Shoulder Pain
Introduction
This chapter is intended to provide a basic understanding of the evaluation and
treatment process for common shoulder complaints. Necessity for supplemental testing (i.e.
CT, MRI etc.) indicates referral to a specialist.
Acromioclavicular (A/C) Degeneration
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Key Findings: Pain over A/C joint with forced
adduction of the arm.
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Key Tests: Lidocaine injection into joint, 1 to 2cc
relieves the symptoms. X-ray demonstrates DJD or osteolysis.
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Treatment: Rest; NSAIDs. After about 12 months
consider excision of the distal 1-2 cm of clavicle and A/C joint.
Acromioclavicular (A/C)
Dislocation
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Type I - Strain of A/C and coracoclavicular (C/C) ligaments
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Type II - Rupture, A/C ligament
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Type III - A/C and C/C ligaments torn
Impingement (Rotator
Cuff), Supraspinatus Tendonitis
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Key Findings: Rotator cuff inflammation. Pain with forward
elevation. Pain radiates to deltoid and biceps and pain at night.
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Key Tests: Impingement test; pain with forced elevation of the shoulder.
Lidocaine injected into the subacromial bursa will relieve symptoms.
-
Treatment: Rest; NSAIDs, and avoid overhead activity. If no improvement in
12 months, consider subacromial decompression.
Rotator Cuff Tear
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Key Findings: Most often patients are greater than
40 years old. A tear results from chronic attrition against the under surface of the
acromion. Occasionally acute traumatic tears will present with pain similar to
impingement. Check for weakness of external rotation and forward elevation. Examine the
posterior shoulder for infraspinatus atrophy.
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Key Tests: Subacromial lidocaine injection will improve symptoms.
X-rays can give hint of rotator cuff tear but are not diagnostic. Arthrogram is the gold
standard, and may need to be scheduled. MRI is non-invasive and is an excellent choice for
large tears and when ruling out a tear. MRI is less specific for small or partial tears.
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Treatment: Chronically painful rotator cuff tears require
treatment with operative fixation. Small or partial tears may respond to non-operative
treatment. These should be referred to orthopedics for evaluation.
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Outcome: Excellent results in small to medium tears; large tears
often continue with some residual weakness.
Anterior Dislocation
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Key Findings: Arm held close to body, internally
rotated and adducted. Axillary nerve palsy is possible, shoulder capsule stretched in the
majority of cases; avulsed from glenoid (Perthes lesion) in minority.
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Key Tests: The axillary x-ray view will demonstrate
anterior dislocation and possible glenoid fracture.
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Treatment: Reduction with IV sedation or intra articular lidocaine
injection.
Posterior Dislocation
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Key Findings: Arm held in internal rotation adduction and
pronation. Majority are missed initially. Beware of seizures as a cause, such as in
diabetes.
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Key Tests: The AP x-ray view will look normal. Always obtain an
axillary view.
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Treatment: Very rare as acute injury. Often chronic, requiring
reduction in the operating room.
Anterior Subluxation
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Key Findings: Apprehension or pain with abduction and
external rotation. Inferior traction produces sulcus sign; often only diffuse anterior
pain dubbed as "occult instability".
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Key Tests: The axillary view may show anterior glenoid wear.
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Treatment: A majority of patients improve with physical therapy.
Capsulorrhaphy when physical therapy treatments are no longer productive (6 to 12 months).
Posterior Subluxation
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Key Findings: Pain or apprehension with posterior directed
force at 90 degrees shoulder elevation. Patient can voluntarily sublux or dislocate. Mild
winging of the scapula.
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Key Tests: The axillary x-ray view demonstrates potential glenoid
malformation. CT and MRI are not helpful.
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Treatment: Physical therapy improves the majority. Posterior
capsulorrhaphy for recurrent subluxation. Capsular avulsion is an unusual presentation.
Pathology involves patulous capsule.
Multi-directional
Instability (MDI)
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Key Findings: Pain or apprehension with extremes of motion;
Check hyperextension of elbows and MP joints. Globally loose shoulder: subluxation with
minimal or no trauma, i.e., sleeping.
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Key Tests: The x-rays are usually normal. MRI & CT cannot
indicate capsular laxity. Sulcus sign with inferior traction.
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Treatment: Physical therapy improves the majority. Capsulorrhaphy
to tighten direction of greatest laxity sometimes requires anterior and posterior
approaches. Surgical failure rate is higher than pure anterior or posterior instability.
Winging of Scapula
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Key Findings: Long thoracic or spinal accessory, neck palsy, shoulder
instability, scapular osteochondroma, and possibly A/C joint pathology.
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Key Tests: Electromyelogram (EMG) / nerve conduction study (NCS); x-ray for
scapular abnormality.
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Treatment: For neurologic causes, if no clinical or EMG evidence of improvement
by 12 months, consider muscle transfers. Nerve reconstruction alone are not very
successful.
Shoulder Dislocation
(elderly patient)
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Key Findings: Arm held adducted, inferior sag of shoulder
due to deltoid atony. Associated rotator cuff tears at higher frequency in elderly
patients.
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Key Tests: Associated fractures much more common than in younger
patients. Axillary view essential for greater tuberosity fracture. Vascular injury is a
significant risk in elderly patients, must check neurovascular status.
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Treatment: Very gentle reduction required, AVOID TORQUE STRESS.
Simple dislocation can be converted to proximal humerus fracture. Most associated
fractures reduce after shoulder is reduced. If the patient continues with slow progress at
several weeks, consider the possibility of a rotator cuff tear.
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Outcome: Excellent with no fracture stiffness is a greater risk
than in young patient.
Glenohumeral Arthritis
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Key Findings: Pain or loss of motion of shoulder: Passive
motion restricted.
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Key Tests: X-ray demonstrates degenerative changes (decreased
joint space, and osteophytes.)
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Treatment: NSAIDs. Non-operative care in the majority of cases. If
significant pain persists, consider arthroplasty. Loss of motion without pain is not an
indication for joint replacement.
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Outcome: Excellent results (pain relief in patients with intact
rotator cuff and deltoid.
Frozen Shoulder
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Key Findings: Lack of muscle atrophy, with idiopathic loss
of shoulder motion, often of gradual onset. Rule out all identifiable pathology before
diagnosis. Loss of passive and active motion with pain at extremes of motion.
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Key Tests: More common in diabetics and in patients with thyroid
dysfunction. Sometimes initial presentation of both. Occasionally associated with
intrathoracic pathology, i.e., tuberculosis, or carcinoma.
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Treatment: Symptoms often last 1-2 years. Physical therapy should
emphasize stretching. If no improvement after 12 months, consider manipulation under
anesthesia in nonosteoporotic patients.
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Outcome: The vast majority of patients recover by 2 years with
mild permanent loss of motion. Diabetics however have a poor prognosis.
Proximal Humerus Fracture
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Key Findings: Evaluate neurovascular status. Axillary nerve
or artery injuries are potential complications.
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Key Tests: A minimum of 3 x-ray views for proper evaluation. True
AP, axillary and "Y"-lateral views.
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Treatment: Non displaced fracture treated in sling. Significant
displacement requires surgical fixation or prosthetic replacement.
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Outcome: Permanent partial loss of motion depending upon fracture
and displacement.
Submitted by LCDR S. P. Steinmann MC, USNR, Department of
Orthopedics Hand and Shoulder, National Naval Medical Center, Bethesda, MD.
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Preface
· Administrative Section
· Clinical Section
The
General Medical Officer Manual , NAVMEDPUB 5134, January 1, 2000
Bureau
of Medicine and Surgery, Department of the Navy, 2300 E Street NW, Washington, D.C.,
20372-5300
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