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Evaliuation of shoulder pain

Intodution
Shoulder pain is the third-leading cause for patients to see
musculoskeletal care. The impact of shoulder pain on health-related
quality of life is also substantial. It is important to obtain the history,
physical examination and relevant investigation, which are essential for
reaching the diagnosis. For many disease entities, a diagnosis can be
accurately reached even without the use of imaging studies. In this
chapter an overview of common causes of shoulder pain and basic
clinical approach to diagnosis are discussed.
Classification
The causes for shoulder pain can be classified as follows:
A. Non traumatic
Intrinsic causes
1. Genohumeral
i.
Rotator cuff tendinopathy
ii.
Rotator cuff tear
iii.
Subacromian bursitis
iv.
Glenohumeral arthritis
v.
Labral rear
2. Extra glenohumeral
i.
Bicipital tendinopathy
ii.
Acromioclavicular arthritis
iii.
Subscapular bursitis
iv.
Distal clavicle osteolysis
Extrinsic causes
1.
2.
3.
4.
5.
6.

Disc herniation with neural imppigment at C5 or C6 LEVEL


Cervical spinal canal stenosis
Long thoracic and supracapsular neuralgia
Post-herpetic neuralgia involving C4, 5 nerve root
CPRS involving upper arm and shoulder
Referred pain
i.
Myofascial pain syndrome (commonly trapezius)
ii.
Diagphragm irritation
iii.
Myocardial ischemia
iv.
Intrathoracic tumors

B. Traumatic
- Fracture clavicle
- Fracture humerus
- Glenohumeral dislocation
- Acromioclavicular ligament sprain

History the first step in diagnosis the cause of shoulder pain is taking
thorough history. Readers can refer to chapter 2 for basic concepts on
history taking. Initially all the red flag indicators must be ruled out.
Red Flags
These include:
-

Tumor
Acute rotator
Unreduced dislocation
Infection
Unexplained significant sensory ad motor deficit
Pulmonary or vascular compromise

The following issues should be covered in history:


-

Age: instability is common is age less than 35 years


whereas rotator cuff and glenohumeral pathologies are
common on age more than 35 years.
Trauma: any significant trauma or any strenuous activity
that preceded the pain should be asked. Fracture and
traumatic rotator cuff tear ,ay have pain immediately but
adhesive capsul it is tends to have more gradual onset.
Pain history: history should be targeted for onset,
nature, duration, exacerbating and relieving factors,
quality, location, and radiation which helps in diagnosis.
Some important facts on shoulders pain are discussed
below.
o Location of pain should be noted. Anterolateral
shoulder pain is often associated with impingement
syndrome and the various stage of rotator cuff
tendinotapathy. However rotator cuff

Investigation
Diagnostic imaging of the shoulder may be valuable when directed by
the history and physical examination. A variety of modalities may be
employed.

Plain fotograph
Plain fotographs of the shoulder general have limited benefit in the
evaluation of non-traumatic shoulder pain. While there are no specific
guideline for when radiography is indicated, it is generally
recommended to obtain plain in patiens who have lost rang of motion,
particularly when there is serve pain, and after trauma. When plain film
are obtained in a patient with a history of trauma, both AP and axillary
view are warranted since some conditions can be missed on the former
alone. Plain films can identity the following:
-

Fracture of proximal humerus, clavicle, and scapula


Glenohumeral dislocation
Glenohumeral osteoarthritis
AC joint arthritis or injury
Sternoclavicular (SC) joint arthritis

Magnetic Resonance Imaging (MRI)


MRI is preferred imaging study for patient with suspected impingement
and rottor cuff injury. A normal MRI suggests that the likelihood of a
rotator cuff tear is less than 10%. On the other hand, MRI findings for
rotator cuff tears are not hightly specific, particularly in older patients.
The sensitivity and specificity of MRI for the diagnosis of impingement
are approximately 93 and 87%. Respectively. MRI is also useful in the
evaluation of vascular necrosis, biceps tendinopathy and rupture,
inflammatory processes and tumors.

Ultrasonography
In the of skilled operators, the diagnostic accuracy of ultrasound has
been found to be the equivalent of MRI in identifying rotator cuff tears,
labral tears, and biceps tendon tears and dislocations. Ultrasound is
less expensive than MRI and preferred by patient