Skip to Main Content

++

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.

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.