EVALUATION

OF SHOULDER
PAIN
SHOULDER BASIC
PAIN
EVALUATIO KNOWLEDGE
N OF ANATOMY
POSTERIOR VIEW
Rotator cuff muscles
EVALUATI
ON OF
SHOULDER
PAIN
 Goal of evaluation
Make a diagnosis

Shoulder
Pain:
A Puzzle
Causes & Red Clinical Diagnostic
History Investigations
Flags examination interventions

Solve
Solvethe
thePuzzle:
Puzzle:
Make
Makea aDiagnosis
Diagnosis
Causes &
red flags
Shoulder Pain-Causes
1. Non-traumatic
I. Intrinsic Causes
A. Glenohumeral
Rotator cuff tendinopathy, Rotator cuff tear, Subacromian bursitis, Glenohumeral
arthritis, Glenohumeral instability, Labral tear
B. Extra-Glenohumeral
Bicipital tendinopathy, Acromioclavicular arthritis, Subscapular bursitis, Distal
clavicle osteolysis
II. Extrinsic Causes
Disc herniation with C4, C5 radicular pain, Cervical spinal canal
stenosis/myelopathy, Long thoracic and suprascapular neuralgia, Post-herpetic
neuralgia involving C4, C5 nerve root, CRPS involving upper arm and shoulder
(Shoulder-Hand syndrome), Referred pain (Myofascial pain, Diaphragm
irritation, Myocardial ischemia, Intrathoracic tumors)
2. Traumatic
Fracture clavicle, Fracture humerus, Glenohumeral dislocation,
Acromioclavicular ligament sprain
Red flags
1. Tumour like pan coast tumour
2. Acute rotator cuff tear
3. Unreduced dislocation
4. Infection
5. Unexplained sensory and motor deficit
6. Pulmonary or vascular compromise
7. Myocardial infarction
History
History
Pain history (intensity, quality, aggravating & relieving
factors, diurnal variation etc)
Age & Sex
H/O Trauma
Past medical history
Family history
Examination
 Shoulder Joint Examination: at a
glance
Inspection Palpation Range of Neurologica Specia

2nd step
1st step

3rd step

4th step

5th step
movement l l tests
s examination
s including
muscle
power

Special tests

Tests for Rotator cuff Tests for Tests for AC Tests for
impingement tests instability joint Bicipital
• Neer’s test • Drop arm test • Apprehension test • Local tenderness Tendon
• Hawkin’s Kennedy • External rotation • Relocation test • O’Brien test • Speed test
test lag sign • Anterior release test • Yergason test
I. INSPECTION
 INSPECTION
ANTERIOR ASPECT
•CLAVICLE– Fracture is common in the middle 1/3 rd
•STERNOCLAVICULAR JOINT– Dislocation, Enlargement due to
degenerative changes
•ACROMIOCLAVICULAR JOINT--Enlargement due to degenerative
changes or, acute injury
•DELTOID -- atrophy increases visibility of under lying bones
POSTERIOR ASPECT
•SCAPULA – medial border is clearly visible… protrusion of medial
border that is Winging of Scapula can occur due to weakness or
denervation of Serratus Anterior Muscle because of Long Thoracic
Nerve injury
ALIGNMENT
•Viewed anteriorly or posteriorly both shoulders should appear symmetric
II. PALPATION- bones & joints
Bones:
•CLAVICLE –Tenderness …if there is a fracture
•ACROMION -- Os Acromionale (a second ossification centre fails to unite
with the main body of the acromion).. Tenderness maybe present
Joints:
•STERNOCLAVICULAR JOINT – tenderness may be present due to injury
•ACRMIOCLAVICULAR JOINT- tenderness may be present in AC joint
arthritis
•GLENOHUMERAL JOINT- tender may be present in arthritis
•CERVICAL FACET JOINTS- there might be referred pain around shoulder
PALPATION– muscles-tendons-
bursa
Bicipital tendon & bursa
Supraspinatus & subscapularis muscles and bursa
Subacromian/subdeltoid bursa
Infraspinatus muscle and bursa
Trigger points at trapezius, deltoid, supra/infraspinatus muscle
III. Range of Motion (ROM) Tests
• ROM tests : both active & passive
•Pain or/and restriction of movements
•Flexion- Extension-Abduction-Adduction(horizontal
adduction)- Internal/External Rotation (at adducted & 90
degree abducted position)
•Apley’s scratch test
Apley’s scratch test
IV. Neurological examinations
Sensory-
Motor-
1. Power
2. Tone
3. Reflexes
Sensory
Motor power Belly press
test

Empty can test

External rotation
against resistance
 Biceps C5

Reflexes Brachioradialis C6

Triceps C7
V. Special Tests
1. Tests for impingement

Neer’s Test Hawkin’s-Kennedy

Test
2. Rotator cuff tests

Drop arm Test

External Rotation Lag sign

3. Tests for shoulder instability

Apprehension test Relocation test

Anterior release test

4. Tests for AcromioClavicular
Joint

AC joint tenderness test

O’Brien test
5. Tests for Bicipital tendon

Speed test Yergason test

Investigations
 1. X-ray helpful mostly in traumatic pain

Fractures of the proximal humerus, clavicle, and scapula

Glenohumeral dislocations & osteoarthritis

AC joint arthritis or injury

2. MRI

Rotator cuff tear & tendinopathy,

Avascular necrosis

Investigations Biceps tendinopathy and rupture

Tumors

3. Ultrasonography

Rotator cuff tears

Labral tears

Biceps tendon tears

Dislocations

4. Blood tests: Infections, inflammatory arthritis, coagulopathy

 Diagnostic
interventions
 Trigger point inj (Myofascial pain)

Stellate ganglion/T2-T3
Sympathetic (CRPS/Shoulder-hand
syndrome)
Diagnostic Selective nerve root block (radicular
pain)
interventions
Local anaesthetic inj for
impingement

Suprascapular nerve block (for

treatment plan)
Shoulder Pain Algorithm
Shoulder Pain Algorithm
Shoulder Pain Algorithm
Thank
you