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Chronic Shoulder Pain - Part I Evaluation & Diagnosis

Chronic Shoulder Pain - Part I Evaluation & Diagnosis

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Chronic Shoulder Pain
Chronic Shoulder Pain

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Published by: gozjasa on Dec 05, 2009
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Chronic Shoulder Pain:Part I. Evaluation and Diagnosis
KeltonM.BurBanK,MD,
Leominster, Massachusetts
J.HerBertStevenSon,MD,
University of Massachusetts, Fitchburg, Massachusetts
GreGoryr.CzarneCKi,Do,
University of Connecticut, Hartford, Connecticut 
JuStinDorMan,Do,
Southboro, Massachusetts
S
hdpsspsbppxm16pcmscskcmps,
1
wh cdc15wpsdsp1,000psshpmcsg.
2
Pihsw-pcwpdhpmcphscwhsmp,cppchhdg-sschcshddsdsschscphg,dhscpss,cmccshs,gh-mshs,dsb.Pii,whchppshsss
 AFP 
(p. 493),
dscssshmschcshdphcsswhcdc-bsdgds.
3,4
Shdpsddschcwhhsbpsghsxmhs,gdsswhhhphspssghm.icbdddsxdgscc-gs:(1)cdsds,cdgdss,phcksss,cccds;(2)dhscpss;(3)ghmshs;(4)g-hmsb;(5)cmcc jphg;d(6)hchcp,cdgsscmmshdpbmsd-shdpbms.
Cc D
MeDiCal history
Table 1
5-11
smmshhsdpsscdshdcdspswhchcshdp.
Shoulder pain is defned as chronic when it has been present or longer than six months. Common conditions thatcan result in chronic shoulder pain include rotator cu disorders, adhesive capsulitis, shoulder instability, and shoul-der arthritis. Rotator cu disorders include tendinopathy, partial tears, and complete tears. A clinical decision rulethat is helpul in the diagnosis o rotator cu tears includes pain with overhead activity, weakness on empty canand external rotation tests, and a positive impingement sign. Adhesive capsulitis can be associated with diabetesand thyroid disorders. Clinical presentation includes diuse shoulder pain with restricted passive range o motionon examination. Acromioclavicular osteoarthritis presents with superior shoulder pain, acromioclavicular joint ten-derness, and a painul cross-body adduction test. In patients who areolder than 50 years, glenohumeral osteoarthritis usually presents asgradual pain and loss o motion. In patients younger than 40 years,glenohumeral instability generally presents with a history o dislo-cation or subluxation events. Positive apprehension and relocationare consistent with the diagnosis. Imaging studies, indicated whendiagnosis remains unclear or management would be altered, includeplain radiographs, magnetic resonance imaging, ultrasonography,and computed tomography scans. Plain radiographs may help diag-nose massive rotator cu tears, shoulder instability, and shoulderarthritis. Magnetic resonance imaging and ultrasonography are pre-erred or rotator cu disorders. For shoulder instability, magneticresonance imaging arthrogram is preerred over magnetic resonanceimaging. (
 Am Fam Physician.
2008;77(4):453-460. Copyright © 2008American Academy o Family Physicians.)
This is pt I f  tw-pttic  chic shdpi. Pt II, “Ttmt,”pps i this iss f 
 AFP 
 pg 493.
   I   L   L   U   S   T   R   A   T   I   O   N   B   Y   j   O   h   N   w .   k   A   R   A   p   e   L   O   U
Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 200
8
American Academy of Family Physicians. For the private, noncommercialuse of one individual user of the Web site. All other rights reserved. Contact copyrights@aafp.org for copyright questions and/or permission requests.
 
sd P e
454
 American Family Physician
www.p.g/p
Volume 77, Number 4
 
 
February 15, 2008
thghpsmpcsd-.Psgh40smkpswhshdsbmdcdss(mpgm,dph),whspsdh40scsdskdcd,chccdss(pcmp),dhscpss,ghmshs.
3-5,12-14
thccpdcsshpsmphshdp.ahscsspswghgmghmksbcmccshsmk,whshdspswkcsmghmkcphgmk.thchpcbhpdg-ss.a-sppcbcdhcmccj,whsddpscdwhcphg.nckpddgsmpmsshdbxpdbcsc-cphgcmmcshdp.tpc,phdspshbwhhdsdshdphg.Hw,scmmhphdshckbcsh-psmscspsmspswhd-gchcshdphg.thpscbhsmkbdccphg.D,chghpssscdwhcssghmshs.Psmsdcshgg-hpcbmpcshdgss.nghpmspghcdshd,swshsm,hsbsscdwhcs.
10
apc,dbpwhhdc,ssscdwhmdcdssddphswscs.
10,15
ahspsshdsgsmpbcsdhscpssdghmshscbcmpcssg.
 
sort: Key reCoMMenDations for PraCtiCe
Clinical recommendationEvidenceratingReerences
All paiens should receive radiographs as parohe iniial work-up or chronic shoulder pain.C23Furher esing o chronic shoulder pain, using imaging*, should be perormed when he diagnosis remainsunclear or he oucome would change managemen.C23, 24I acromioclavicular oseoarhriis is suspeced, he acromioclavicular join should be assessed or enderness,and a cross-body adducion es should be perormed o help confrm he diagnosis.C16, 18When roaor cuinjury is suspeced, assess or nighpain and pain wih overhead aciviy.C10When he paien has a painul shoulder wih severely limied acive and passive ranges o moion,a diagnosis o adhesive capsuliis should be considered.C8, 9
*— Imaging options include magnetic resonance imaging, arthrography, computed tomography scan, and ultrasonography. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For inormation about the SORT evidence rating system, see page 410 or http:// www.aap.org/apsort.xml.
t 1. h fd d acdsd Dd
HistoryAssociated condition
Age
5,6,7
I younger han 40 years: insabiliy,roaor cu endinopahyI older han 40 years: roaor cu ears,adhesive capsuliis, glenohumeraloseoarhriisDiabees or hyroiddisorders
8,9
Adhesive capsuliisHisory o rauma
10
I younger han 40 years: shoulderdislocaion/subluxaionI older han 40 years: roaor cu earsLoss o range omoionAdhesive capsuliis, glenohumeraloseoarhriisNigh pain
10
Roaor cu disorders, adhesivecapsuliisNumbness, ingling,pain radiaingpas elbowCervical eiologyPain locaionAnerior-superior shoulder pain associaedwih acromioclavicular join pahologyDiuse shoulder pain in deloid regionassociaed wih roaor cu disorders,adhesive capsuliis, or glenohumeraloseoarhriis
Pain with overheadactivity
10
Roaor cu disordersSporsparicipaion
11
Shoulder insabiliy associaed wihoverhead spors (e.g., baseball,soball, ennis), and collision spors(e.g., ooball, hockey)Acromioclavicular join pahologyassociaed wih weigh liingWeakness Roaor cu disorders, glenohumeraloseoarhriis
Inormation rom reerences 5 through 11.
 
sd P e
February 15, 2008
 
 
Volume 77, Number 4
www.p.g/p
 American Family Physician
455
thp’smdchs,cdgjpb-ms,chpwhddgss.ammdsssdfmmhscchshd,sgssdwhghmj,whsdbsdhdds-dscbsscdwhdhscpss.
8,9
PhysiCal exaMination
Table 2
10,15-19
smmssmhshdm-ssdhsscdcds.thpddhxms:spc,pp,gmdsghss,dpcss.ispcshdhshd,whppxpsh,,dpsshd.asccdcpssgm.thpscdm,pchcm-ccj,dcsdm.aphhspsps,dsscmmhsp-s,mbpswhchcc.Ppcdsphg,spcwhhcmccj.isddsshscdhcmccjsdccmccshs.Sbc-mdssmsggscphg.Mpggpsdhshdmd-c-shdphgschsbmg.ismpppbhshdsbcscscscbp(.g.,ccdpcss,ghdbcpsd),hhshd.thpscdsppmdscmshpdgss.rgmshdbdfx,bdc,,dx.ihphscgm,pssgmdbssssd.lsscdpssgsmshhmkdhscpss,bscbdwhmdss-hshg-hmj.lsscgm,whpsdpssgm,spspswhcphg.Pwhcgmbw60d100dgsbdcskwsh“pc”dssscdwhcdss.
20
thmspcsshsh-d.ahghkwdghsscbhpdgsphg,hpmcphscshdbmwhsddssshshdbpmdshd.thHwks’sssddmmpgm
(Figures 1a and 1b)
.tsscphghdp-mcs
(Figures 2a and 2b)
;hmp-cspspss
(Figure 3)
;h-sbscpss
(Figure 4)
;dhxs
(Figure 5)
.thcss-bd
P  d p w   d  -  d  dp.
 
t 2. scd t   sd
Examination maneuverAssociated conditionSensitivity (%)Specifcity (%) LR+LR-
ipc
 Supraspinaus or inraspinaus arophy
10
Chronic roaor cuear56732.070.60
Pp
 Acromioclavicular enderness
16
Acromioclavicular joinOA or chronic sprain96101.070.4
r  m
 Resricive acive
10
Roaor cudisorder30781.360.90
Pc 
 Hawkins’ impingemen
15
Impingemen/roaor cudisorder72662.10.42Drop-arm
15
Large roaor cuear27882.250.83Empy-can supraspinaus
15
Roaor cudisorder involving supraspinaus44904.40.62Li-o subscapularis
17
Roaor cudisorder involving subscapularis62100> 250.38Exernal roaion/inraspinaus srengh
15
Roaor cudisorder involving inraspinaus42904.20.64Cross-body adducion
18
Acromioclavicular joinOA or chronic sprain77793.500.29Apprehension
19
Glenohumeral insabiliy729620.220.29Relocaion
19
Glenohumeral insabiliy819210.350.2
LR+ = positive likelihood ratio; LR- = negative likelihood ratio; OA = osteoarthritis.
NOtE:
The recommended progression o shoulder examination maneuvers is inspection, palpation, range o motion and strength tests, and provoca-tive tests.Inormation rom reerences 10 and 15 through 19.

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