Shoulder painsenior

Shoulder pain

• Shoulder pain is a common complaint– there are many common causes of this

problem

• It is important to make an accurate diagnosis – so that a treatment appropriate to the cause

may be instituted

Anatomy

• The main joint in the shoulder is formed by humerus and scapula

• The joint socket is shallow, allowing a wide range of motion in the arm

• The rotator cuff is made up of 4 muscles that surround the arm bone

• This cuff keeps the shoulder steady as the arm moves

Shoulder Joints

• Sterno-clavicular joint

• Acromioclavicular joint

• Glenohumeral joint

• Scapulothoracic joint

The Rotator Cuff

• Supraspinatus

• Infraspinatus

• Teres minor

• Subscapularis

Rotator Cuff

Shoulder Joint Movements

Movement Muscles

Fwd Flex Deltoid, Pec maj, Coracobrach, Biceps

Extension Deltoid, Teres maj, Teres min, Lat dorsi, Pec maj, Triceps

Abduction Deltoid, Supraspin, Infraspin, Subscap, Teres maj

Adduction Pec maj, Lat dorsi, Teres maj, Subscap

Int rotation Pec maj, deltoid, Lat dorsi, Teres mja, Subscap

Ext Rotation Infraspin, Deltoid, Teres min

Shoulder Pain• Pain arising from elsewhere

– Referred pain: neck pain, myocardial ischaemia, referred diaphragmatic pain

– Polymyalgia rheumatica

– Malignancy: apical lung cancers, metastases

• Pain arising from the shoulder

Shoulder joint

Extrinsic Shoulder Pain

• A careful history and preliminary examination should enable the clinician to make this distinction

• Often the patient has difficulty localizing the pain

• The pain itself is often vague, if it is referred from a thoracic or abdominal source

• Sharp with radiation if it is neurogenic

Extrinsic Shoulder Pain

• Cervical nerve root impingement may be present in a patient with sharp pain radiating from the neck into the posterior shoulder area or arm

• Splenic injury may be present in a patient with shoulder pain recently involved in an automobile accident in which the shoulder was not initially injured

• Myocardial ischemia may be the reason when diaphoresis or dyspnea occurs with exercise-induced shoulder pain

Extrinsic Shoulder Pain

• Painless range of motion

• No asymmetry in appearance, motion, or strength when compared with the opposite shoulder,but muscle atrophy if nerve root compression.

Pain Arising From Shoulder

• Rotator cuff disorders: rotator cuff tendinopathy, impingement, subacromial bursitis, rotator cuff tears

• Glenohumeral disorders: capsulitis

("frozen shoulder"), arthritis, infection

(rare), labral tear

• Structures outside GHJ & RC

Glenohumeral Disorders

Adhesive Capsulitis

• Pain and loss of motion or stiffness in the shoulder

• Affects two percent of the general population

• More common in women between the ages of 40 years to 70 years

Causes

• The causes of frozen shoulder are not fully understood

• The process involves thickening and contracture of the capsule surrounding the shoulder joint

Risk Factors

• RC tendinopathy is the commonest cause• Diabetes, affecting 10 percent to 20 percent

of these individuals• Other medical problems associated with

increased risk of frozen shoulder include: hypothyroidism, hyperthyroidism, Parkinson's disease, and cardiac disease or surgery

• Frozen shoulder can develop after a shoulder is injured or immobilized for a period of time

Natural Course • Stage one: In the "freezing" stage, which

may last from six weeks to nine months, the patient develops a slow onset of pain. As the pain worsens, the shoulder loses motion.

• Stage two: The "frozen" stage is marked by a slow improvement in pain, but the stiffness remains. This stage generally lasts four to nine months.

• Stage three: The final stage is the "thawing", during which shoulder motion slowly returns toward normal. This generally lasts five months to 26 months.

Symptoms• Pain due to frozen shoulder is usually dull

or aching• It can be worsened with attempted motion• The pain is usually located over the outer

shoulder area and sometimes the upper arm

• The hallmark of the disorder is restricted motion or stiffness in the shoulder

Diagnosis

• Based on the history of the patient's symptoms and physical examination.

• X-rays or MRI are sometimes used to rule out other causes of shoulder stiffness and pain, such as rotator cuff tear

Impingement Syndrome

• Symptoms and signs that result from compression of the rotator cuff tendons and the subacromial bursa between the greater tubercle of the humeral head and the lateral edge of the acromion process

• To whom acrom is more curve mostly develop impingment

Shoulder Anatomy

Acromion

Bursae

• Overhead reaching and positioning cause pain over the outer deltoid

• Atrophy of the muscles around the top and back of the shoulder may be apparent if symptoms are longstanding

• Crepitus may be felt with attempts to abduct the arm beyond 60 degrees.

Rotator Cuff Tendinitis: Symptoms

• Shoulder pain aggravated by– reaching, pushing, pulling, lifting– positioning the arm above the shoulder level– lying on the affected side

• Most patients do not describe an injury or fall

• Places the hand over the outer deltoid, rubbing the muscle in an up-and-down direction when describing the pain

Rotator Cuff Tendinitis: Signs

• Atrophy of supraspinatus and infraspinatus muscles – A sunken appearance in the corresponding

scapular fossa

Rotator Cuff Tears

• A common cause of pain and disability in the adult population

• Most common in people over 40• May occur in younger patients following acute

trauma or repetitive overhead work or sports activity

• A cuff tear may also happen with another injury to the shoulder, such as a fracture or dislocation

• The rotator cuff helps to lift and rotate the arm and to stabilize the ball of the shoulder within the joint.

• Most tears occur in the supraspinatus but other parts of the tendon may be involved

Rotator Cuff Tears

Symptoms….• Symptoms may develop acutely or have

a more gradual onset– Commonly, the onset is gradual and may

be caused by repetitive overhead activity or by wear and degeneration of the tendon

• May feel pain in the front of the shoulder that radiates down the side of the arm

• At first the pain may be mild and only present with overhead activities such as reaching or lifting.

• It may be relieved by medication such as aspirin or ibuprofen.

• Over time the pain may become noticeable at rest or with no activity at all.

• There may be pain when the pt lies on the affected side and at night.

Signs of Rotator Cuff Tear

• Atrophy or thinning of the muscles about the shoulder

• Pain when the patient lifts his arm • Pain when the patient lowers his arm from a fully

raised position • Weakness when lifts or rotates the arm • Crackling sensation when someone moves his

shoulder in certain positions

• Plain X-rays of a shoulder with a rotator cuff tear are usually normal or show a small spur

• Ultrasound or MRI. • MRI can sometimes distinguish between a full

thickness (complete) and partial tear• In some circumstances, an arthrography may

also be helpful

Imaging

Diagnosis• Diagnosis of a rotator cuff tear is based on

symptoms, examination, X-rays, and imaging studies such as MRI (magnetic resonance imaging)

• Examine shoulder to see if it is tender in any area or if there is a deformity

• Measure the range of motion of shoulder in several different directions and test the strength of arm

• Check for instability and problems with the (acromioclavicular) joint

Bicipital Tendinitis• Inflammation of the long head of the

biceps tendon as it passes through the bicipital groove of the anterior proximal humerus

• Repetitive lifting, and to a lesser extent overhead reaching, leads to inflammation, microtearing, and, if untreated, degenerative change

Bicipital Tendinitis: Features

• Pain in anterior shoulder with radiation distally over the biceps muscle

• The pain is aggravated by lifting, pulling, or repetitive overhead activities

• Patients may complain of a painful arc of motion associated with a click and pain that worsens at night

Causes of ant shoulder pain

General Background

Age

• Adolescents and young adults: subluxation of GH, AC, muscular strain (after overuse), RC tear, subacromial bursitis

• Middle-aged or elderly: RC tendinitis, impingement, capsulitis

Characteristics of Pain

• Onset: acute-RC tear, septic arth vs. insidious

• Severity- malig

• Character– Dull, diffuse– Sharp, diffuse– Localized

• Exact location

Location of Pain• Lateral deltoid pain:

– Impingement

– Rotator cuff tendinopathy

– Adhesive capsulitis

• Anterior:

– AC separation/OA, GH OA, bicipital tendinopathy

– Labral tear

• Localized at end of clavicle: AC joint conditions

• Posterior: RC tendinopathy affecting teres minor or infraspinatus, cervical root pain

• Poorly localized: cervical root compression, visceral, labral tear, AVN of humeral head

Aggravating Factors

• Shoulder movement in any direction: intrinsic shoulder pathology

• Rest (bilateral): synovitis (RA), PMR

• Pain at night: tendon tear, metastesis

• Lying on affected side: RC tear, tendinitis

• Overhead reaching and positioning

– Impingement syndrome, RC tendinopathy

• Movement in multiple direction: GH pathology

• Lifting, carrying: bicipital tendinitis

Downward Radiation

• Along outer side of arm: RC tear

• Along front of arm: bicipital tendinitis

• Along the post arm:cervical rediculopathy

Accompanying Features

• Stiffness and restriction: capsulitis

• Weakness/loss of movement: RC tear, cerv root compressn

• Catching sensation during movement: tendon tear, labral tear

• Grinding or popping sensation when reaching overhead or across the chest: AC OA

Bone metastasis pain

• Prog severe

• mid nt pain

• feature of prim

• const sympt

Acute shoulder pain & swelling

• Septic arthritis

• Screening general examination

• Screening examination of the MSK system

• Focused examination of other system– Nervous system

• Examination of shoulder joints

Inspection At Rest

Position of shoulder

Swelling

Redness

Deformities

Muscle atrophy

Causes of Failure of Abduction

• Painful– capsulitis– RC tendinopathy, particularly tear– arthritis

• Painless– complete rotator cuff tear– severe atrophy of the rotator cuff and deltoid muscles– severe C5 radiculopathy– supracapsular nerve palsy

Palpation at Rest

• General palpation of joint: warmth, joint line tenderness

• AC joint

• Subacromial area

• Tendon of long head of biceps

Palpation During Passive Movement

• Shoulder has to be fixed with left hand

• Passively carry out abduction and external rotation– Range of motion (capsulitis)– Feel for crepitus during abduction beyond 60˚

(impingement)– Popping ,grinding sensation-AC OA– Crackin sensation-RC tear and Labral tear.

Focused Examination

Impingement

RC tendinopathy

Bicipital tendinitis

Shoulder instability

Criteria for Impingement

• Pain over outer deltoid

• Pptd or aggravated by overhead reaching or positioning

• Tenderness in subacromial area

Criteria for RC Tendinopathy

• Shoulder pain aggravated by– reaching, pushing, pulling, lifting– positioning the arm above the shoulder level– lying on the affected side

Criteria for Bicipital Tendinopathy

• Pain in anterior shoulder with radiation distally over the biceps muscle

• The pain is aggravated by lifting, pulling

• Tenderness over bicipital groove

Criteria for Shoulder Instability

• A feeling of looseness and noisiness of shoulder

• Anterolateral pain

• Pain aggravated by mid-range abduction

Laboratory in Shoulder Pain

Usually not required

• CBC, ESR

• Blood glucose

• Imaging– X-rays– USG– MRI– Isotope scanning

Indications for X-ray

• Trauma with suspicion of fracture or dislocation

• Features of GH and AC OA

• Features suggestive of malignancy

Indications for USG

• Particularly useful for bursitis– RC tendinitis vs. subacromial bursitis

• Definite:– Impingement with severe pain not relieved by

immobilization and NSAID in 3 days– Adhesive capsulitis not relieved by NSAIDs and

passive exercise in 2 weeks

• Probable:– Any other shoulder syndrome not relived by

appropriate treatment for 2 weeks

Indications for MRI

• Suspected labral tear (MR arthrography more sensitive)

• RC tear

• Subtle fractures

• Suspected malig

Routine Clinical Evaluation

• Screening general history, GE, MSK & others• Detailed history of shoulder pain• Inspection at rest• Inspection during active movement:

– Overhead arm raise– Appley scratch test

• Palpation at rest• Palpation with passive abduction & external

rotation

Focused Examination

Impingement

RC tendinopathy

Bicipital tendinitis

Shoulder instability