SHOULDER PAIN: PHYSICAL

EXAMINATION AND DIFFERENTIAL

DIAGNOSES

A PRESENTATION
BY
ADESANYA TEMILADE BOLUWATIFE
AT THE
DEPARTMENT OF PHYSIOTHERAPY, FMCA
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OUTLINE
• Introduction
• Prevalence of shoulder pain
• Anatomy of the shoulder
• Aetiology
• Physiotherapy examination
• Physical examination
• Shoulder pain differential diagnosis
• Physiotherapy management
• Conclusion
• Bibliography
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INTRODUCTION
• Shoulder pain is a common and disabling complaint

• It is a symptom seen in most shoulder disorders

• It is often the major presentation of shoulder disorders,

with or without limitation in range of motion

• It could also arise from conditions affecting the

surrounding structures

• It usually causes disability in activities of daily living

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INTRODUCTION CONTD.
• Common causes of shoulder pain should be understood
to give a correct diagnosis and effective management

• Pain experienced in the shoulder can be as a result of a

myriad of medical conditions

• Knowledge of common shoulder disorders is important

as they are usually managed conservatively.
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PREVALENCE OF SHOULDER
PAIN
• 3rd most common musculoskeletal complaint presenting to
Physiotherapy

• About half the population will have at least one episode of

shoulder pain annually

• Reported annual incidence of shoulder pain is 29.3 per

1000 persons with a lifetime prevalence of 70%

• One year prevalence rate of shoulder disorder ranges from

14-21%.

• Shoulder pain is a common condition in the country

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ANATOMY OF THE SHOULDER

• The shoulder is a complex arrangement of bones,
ligaments, muscles and tendons that is better called the
shoulder girdle

• It consists of four joints;

o glenohumeral joint
o sternoclavicular joint
o acromioclavicular joint
o scapulothoracic joint
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ANATOMY OF THE SHOULDER CONTD.

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ANATOMY OF THE SHOULDER

CONTD.
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ANATOMY OF THE SHOULDER CONTD.

• The muscles of the shoulder consist of; rotator cuff,
deltoid, pectoralis major, trapezius, latissimus dorsi, teres
major, biceps
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ANATOMY OF THE SHOULDER CONTD.

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AETIOLOGY
• Shoulder pain often has multiple aetiologies

• Each condition that result in shoulder pain usually have

their distinct cause

• Most of the shoulder conditions are as a result of the

following causes:
o Traumatic
o Non traumatic
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PHYSIOTHERAPY EXAMINATION
• The examination done is to rule out the differentials and
to get the diagnosis of the condition causing the pain

• It involves both subjective and objective examination

• The subjective entails the history taking

• The history serves as a guide for areas to look out for

when carrying out the physical examination

• The objective examination entails physical examination

and radiological findings
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PHYSICAL EXAMINATION
• It involves general and systemic.

• General Examination: general appearance, gait,

height and weight, vitals

• Systemic Examination
o Nervous system
o Intergumentary
o Respiratory system
o Musculoskeletal system
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PHYSICAL EXAMINATION CONTD.

• Shoulder Examination
• It includes; inspection, palpation, range of motion,
strength test and special tests

• Inspection: Observe the patient (front and back),

inspect for swelling, muscle atrophy, scars, observe
for posture and deformity

• Palpation: for warmth and tenderness of the shoulder

and cervical spine

• Muscle strength : use of manual muscle grading

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PHYSICAL EXAMINATION CONTD.

• Shoulder Examination
• Range of Motion: Cervical spine and shoulder, active and
passive ROM is assessed with bilateral comparison.

MOVEMENTS NORMAL RANGE (º)

Flexion 0-180
Extension 0-40
Abduction 0-180 (with palms up)
Adduction 0-40
External rotation 0-45 (arm at the side, elbow
flexed)
Internal rotation 0-55 (arm at side, elbow flexed)
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SHOULDER PAIN DIFFERENTIAL

DIAGNOSIS
• Impingement and rotator cuff syndrome: subcoracoid
impingement, rotator cuff tear

• Acromio-clavicular (AC) pathologies: injuries and

arthritis

• Shoulder instability

• Injuries in throwing athletes: SLAP lesion

• Tumours
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SHOULDER PAIN DIFFERENTIAL

DIAGNOSIS CONTD.
• Degenerative conditions: glenohumeral arthritis,
adhesive capsulitis

• Neurovascular disorders: suprascapular neuropathy,

thoracic outlet syndrome

• Referred pain: cervical spine spondylosis, cardiac

disease (myocardial ischemia)

• Muscle rupture: pectoralis major rupture, deltoid

rupture
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ADHESIVE CAPSULITIS
• Also known as frozen shoulder

• Inflammatory condition that causes fibrosis of the

glenohumeral joint capsule with an insidious onset

• Three clinical stages

o Freezing stage: constant shoulder pain with limited range
of motion (ROM) in a capsular pattern
o Frozen or stiff phase: rest pain resolves but severely limited
ROM and pain with extreme movements
o Thawing phase: spontaneous progressive improvement in
functional range of motion
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ADHESIVE CAPSULITIS CONTD.

• Patients frequently have difficulty;
o grooming
o performing overhead activities
o dressing
o fastening items behind the back

• It is more prevalent in women, individuals aged 40-65

years and diabetic population

• It has a spontaneous complete or near complete recovery

over a varied period of time (6 months – 11 years)
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BICEP TENDONITIS
• Inflammation of the tendon around the long head of the
biceps muscles

• It is caused by repetitive motion from certain sports or a

fall or activities that causes strain to the biceps tendon

• Occurs in athletes aged over 35 years or patients aged over

65 years
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BICEP TENDONITIS CONTD.

• Patients complain of deep, throbbing pain in the anterior
shoulder that intensifies when lifting

• Pain on palpation of the bicipital groove that occasionally

radiates to the elbow

• Pain is aggravated by elbow flexion and resisted supination

• Pain worsens at night especially when sleeping on affected

limb
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BICEP TENDONITIS CONTD.

• YERGASON’S TEST
• Starting position: sitting or standing

• Technique: humerus in neutral position with 90º of

flexion, the patient is asked to externally rotate and
supinate their arm against the manual resistance of the
examiner.

• Positive test: pain reproduced at the bicipital groove

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SUBACROMIAL BURSITIS
• It is the inflammation of the subacromial bursa

• Characterized by pain at the anterior and lateral shoulder

that may cause weakness or stiffness

• Tenderness below the acromion and the greater

tuberosity
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SUBACROMIAL BURSITIS CONTD.

• Night pain that interrupts sleep

• Reduced active range of motion with decreased flexion,

internal rotation and abduction

• Glenohumeral abduction greater than 45º

• Pain between 60-120º of abduction

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ROTATOR CUFF TEAR

• It is mostly caused by repetitive micro traumas and severe
traumatic injuries

• Most common tendon affected is the supraspinatus

presenting with tenderness over the greater tuberosity and
pain at the anterior shoulder radiating to the arm

• Severe pain at time of injury with associated pain at night

and overhead activities

• Weakness of the rotator cuff muscles

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ROTATOR CUFF TEAR CONTD.

• EXTERNAL ROTATION LAG SIGN
• Purpose: assess presence of full-thickness rotator cuff tear

• Technique:
o Elbow is passively flexed to 90º and shoulder abducted to
90º and held 5º off maximum external rotation
o The patient is asked to maintain the position actively,
while examiner releases the wrist and maintaining
support through the elbow

• Positive test: inability to maintain the position

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ACROMIOCLAVICULAR INJURY
• Injury to the acromioclavicular joint can be due to trauma
or degenerative conditions

• Pain on the top of the shoulder aggravated by overhead

movement or heavy lifting, radiating to the neck and
deltoid

• The joint may be swollen and upper extremity held in

adduction

• Acromion depressed with clavicle elevated

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ACROMIOCLAVICULAR INJURY
CONTD.
• RESISTED AC JOINT EXTENSION TEST
• Purpose: AC joint pathology in both traumatic and non
traumatic cases

• Technique:
o patient shoulder is positioned in 90º of flexion followed by
internal rotation.
o therapist places his/her hand on patient elbow and ask
patient to abduct the arm against isometric resistance

• Positive test: pain at the AC joint

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SHOULDER INSTABILITY
• Inability to maintain the humeral head in the glenoid
fossa

• It could be a subluxation or a dislocation

• The direction of instability could be anterior, inferior or

posterior, associated with increased mobility in the
directions
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SHOULDER INSTABILITY CONTD.

• A persistent sensation of shoulder feeling loose, slipping in
and out of the joint, or just hanging

• Characterized by clicking, complaint of dead arm with

throwing and apprehension with movements

• There might be shoulder asymmetry, atrophy and scapular

winging
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PHYSIOTHERAPY MANAGEMENT
Adhesive Bicep Sub- Rotator Acromio- Shoulder
capsulitis tendonitis acromial cuff clavicular instability
bursitis tear injury
Freezing PRICE RICE Rest RICE Patient
TENS Ultrasound Ultrasound Cryo or Shoulder sling education
Moist heat + Bicep brace Assisted thermo immobilization Shoulder sling
stretching Bicep active therapy Taping immobilization
Pulley stretch mobilizatio Massage ROM exercises RA exercises of
Frozen Passive n Open Pectoralis the deltoid,
End range ROM and Isometric and minor stretch rotator cuff
joint assisted RA exercise closed Closed chain Stretching of
mobilization active ROM of the chain exercises the pectoralis
Thawing exercises rotator cuff exercises major and
Resisted and deltoid minor
active (RA)
exercises
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CONCLUSION
• The knowledge of the differential diagnosis of shoulder
pain is important for the effective diagnosis of the
condition causing the pain

• Physical examination helps rule out other conditions,

especially with the use of special tests

• The correct diagnosis helps Physiotherapist offer the

best care for their patients
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BIBLIOGRAPHY
• Ascension via christi Joint-by-Joint musculoskeletal physical exam (2020): soulder
and neck
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Clinic Journal of Medicine 74(7):473-482
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1456
• Kelly M, Mcclure P, Leggin B (2009): Frozen shoulder Evidence and proposed model
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Korean Medical Association. 57(8):653-660
• Levangie P.K, Norkin C.C (2011): Joint structure and function: A comprehensive
analysis. FA Davis
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