Shoulder Pain
Julie Adkins and Jill C. Cash
Definition
A.The shoulder is the most mobile joint in the body. The shoulder can abduct, adduct, rotate, be raised in front and back of torso, and move through a full 360-degree plane. Because of its full range of motion (ROM), the shoulder is more prone to injury than any other joint.
B.Anatomy of the shoulder:
1.The shoulder joint is made up of bones held in place by tendons, ligaments, and muscles.
2.The shoulder joint has three joints:
a.Glenohumeral joint (the main joint of the shoulder).
b.Acromioclavicular joint.
c.Sternoclavicular joint.
3.Unlike other joints, all joints work together to permit a universal motion of the shoulder.
4.Types of cartilage in the shoulder:
a.White cartilage is present on the ends of the bones and allows the bones to glide and move on each other (articular cartilage).
b.Labrum cartilage is fibrous cartilage found only around the shoulder socket.
5.Multiple muscles are responsible for movement in the shoulder. These muscles attach to the scapula, humerus, and clavicle forming the shoulder cap and underarm. These muscles include the following:
a.Serratus anterior.
b.Subclavius.
c.Pectoralis minor.
d.Sternocleidomastoid.
e.Levator scapulae.
f.Rhomboid major and minor.
g.Trapezius.
h.Deltoid.
Incidence
A.According to the Centers for Disease Control and Prevention, in 2010 nearly 1.2 million people in the United States visited an emergency department for shoulder problems.
B.A community survey of 644 elderly people over the age of 70 (318 male and 326 female) revealed the prevalence of shoulder disorders as being approximately 21%.
C.Shoulder disorders were more common in women (25% vs. 17%).
D.70% of the cases involved the rotator cuff.
E.Fewer than 40% of the subjects sought medical attention for their symptoms.
F.Studies confirm that shoulder pain is a chronic problem that interferes with daily care and activities for the elderly population.
Pathogenesis
A.The shoulder is an unstable joint due to the joint’s ROM, which increases the likelihood of joint injury and degenerative changes. Major injuries to the shoulder include rotator cuff tears and bone fractures involving the clavicle, scapula, and proximal humerus.
B.The most common shoulder problems are dislocation, separation, rotator cuff disease, rotator cuff tear, frozen shoulder, fracture, and arthritis.
Predisposing Factors
A.Overuse of the shoulder and/or frequent overhead reaching.
B.Manual labor.
C.Sports.
D.Injury.
E.Arthritis.
F.Tendon inflammation or tear.
G.Fracture.
H.Instability.
Common Complaints
A.Pain on movement of the shoulder or arm.
B.Limitation of movement of the shoulder.
C.Stiffness of the shoulder.
Other Signs and Symptoms
A.Swelling of the shoulder.
B.Difficulty lifting the arm and getting dressed.
C.Difficulty with routine activities of daily living (ADLs).
Potential Complications
A.Fracture.
B.Gallbladder disease.
C.Heart disease/myocardial infarction (MI).
D.Disease of the cervical spine.
E.Tumors.
F.Infection.
G.Nerve-related disorders.
Subjective Data
A.Ask patient what activity brought about or preceded the episode. Any falls? Any direct blow injuries?
B.Inquire about the duration of pain, what makes it worse, what makes it better.
C.Ask patient to describe pain, for example, dull, aching, or burning. Any numbness or tingling?
D.Does pain radiate to other areas of the back, arm, or neck?
E.Have patient rate pain on a scale of 0 to 10, with 0 being no pain.
F.Note a list of all medications currently being taken, particularly any over-the-counter (OTC) preparations, rubs/creams, splints/sling, or electrical stimulation devices.
Physical Examination
A.Vital signs: Check temperature (if applicable), pulse, respirations, and blood pressure.
B.Inspect:
1.Always compare each area bilaterally for comparison and contour of anatomy.
2.Inspect general appearance and gait, noting evenness and symmetry of motion, as well as wing arm in tandem with opposite lower extremity.
3.Observe shoulder movement as patient disrobes—normal is smooth, natural, and bilateral. Abnormal findings are jerkiness and patient’s attempt to move to decrease pain.
4.Inspect skin for discoloration, abrasions, scars, or evidence of previous pathology.
5.Inspect the clavicle for distortion or abnormality, possibly indicating a fractured clavicle
6.Inspect the deltoid portion of the shoulder, which should be rounded as a result of the draping of the deltoid muscle over the greater tuberosity of the humerus. Normally, the area is full and round and the two sides are symmetrical. Inspect for atrophy or asymmetry, possibly representing a dislocation.
7.Inspect the posterior shoulder, the scapula. In the resting position, the scapula is positioned over ribs 2 to 7 and medial border is approximately 2 inches from the spinous processes. The triangular area of the scapula is opposite T3. Inspect for winged effect, which may indicate weakness or atrophy of the serratus anterior muscle. Scapular asymmetry also occurs when the scapula has only partially descended from the neck to the thorax, causing a webbing or shortening of the neck (Sprengel’s deformity).
C.Auscultate:
1.Auscultate carotid arteries.
2.Auscultate abdomen.
3.Conduct a complete heart exam and lung exam.
D.Palpate: (The provider should position self behind the seated patient with cupped hands on the deltoid and acromion.)
1.Palpate the suprasternal notch and the joint that holds the clavicle in place.
2.Palpate in a sliding motion the anterior superior surface of the clavicle.
3.Palpate the acromioclavicular joint by pushing in a medial direction against the thickness end of the clavicle. Then ask the patient to flex and extend the shoulder. Movement of the joint will be palpated under the fingers. Note any crepitation, which may indicate osteoarthritis or dislocation of the lateral end of the clavicle.
4.Palpate the acromion and the greater tuberosity of the humerus
5.Palpate the bicipital groove, which is located anterior and medial to the greater tuberosity. It is more easily palpable if the arm is externally rotated, providing for a more exposed position for palpation. This requires gentle palpation because the long head of the biceps lies within it, and too much pressure may elicit pain, causing difficulty with further evaluation.
6.Palpate the scapula. It is clinically important to palpate this area, for it is frequently a site of referred pain from the cervical spine.
7.Palpate the soft tissues of the shoulder, which is divided into four clinical zones:
a.Rotator cuff (the supraspinatus, infraspinatus, subscapularis, and the teres minor muscles). Note tenderness during palpation. This may be due to defects, tears, or tendon detachment. The supraspinatus muscle is the most commonly ruptured muscle, especially near its insertion. Passive extension of the shoulder moves the rotator cuff into a palpable position. Hold the patient’s arm and lift the elbow posteriorly.
b.Subacromial and subdeltoid bursa can be very tender if bursitis is present. Palpate for thickening, masses, specific tenderness, or crepitation.
c.Axilla—abduct the arm with one hand as you gently insert your index and middle fingers into the axilla. Then return the patient’s arm to the side to relax the skin; your fingers will be able to penetrate higher into the axilla. Palpate for lymph node enlargement or tenderness. Palpate the anterior wall, medial wall, and posterior walls of the axilla.
d.Prominent muscles of the shoulder girdle—palpate the muscles bilaterally for size, shape, consistency, and tone. Palpate the sternocleidomastoid, the pectoralis major, bicep, deltoid, trapezius, rhomboid minor and major, latissimus dorsi, and serratus anterior.
8.Evaluate the ROM, both active and passive. The shoulder girdle involves six motions: abduction, adduction, extension, flexion, internal rotation, and external rotation.
9.Two useful tests to help to diagnose a rotator cuff tear are the following:
a.Empty can test for detecting a supraspinatus tear. Arm is elevated to 90 degrees and angled forward 30 degrees to place the humerus in line with the scapula. The shoulder is internally rotated by pointing the thumb down to the ground. The clinician applies a downward force as the patient attempts to resist. Pain and/or weakness are deemed a positive test.
b.Drop arm test. The arm is abducted to at least 90 degrees. Lower the arm slowly and control the descent. The inability to perform this task slowly and with control is a positive test. The patient may still have a tear even if this test is negative.
E.Mental status: Assess for confusion.
Diagnostic Tests
A.Plain x-rays of the shoulder—will show any injuries or fractures to the bones.
B.MRI and/or ultrasound—these tests create a better picture of soft tissues, identifying injuries to the ligaments and tendons.
C.Arthrogram—a dye is injected into the shoulder to visualize the joint, muscles, and tendons.
D.Arthroscopy—a surgical procedure using a fiber-optic camera to inspect the joint. This procedure may show injuries that may not be apparent on exam or other tests. Sometimes arthroscopy may be used to correct the problem.
E.Electromyogram (EMG) can be used to evaluate nerve function, if indicated.
Differential Diagnosis
A.Shoulder pain.
B.Heart disease.
C.Gallbladder disease.
D.Liver disease.
E.Disease of the cervical spine.
Plan
A.General interventions:
1.Educate the patient regarding proper treatment and care for the injured shoulder.
B.Patient teaching:
1.Educate the patient on rest, altering activities to avoid overexertion or overdoing activities to prevent shoulder pain.
2.Educate the patient on sling use, if indicated.
3.Educate the patient on RICE: Rest, Ice, Compression, and Elevation.
4.Educate the patient on ROM, strengthening exercises.
C.Pharmaceutical therapy:
1.Nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin as indicated. Consider kidney function and other chronic conditions.
2.Injection of corticosteroid drug if shoulder does not get better or injection of lidocaine for numbing effect.
3.Oral prednisone therapy to reduce inflammation, short term only.
4.Cautionary use of opioid analgesics for pain.
Follow-Up
A.Approximately 23% of all new episodes of shoulder pain completely resolve within 1 month and 44% within 3 months of onset.
B.Approximately 50% of patients with an acute shoulder who are treated conservatively recover within 5 months, and approximately 60% recover within 12 months.
C.The patient’s personality traits, coping styles, and occupational factors may determine otherwise.
D.Follow-up should be in 1 to 2 weeks to reevaluate shoulder function, pain status, and impact of daily life abilities.
Consultation/Referral
Acute fracture or dislocation requires immediate referral to orthopedic surgeons. Urgent referral as needed for any red flag diagnoses.
A.Referral to orthopedic surgeon if there are positive imaging findings or surgical interventions are needed.
B.Referral to physical therapy or physiotherapist for exercise, strengthening, strapping, immobility devices, or ultrasound therapy as well as prevention of further injuries.
Individual Considerations
A.Geriatrics:
1.Soft tissue lesions are the prevalent cause of shoulder pain with geriatric population. These include rotator cuff tendinitis/rupture, frozen shoulder, acromioclavicular joint OA, and subacromial impingement. Studies indicate that geriatric patients suffering with shoulderrelated pain experience an impact on their functional level and quality of life, which increases the risk of proximal humerus fractures.
2.Consider acute versus chronic shoulder interventions. Current recommendations are home exercises with a physical therapist (PT) and a focus on assisted wall walking
and ROM.
3.NSAID use is dependent on comorbid diseases such as gastrointestinal, cardiac, or renal disease.