Shoulder Tension Pain

Shoulder Pain
Review of Physical Exam and

An Approach To The Differential Diagnosis
David G. Liddle, MD
Assistant Professor of Orthopedics
Assistant Professor of Internal Medicine
Vanderbilt University Medical Center
Nashville, TN
Vanderbilt Sports Medicine

Disclosures
• No financial disclosures or conflicts of interest

Objectives
• Review pertinent anatomy and pathology associated
with common causes of shoulder pain
• Review historical and physical exam findings that
help differentiate common causes of shoulder pain
• Review imaging findings relevant to these causes of
pain and discuss a rationale for appropriate use of
diagnostic tests
• Review the best evidence available to the guide
treatment of these conditions

Syst.
Reviews
of RCT
Level I – Randomized
Controlled Trials
Observational studies
Level II – Prospective Cohort
Level III – Case-Control or
Retrospective Cohort
Level IV – Case studies
Level V – Anecdote and personal opinions

Anatomy Review
http://www.aafp.org/afp/2004/1115/p1947.html
http://www.bandhayoga.com/images/Blog/blog2
3_serratus_anatomy.jpg Vanderbilt Sports Medicine
XR Review
AP Int. & Ext. Rotation & Axillary views
+/- Scapular-Y view

Non-Arthritis Shoulder Pain
Non-Operative Operative &/or Non-Op
• Subacromial Impingement • Rotator Cuff Tear
• Subacromial Bursitis – Acute, Known Injury
– Chronic, Unknown Injury
• Adhesive Capsulitis
– “Frozen Shoulder” • Proximal Biceps Tendon Tear
• Biceps Tendonitis • Labral Tear
• Glenohumeral or AC Joint Arthritis
• AC Joint Sprain
– “Separated Shoulder”
• Shoulder Instability

• Subacromial Bursitis – Acute, Known Injury
– Chronic, Unknown Injury
• AC Joint Sprain

Shoulder Pain Radiating Patterns
• Sternoclavicular Joint  Up SCM/Front of Neck
• Acromioclavicular Joint  Upper Trap/Lat. Neck
• Subacromial Space  Lateral Brachium
• Biceps Tendons  Anterior Brachium

Subacromial Impingement
History Exam
• Pain radiates from superolateral • Scapular dyskinesis on forward
shoulder to lateral brachium elevation (FE)
• Pain with reaching • Limited passive internal rotation (IR)
• No rest pain • PROM ≥ AROM
– Different than sleep/night pain… • Tender To Palpation at Coracoid
this will hurt
• Pain AND weakness on Empty-Can
– Rest = Sitting with hands in lap testing at 90 ABduction in scapular
• Usually insidious onset plane but NL at 30 and other Rot.
• May be capped by an event or start Cuff/Shoulder/Arm muscle strength NL
some time after an event • Pain AND Weakness resolve/improve
• Primary or Secondary disorder with scapular retraction test
• No change in shoulder pain with • Pain with Neer’s and Hawkins’ tests
Neck ROM
Scapular Dyskinesis
http://www.youtube.com/watch?v=ROsiiDsjm2o Vanderbilt Sports Medicine

Empty-Can Test

http://www.mhhe.com/hper/physed/athletictraining/illustrations/ch22/22-16a.jpg
Scapular Retraction Test

Kibler WB. Br J Sports Med 2010
Neer’s and Hawkins’ Tests
for Impingement

http://thepainsource.com
Subacromial Impingement
Imaging Treatment
• 3-4 views of the Shoulder • Rehab
– AP Int. & Ext. Rotation & – Strengthen Scapular Stabilizers
Axillary +/- Scapular-Y view • Rhomboids, Middle Trapezius,
– Usually normal Serratus Anterior
• Obtain these in setting of – Stretch Tight Posterior Capsule

and Pectoralis Minor
injury and/or to screen for
calcific rotator cuff • Subacromial CS Injection
tendonopathy or – To improve tolerance for Rehab
osteoarthritis • Subacromial Decompression
• Neck XR only if reproducible only if conservative Tx fails
radicular signs/symptoms
Calcific Rotator Cuff Tendonopathy

http://www.orthopaedicsone.com/display/MSKMed/Calcific+tendonitis+of+the+shoulder
Calcific Rotator Cuff
Tendonopathy Treatment
• U/S Guided Lavage & CS Injection; Debridement if too large or failed CSI

http://www.ultrasoundcases.info/files/Jpg/lbox_22380.jpg http://www.nguyenthienhung.com/2012_09_01_archive.html
Subacromial Bursitis
physioworks.com.au Vanderbilt Sports Medicine

History Exam
• Pain radiates from superolateral • Scapular dyskinesis on fwd. elev. (FE)
shoulder to lateral brachium • Limited passive internal rotation (IR)
• Pain with reaching • PROM ≥ AROM but pain in all planes
• (+) Rest pain of motion
– Different than sleep/night pain… • Tender To Palpation deep to
this will hurt acromion
– Rest = Sitting with hands in lap • Pain AND weakness in all planes but
• Usually rapid/sudden onset esp. on Empty-Can testing; Biceps
– 10/10 Pain out of “Clear Blue Sky” and Triceps usually NL
• May start soon after an event or • Symptoms may improve with
recent incr. in activity scapular retraction test
• No change in shoulder pain with • Pain with Neer’s and Hawkins’ tests
Neck ROM
Imaging Treatment
• 3-4 views of the Shoulder • Subacromial CS Injection
– AP Int. & Ext. Rotation & • PO NSAIDs +/- Narcotics
Axillary +/- Scapular-Y view
– Ketorolac (Toradol)
– Usually normal
• Rehab after pain improvement
• Obtain these in setting of to address Impingement
injury and/or to screen for
• Subacromial Decompression
calcific rotator cuff
+/- Bursectomy only if
tendonopathy or
conservative Tx fails
osteoarthritis
• Neck XR only if reproducible
radicular signs/symptoms
Adhesive Capsulitis
http://physioworks.com.au/images/Injuries-Conditions/Frozen_Shoulder_Adhesive_Capsulitis.jpg

Adhesive Capsulitis
History Exam
• (+) Rest Pain • Limited passive IR > ER > Abd > FE
– Rest = Sitting with hands in lap • PROM = AROM
• Pain worse with reaching • Diffusely Tender To Palpation
• Progressive Loss of Motion • Pain in all planes of motion may limit
– IR  ER & Abd  FE strength
– Motion returns in opposite sequence
• Limited motion can prohibit Neer’s
• Most common in Females, 40-60 y/o and Hawkins’ tests
• May have autoimmune or chronic
inflammatory etiology
– Diabetes (25%), Hypothyroidism, IBD
• Usually insidious onset
• May be capped by event or the start
some time after an event/trauma
• No change in pain w/ Neck ROM Vanderbilt Sports Medicine
Adhesive Capsulitis
• Education & Expectations
• Average of 9-18 months to run its course
– Stage 1 – Freezing
• Pain at rest AND progressive loss of motion
– Internal Rotation  External Rotation and Abduction  Forward Elevation
– Motion returns in opposite sequence
– Stage 2 – Frozen
• Rest pain resolves but severely limited motion and pain with reaching
– Stage 3 – Thawing
• ROM returns (IR last) and Impingement symptoms predominate
– Stage 4 – Shoulder function is back to normal
Adhesive Capsulitis
Imaging Treatment
• 3-4 views of the Shoulder • Education and Expectations
– AP Int. & Ext. Rotation & Axillary • Glenohumeral CS Injection
+/- Scapular-Y view – Level I – Superior to PO with fewer
• Axillary view most difficult due to systemic effects; Repeat every 4-6
loss of motion weeks in Stage 1 and early Stage 2
– Usually normal Lorbach O et al. J Shldr Elb Sg. 2010
• Narcotics, Sleep Aids, NSAIDs

• Rehab only AFTER Rest Pain resolves
• Viscosupplementation
– Level I – Not Clinically Significant
Callis M. Rheumatol Int. 2006
• Manipulation Under Anesthesia if


Rotator Cuff Tear
orthop.washington.edu

http://stemcelldoc.files.wordpress.com/2009/01/mri-of-torn-rotater-cuff1.jpg
Rotator Cuff Tear
History Exam
• Fall on outstretched arm • Limited AROM 2/2 weakness >
– Abduction in scapular plane = pain but NL PROM
Supraspinatus +/- Infraspinatus
– External Rotation = Subscapularis
• Supraspinatus (70% of RCT)
– Weak Empty Can at 30 & Drop
• c/o weakness > pain Arm test
• Acute • Infraspinatus (20% of RCT)
– Event after which c/o pain and – Weak ER & ER Lag Sign
weakness and disability
– ≤ 2-3 months
• Subscapularis (<1% of RCT)
– Weak IR & Belly Press or Lift Off
• Chronic tests
– Process/Gradual onset of
weakness and pain
– Event >3 months ago Vanderbilt Sports Medicine
Drop Arm Test
http://www.youtube.com/watch?v=qvwYEoeHPaA

Lag Sign and Belly Press Tests
• Infraspinatus/Teres Min. Tear • Subscapularis Tear

http://www.psychiatrictimes.com/sites/default/files/rm/1628757.png http://www.psychiatrictimes.com/sites/default/files/rm/1628765.png
Rotator Cuff Tear
Imaging Treatment
• 3-4 views of the Shoulder • Acute Tear = RCT Repair
– AP Int. & Ext. Rotation & • Chronic Tear = Rehab
– Level II – 75% Return to NL Function
– Usually normal & No Pain without Surgery at 2 yrs.
– May show high riding humeral Kuhn JE. J Shoulder Elbow Surg. 2013
head above center of glenoid – Subacromial CS Injection for Pain

• Loss of supraspinatus cap • Viscosupplementation
• MRI if Acute RCT – Level I – Not Clinically Significant
Chou WY. J Shoulder Elbow Surg. 2010
Meloni F. Eur J Radiol. 2008

Biceps Tendonopathy

http://chiropracticdubai.files.wordpress.com/2012/06/bicep-tendonitis-image1.jpg
Biceps Tendonopathy
History Exam
• Pain radiates from anterior • Tender To Palpation overlying
shoulder to anterior brachium proximal biceps tendon at bicepital
• Pain with biceps flexion, especially groove
with supinated wrist • Pain with extension of the shoulder
• Usually insidious sudden onset • Pain with resisted supination of wrist
• May start soon after an event or and resisted biceps flexion
recent incr. in activity • Pain with Speed’s (resisted shoulder
• Often accompanies Impingement flexion with wrist supinated and
• No change in shoulder pain with elbow extended) and Yergason’s
Neck ROM (resisted wrist supination with elbow
at 60-90°) tests

Speeds’ and Yergason’s Tests
http://www.mhhe.com/hper/physed/athletictraining/illustrations/ch22/22-17b.jpg Vanderbilt Sports Medicine

http://www.studyblue.com/notes/note/n/upper-extremity-physical-exam/deck/6425897
Biceps Tendonopathy
Imaging Treatment
• 3-4 views of the Shoulder • Rehab
– AP Int. & Ext. Rotation & – Eccentric Biceps exercises
Axillary +/- Scapular-Y view – Stretch Biceps in extension
– Usually normal • Tendon Sheath CS Injection
• Consider MSK U/S • Topical or PO NSAIDs or APAP
– Usually used to confirm if Dx is
unclear on exam or if using U/S • Ionto/Phonophoresis
for guided CS injection • Biceps Tenodesis if

Interim Summary
• Was there an injury/event? Or was it a process?
– Injury/Event – Rot. Cuff Tear, Subacromial Bursitis, AC or GH Dislocation
– Process – Impingement, Frozen Shoulder, Biceps Tendonitis, DJD
• Do they have “Rest Pain”?
– No – Impingement, Rotator Cuff Tear (after initiating pain), Prox. Biceps Tear
– Yes – Subacromial Bursitis (rapid), Frozen Shoulder (gradual), DJD (constant),
AC or GH Dislocation (acute)
• Where does it hurt? Where does the pain go? What causes it?
– AC-Lateral Neck, Subacromial Space-Lateral Brachium, Biceps-Ant. Brachium
– Tendonopathy hurts with palpation, stretch, and contraction
• Appropriate XR will adequately address most shoulder pain
– Always include an A/P Int./Ext. Rotation views with an Axillary view
– If Acute Rotator Cuff Tear suspected  MRI
– If Glenohumeral Instability  Scapular-Y Vanderbilt Sports Medicine
Questions or Comments

www.vanderbiltsportsmedicine.com
Thank You
• Subacromial Bursitis – Acute, Known Injury – Surgery
– Chronic, Unknown Injury – Non-Op
• AC Joint Sprain

Proximal Biceps Tendon Tear
Proximal Distal
www.eastbaysportsmed.com http://images.ookaboo.com/photo/m/Bicepstendon10_m.jpg

images.rheumatology.org
History Exam
• Pain and/or pop at anterior • “Popeye Deformity” with defect
shoulder but usually not painful proximal and bulge distal
after initial event • ROM usually normal
• May have bruising at anterior • May be Tender To Palpation at site of
shoulder that tracks distally tear
• Weakness on elbow flexion with
hand in supinated position
• Usually normal strength with hand
at neutral or pronated

Imaging Treatment
• None required unless history • Reassurance
of trauma • Surgery if
– If trauma, XR to r/o fracture – Relative strength deficit is
– MRI usually does not change intolerable or affects work/play
management – Deformity is cosmetically
unacceptable

Inflammatory
Arthritides
Posttraumatic
Osteoarthritis
Arthritis
Capsulorraphy
Arthropathy
Shoulder Rotator Cuff
Arthropathy
Arthritis
Neuropathic
Osteonecrosis
Arthritis
Infection

Glenohumeral DJD
History Exam
• Pain deep in the shoulder • Limited P/AROM on IR/ER > FE
that is constant; worse with • PROM = AROM
reaching • Often have scapular dyskinesis
– “Hopeless” pain
• Usually NL Strength but may
• (+) Rest Pain
have Pain AND weakness on
– Different than sleep/night
pain… this will hurt
Empty-Can testing at 90
– Rest = Sitting with hands in lap
ABduction in scapular plane
– May be weak w/ Rot. Cuff
• Usually insidious onset Arthropathy
• No change in shoulder pain • Pain AND Weakness may
with Neck ROM resolve/improve with scapular
retraction Vanderbilt Sports Medicine
Glenohumeral DJD Imaging
• 3-4 views of the Shoulder
– AP Int. & Ext. Rotation & Axillary
+/- Scapular-Y view
– Joint space narrowing,
osteophytes, and humeral head
and/or glenoid flattening

Glenohumeral DJD Treatment
Non-Operative Operative
• Physical Therapy • Non-Joint Replacement
• Pain Medicine • Partial Joint Replacement
– NSAIDs • Total Joint Replacement
– Tylenol (APAP)
• Reverse Total Joint Replacement
– Narcotics
• Steroid Injections
Blaine T et al. JBJS Am 2008
– Level II – Helps with Rotator Cuff

Arthropathy
Tagliafico A. Eur Radiol. 2011

– Tylenol (APAP)
– Narcotics

Arthropathy

– Tylenol (APAP)
– Narcotics

Arthropathy

– Tylenol (APAP)
– Narcotics

Arthropathy

AC Joint DJD
www.shouldersurgery.com.au
AC Joint DJD
History Exam
• Pain radiates from superior • Tender To Palpation at AC joint
shoulder to lateral neck and upper • Pain with Cross-Arm Adduction test
trapezius • Likely will have secondary
• Pain with reaching, especially Impingement signs
across body – Scapular dyskinesis
• Pain with pushups, bench press, – Limited passive internal rotation (IR)
and overhead lifting – Symptoms resolve/improve with scapular
retraction test
• Aching rest pain
– Pain with Neer’s and Hawkins’ tests
• Usually insidious onset
• No change in shoulder pain with
Neck ROM

Cross-Arm Adduction Test
http://i3.ytimg.com/vi/fV97PJxXJQg/default.jpg http://www.massagetherapy.com/ce/content/images/664.jpg

AC Joint DJD
Imaging Treatment
• 3-4 views of the Shoulder • AC joint CS Injection
– AP Int. & Ext. Rotation & • Topical or PO NSAIDs and Ice
• Rehab
– Joint space narrowing and
osteophytes – Addressing Impingement
mechanics off loads the AC joint
• Neck XR only if reproducible • Strengthen Scapular Stabilizers
radicular signs/symptoms • Stretch Tight Posterior Capsule
and Pectoralis Minor
• Distal Clavicle Excision if

AC Joint Sprain

AC Joint Sprain
History Exam
• Fall onto/Blow to superolateral • Tender To Palpation at AC joint
shoulder with ADducted arm • May have step off at AC Joint
• Pain radiates from superior • Pain with Cross-Arm Adduction test
shoulder to lateral neck and upper • Likely won’t have secondary
trapezius Impingement signs unless they
• Pain with reaching, especially present late
across body
• Pain can prohibit pushups, bench
press, and overhead lifting
• Aching rest pain
• No change in shoulder pain with
Neck ROM

AC Joint Sprain
Imaging Treatment
• 3-4 views of the Shoulder • Type I and II – Non-Op
– AP Int. & Ext. Rotation & Axillary – Sling initially and Ice
+/- Scapular-Y view – PO NSAIDs or APAP or Narcs (rare)
– Degree of Separation determines – AC joint CS Injection
type of dislocation – Rehab
• Avoid developing Impingement
• Type III – Non-Op or Surgery
– If distal clavicle overrides acromion on
Cross Arm ADduction test  Surgery
• Type IV-VI - Surgery
– AC Joint Reconstruction

www.aafp.org
AC Joint Sprain XR
Grade 2 Grade 3

Grade 4 Grade 5
Glenohumeral Instability
http://www.imageinterpretation.co.uk/shoulder.html
http://emcow.files.wordpress.com/2012/09/shoulder-disloc1.jpg Vanderbilt Sports Medicine
http://www.intechopen.com/source/html/40393/media/image6_w.jpg
History Exam
• Subluxation • Arm hanging limp at side
– Popped back in w/o specific Tx • Inability to reach across body
• Dislocation • Inability to externally rotate
– Someone else reduces or specific
technique used to relocate joint
arm
• Direction of Instability • Anterior Instability
– Apprehension/Relocation tests
follows humeral head
• Sensitive & Specific for Fear, Not
– ABduction-ER = Anterior (90%) Pain
– Abduction = Inferior
• Inferior Instability
– Forward Elevation = Posterior
– Sulcus on Traction tests
• Posterior Instability
– Posterior Jerk test
Anterior Instability
Apprehension and Relocation Tests
http://www.chiro.org/LINKS/FULL/Shoulder_Dislocation_in_Young_Athletes.html
Posterior & Inferior Instability
Posterior Jerk Test Sulcus Sign with Traction Test
http://i1.ytimg.com/vi/gPuCikFKUzE/maxresdefault.jpg http://o.quizlet.com/Y8H2wK5Imz4g0bpp.9v3Pw_m.jpg

Imaging Treatment
• 4 views of the Shoulder • Reduce Dislocated Joint
– AP Int. & Ext. Rotation & – Level I – Intra-articular lidocaine is
Axillary & Scapular-Y view preferred to IV sedation
• Axillary view prevents missing • Same success; Less complications (0.9
a posterior dislocation vs. 16.4%)
Fitch RW, Kuhn JE. Acad Emerg Med 2008
• Classification
• Sling Immobilization
– Level I & II – Ext. Rot. may reduce
recurrence; Req. 3 wks. (1/4 studies)
Itoi et al. JBJS 2007
• Sling vs. Surgery (No studies Rehab vs. Sx)

– Level I – Non-Op Tx has higher risk of
recurrence (47 vs. 16%)
Kirkley et al. Arthroscopy 1999
Kuhn JE, Dunn WR et al. J Shoulder Elbow Surg. 2011
Final Summary
• Was there an injury/event? Or was it a process?
– Injury/Event – Rot. Cuff Tear, Subacromial Bursitis, AC or GH Dislocation
– Process – Impingement, Frozen Shoulder, Biceps Tendonitis, DJD
• Do they have “Rest Pain”?
– No – Impingement, Rotator Cuff Tear (after initiating pain), Prox. Biceps Tear
– Yes – Subacromial Bursitis (rapid), Frozen Shoulder (gradual), DJD (constant),
AC or GH Dislocation (acute)
• Where does it hurt? Where does the pain go? What causes it?
– AC-Lateral Neck, Subacromial Space-Lateral Brachium, Biceps-Ant. Brachium
– Tendonopathy hurts with palpation, stretch, and contraction
• Appropriate XR will adequately address most shoulder pain
– Always include an A/P Int./Ext. Rotation views with an Axillary view
– If Acute Rotator Cuff Tear suspected  MRI
– If Glenohumeral Instability  Scapular-Y Vanderbilt Sports Medicine
Questions or Comments

www.vanderbiltsportsmedicine.com
Thanks Again!

Shoulder Tension Pain

Uploaded by

Copyright:

Available Formats

You might also like

Shoulder Tension Pain

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Shoulder Tension Pain

Uploaded by

Copyright:

Available Formats

Shoulder Pain

Review of Physical Exam and

Vanderbilt Sports Medicine

Vanderbilt Sports Medicine

Vanderbilt Sports Medicine

Level IV – Case studies

Level V – Anecdote and personal opinions

Vanderbilt Sports Medicine

Vanderbilt Sports Medicine

Vanderbilt Sports Medicine

Vanderbilt Sports Medicine

Vanderbilt Sports Medicine

http://www.youtube.com/watch?v=ROsiiDsjm2o Vanderbilt Sports Medicine

Vanderbilt Sports Medicine

Vanderbilt Sports Medicine

Vanderbilt Sports Medicine

• Obtain these in setting of – Stretch Tight Posterior Capsule

Vanderbilt Sports Medicine

Vanderbilt Sports Medicine

physioworks.com.au Vanderbilt Sports Medicine

Vanderbilt Sports Medicine

• Narcotics, Sleep Aids, NSAIDs

• Manipulation Under Anesthesia if

Vanderbilt Sports Medicine

Vanderbilt Sports Medicine

Vanderbilt Sports Medicine

Vanderbilt Sports Medicine

head above center of glenoid – Subacromial CS Injection for Pain

Vanderbilt Sports Medicine

Vanderbilt Sports Medicine

Vanderbilt Sports Medicine

http://www.mhhe.com/hper/physed/athletictraining/illustrations/ch22/22-17b.jpg Vanderbilt Sports Medicine

Vanderbilt Sports Medicine

Vanderbilt Sports Medicine

Vanderbilt Sports Medicine

Vanderbilt Sports Medicine

Vanderbilt Sports Medicine

Vanderbilt Sports Medicine

Vanderbilt Sports Medicine

Vanderbilt Sports Medicine

– Level II – Helps with Rotator Cuff

Vanderbilt Sports Medicine

– Level II – Helps with Rotator Cuff

Vanderbilt Sports Medicine

– Level II – Helps with Rotator Cuff

Vanderbilt Sports Medicine

– Level II – Helps with Rotator Cuff

Vanderbilt Sports Medicine

Vanderbilt Sports Medicine

Vanderbilt Sports Medicine

Vanderbilt Sports Medicine

Vanderbilt Sports Medicine

Vanderbilt Sports Medicine

Vanderbilt Sports Medicine

Vanderbilt Sports Medicine

Vanderbilt Sports Medicine

• Sling vs. Surgery (No studies Rehab vs. Sx)

Vanderbilt Sports Medicine