to trauma By Hx: anterior shoulder pain, deformity often localized to the AC joint Exam: pain with reaching across the chest, rotation and elevation Frozen Shoulder: stiffened glenohumeral joint Loss of ROM Most common cause is rotator cuff tendonitis; 10% of patients with this disorder will develop frozen shoulder; those with DM, low pain threshold and poor compliance with exercise therapy are at greatest risk Biceps Tendonditis/rupture: inflammation of the long head of the biceps as it passes through the grove of the anterior humerus Repetitive lifting is etiology By Hx.: anterior shoulder pain aggravated by lifting or overhead reaching and will often localized to biceps grove, pain with flexion o If severe worsening of symptoms and weakness occurs and a lump appears above the actecubital fossa tendon rupture

Subcapular bursitis: results from friction between the superior-medial angle of the scapula and the 2nd and third rib; repetitive to and fro motions (ironing, assembly worker) common By Hx.: localized pain over the upper back, popping with shrugging Glenohumeral osteoarthritis: wear and tear of the glenoid labrum and humeral head; uncommon, usually associated with trauma (may be distant) By Hx.: Gradual anterior shoulder pain Referred Pain: on exam: shoulder movement is normal and does not change pain Neural impingement of c-spine posterior pain Peripheral nerve entrapment distal to the spinal column of either the long thoracic or suprascapular nerves Diaphragmatic irritation, intrathoracic tumors and distension of the hepatic capsule ipsilateral shoulder pain MI left sided shoulder pain Exam (there are several approaches): The uninvolved shoulder is useful as a control Begin with a brief exam of the neck, scapula, shoulder, elbow and wrist Examine active ROM: 1. Elevate arm as much as possible (Nl:180 degrees); NFL touchdown maneuver shows active ROM and strength of abduction 2. With elbow at patient's side and forearm at 90 degrees anterior-posterior measure internal and external rotation (nl: 40 and 55 degrees respectively); further evaluation is achieved by having patient touch back 3. Adduction can be measured by patient touching opposite shoulder Passive ROM: ROM in abduction and external rotation Resisted Exam 1. Pt holds elbow at side with forearm at 90 degrees in anterior-posterior plane 2. Abduction is resisted at elbow 3. Adduction: resistance of inward motion 4. Flexion: forward motion at elbow 5. Extension: resisted backwards motions at the elbow 6. External rotation: Pt presses laterally and external rotates at the elbow agt resistance 7. Resistance to supination and flexion assesses the biceps tendon 8. Painful Arc maneuver (abducting the glenohumeral joint while preventing shoulder shrugging) assesses the subacromial impingement Drop arm test refers to the ability to smoothly lower arm after it is raised; a positive drop arm test is specific for rotator cuff tear (not sensitive) See chart for interpretation Imaging: · Plain films are indicated in the following situations: o Significant trauma o Suspected arthritis o Suspicion of neoplasm o Suspicion of osteonecrosis · MRI: expensive but useful at evaluating soft tissue injuries especially in the following situations o Suspicion of rotator cuff tear o Lack of response to physical therapy o Significant weakness on exam

Treatment: · Most patient with an acute injury will benefit from 2-3 days in a sling · Prolonged immobilization should be avoided as it can lead to frozen shoulder and contractures

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Pendular and wall climbing exercises as well as physical therapy can be useful in improving ROM NSAIDS Joint injections are useful for tendonitis and bursitis Special cases: o Rotator cuff tears: ortho should be consulted; small tears can be managed medically with physical therapy and NSAIDS; larger repairs usually require surgery o Biceps tendon rupture surgery o Frozen shoulder aggressive physical therapy and joint injection o Dislocations (95% are anterior) prompt reduction


Shoulder Pain

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