Approach to shoulder pain: Clinical sciences

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Introduction 0:00–0:34

Shoulder pain is a common symptom with many underlying causes including conditions affecting the joint capsule, tendons or bursa.
Its important to first identify if your patients shoulder pain is due to trauma or infection. Other possible types of shoulder pain include neuropathic pain from nerve damage and nociceptive pain.
From arthralgia, capsulitis, tendinopathy, and bursitis. When a patient presents with shoulder pain, first obtain a focused history and physical examination history reveals shoulder pain.

Focused H&P 0:34–0:56

While the exam might demonstrate edema erythema or warmth over the joints, they may also have shoulder tenderness, effusion, limited joint range of motion, crepitus or even an obvious joint deformity.
Your next step is to assess for trauma. This includes an obvious mechanism of injury such as a motor vehicle crash or sports injury, a joint deformity or ligamentous laxity.

Trauma0:56–2:26

If trauma is present, think fracture dislocation or separation or a tendon rupture or labral tear. Now, if your patient reports an inability to lift their arm above their head and possibly a popping sensation.
And if the physical exam reveals painful, limited range of motion and possibly decreased sensation, decreased muscle strength or diminished pulses.
Consider a fracture dislocation or ac joint separation and order a shoulder X ray. If the X ray results confirm a bone fracture, joint dislocation or ac joint separation, diagnose a shoulder fracture dislocation or separation.
Here's a clinical pearl, shoulder separation is actually not an injury to the shoulder joint itself. Instead, it occurs in the setting of trauma to the ligaments of the acromioclavicular joint known as the ac joint, which is where the clavicle and the scapula meet the coracoclavicular or cc joint also connects the scapula to the clavicle.
This type of injury can occur when a patient falls directly on their shoulder. Injuries range from partial tearing of the ac ligaments with the surrounding bones in place to complete ac and C tears with bony displacement.
Next up is tendon rupture or labral tear. These patients will report increased pain with overhead activity.

Tendon Rupture/Labral Tear 2:26–3:37

They might also note their pain is exacerbated when theyre lying on the affected side, but that it improves with rest or when pressure on the shoulder is relieved.
They may even hear a clicking sound with certain movements. Examination will reveal a painful, limited range of motion of the shoulder and possible tenderness to palpation.
Other findings may include a positive drop arm test, meaning they experience pain as they lower their arm from a fully abducted position to an abducted position.
A positive external rotation lag sign where they're unable to maintain a position of maximal lateral rotation or a positive o'brien test, meaning they experience pain with internal rotation, the drop arm and external rotation, lag sign help diagnose rotator cuff tears.
And the obrien test will help determine if your patient has a labrum tear. With these findings consider tendon rupture or labral tear and obtain an MRI of the shoulder.
If imaging shows a defect of the tendon or labrum, diagnose tendon rupture or labral tear. Now, if trauma is not present, assess for signs of infection like fever, chills, myalgias and localized tenderness.

Trauma Not Present 3:37–3:50

If there are signs of infection, think septic arthritis and osteomyelitis. First up is septic arthritis.
Your patient will report a painful swollen joint and they might have a history of immunosuppression such as diabetes or HIV.

Septic Arthritis 3:50–4:33

Examination will reveal joint effusion, limited range of motion and erythema with warmth of the overlying skin. Based on these findings consider septic arthritis and aspirate synovial fluid for analysis of cell count and differential gram stain culture and the presence of crystals.
If the synovial fluid has a purulent appearance, a white blood cell count of 50,000 or more gram stain and culture are positive for bacteria and negative for crystals.
Diagnose septic arthritis. Next up is osteomyelitis.

Osteomyelitis 4:33–5:33

Patients might report recent shoulder surgery or may have a history of immunosuppression. Examination often reveals tenderness to palpation over bone as well as erythema and edema of the overlying skin.
You might even not a draining sinus tract on the skin as well. Based on these findings consider osteomyelitis of the shoulder and order labs including blood cultures, CBC and inflammatory markers like ESR and CRP.
Also order imaging including an X ray and an MRI of the shoulder. If labs reveal positive blood cultures often with leukocytosis and elevated ESR and CRP.
And if the X ray shows overlying soft tissue swelling with cortical bone destruction and an underlying lucent bony lesion.
And the MRI typically reveals bone marrow edema and overlying periosteal and subcutaneous edema, diagnose osteomyelitis.
On the other hand, if there are no signs of infection, assess for neuropathic pain. This type of pain is lancinating electrical radiating, burning or cold.

Neuropathic shoulder pain 5:33–6:56

In nature with neuropathic pain, the patient might report a history of numbness and tingling in their arms, muscle weakness or neck pain.
Examination may reveal decreased upper extremity, dermatomal sensation, decreased upper extremity, muscle strength, diminished upper extremity, deep tendon reflexes or decreased range of motion of the neck or shoulder.
Based on these findings consider cervical radiculopathy and order an MRI of the cervical spine. If imaging shows nerve root impingement, diagnose cervical radiculopathy.
Here is a clinical pearl to keep in mind. Cervical radiculopathy occurs from nerve impingement due to conditions like cervical degenerative disc disease, herniated discs and foraminal stenosis, cervical nerve four controls upper shoulder motion and provides sensation to parts of the neck, shoulders and upper arms.
And cervical nerve five controls the deltoid muscles of the shoulders if a nerve root becomes compressed at either of these levels in the neck it will cause pain to radiate along the path of the nerve into the shoulder.
Additionally, there might be muscle weakness and sensory disturbances. Ok.
If neuropathic shoulder pain is not present, assess for nociceptive shoulder pain. This type of shoulder pain is localized, dull or sharp, it does not radiate has an identifiable pain source and usually involves joints, capsules, tendons or soft tissues.

Nociceptive shoulder pain6:56–7:19

If this is the case, assess the primary tissue involvement to determine the source of the pain. First, let's discuss arthralgia.

Arthralgia7:19–8:10

These patients may have a history of joint stiffness, fatigue or malaise examination may show joint erythema edema and warmth with possible joint deformity, limited range of motion or crepitus.
If this is the case diagnose arthralgia. Here's another clinical pearl to keep in mind.
Common examples of shoulder arthralgia include osteoarthritis and rheumatoid arthritis, osteoarthritis is a degenerative disease of the joints characterized by mechanical wear and tear injury to articular cartilage resulting in bony and synovial damage.
On the other hand, rheumatoid arthritis is a chronic autoimmune disorder that involves symmetric inflammation of the synovial joints leading to joint effusion with eventual destruction of cartilage and bones.
Next up is adhesive capsulitis, better known as frozen shoulder. These patients will report a significant loss in shoulder range of motion and an increase in pain with shoulder movement in any plane.

Adhesive Capsulitis 8:10–9:19

There may be a history of shoulder injury or surgery or certain systemic conditions such as diabetes, mellitus or thyroid disease.
Examination will reveal a limited active and passive range of motion associated with reproducible pain. With these findings diagnose adhesive capsulitis.
Here's another clinical pearl frozen shoulder occurs when the connective tissue surrounding the shoulder joint is inflamed, resulting in adhesions that cause pain and restricted motion.
Frozen shoulders go through three stages, freezing, frozen and thawing during the initial freezing phase, there is increased pain and reduced shoulder range of motion lasting up to nine months.
The frozen phase lasting up to 12 months leads to a more restricted range of motion with less pain. The final phase lasts up to 42 months and is characterized by improved range of motion.
All right. Now, let's talk about shoulder tendinopathy.

Tendinopathy 9:19–10:24

Your patient may report increased pain at night and with overhead activity. Additionally, they may report that they engage in poor mechanics related to overhead sports like volleyball and tennis.
Examination will reveal localized tenderness over the affected tendon and decreased muscle strength. There may also be a positive drop arm test as well as a positive empty can test where pain and weakness of the supraspinatus muscle are present with these findings diagnose shoulder tendinopathy.
Here's a clinical pearl to keep in mind, chronic rotator cuff tendonitis typically occurs over time with repeated stress on the rotator cuff tendons if left untreated, this can compromise the integrity of the tendon leading to partial or complete tear.
On the other hand, there might be an abrupt onset of pain with limited range of motion or weakness of the arm associated with trauma resulting in acute rotator cuff tendonitis or a rotator cuff tear.
Finally, let's discuss bursitis. In this case, patients will report doing repetitive activities such as with overhead sports and they may have a history of systemic disease like rheumatoid arthritis or diabetes, mellitus examination will reveal tenderness to palpation and reduced active but preserved passive range of motion of the shoulder sometimes along with overlying erythema or edema.

Bursitis 10:24–11:44

With these findings, diagnose bursitis. Heres one last clinical pearl.
The subacromial bursa provides a cushion between the rotator cuff tendons and the acromion of the scapula to allow gliding of the tendons and bones throughout a physiological range of motion.
Like tendonitis, bursitis is usually associated with chronic repetitive activity. Bursitis and tendonitis can both lead to impingement syndrome where the inflamed rotator cuff tendons and bursa are pinched in the limited space beneath the acromion process.
Look for symptoms like stiffness, swelling, skin erythema and a popping sound when moving the shoulder. You'll also note a positive Hawkins Kennedy test with pain elicited in the shoulder during internal rotation or a positive near test, also known as the passive painful arc test which elicits pain when the gleno humeral joint is passively flexed.
All right. As a quick recap.

Review 11:44–12:22

Shoulder pain is a common symptom that can have a variety of underlying causes when evaluating a patient with shoulder pain first, assess for trauma leading to fractures dislocations, shoulder separations, tendon ruptures and labral tears.
Next. Assess for infection like septic arthritis and osteomyelitis.
If trauma or infection are not present, characterize your patient's pain as either neuropathic pain due to underlying neuropathy like cervical radiculopathy or nociceptive due to underlying causes such as arthralgia, adhesive capsulitis, tendinopathy or bursitis.