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++

Probability diagnosis

++

Cervical spine dysfunction (referred pain)

++

Rotator cuff tendonopathy ± a tear

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Adhesive capsulitis (glenohumeral joint)

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Glenoid labral tears

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Bicipital tendonopathy

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Serious disorders not to be missed

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Cardiovascular:

++

  • angina

  • myocardial infarction

++

Neoplasia/cancer:

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  • 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)

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Polymyalgia rheumatica

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Cervical dysfunction

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Gout/pseudogout (uncommon)

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Osteoarthritis of acromioclavicular joint

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Winged scapula--muscular fatigue pain

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Masquerades checklist

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Depression

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Diabetes esp. adhesive capsulitis

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Drugs, e.g. steroids, anabolic steroids

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Thyroid disorder (rarely)

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Spinal dysfunction

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Is the patient trying to tell me something?

++

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

++

Key history

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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:

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  • stiffness and restriction

  • excessive movement/instability

  • weakness

  • rough versus smooth.

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Key examination

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  • 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

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Consider:

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  • 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

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  • 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.

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