The (Cold) Shoulder!

Common causes of shoulder pain: 

  • Rotator cuff pathology
  • Adhesive capsulitis
  • Impingement
  • AC joint disease
  • Referred pain


Anatomy


Top 3 History Questions:

  • Was there an injury/trauma?
  • Are you losing strength?
  • Are you losing ROM?

Exam

  • Visualization (look for skin changes, bony abnormalities, asymmetries, muscle bulk/atrophy)
  • Palpation (start with the cervical spine, then each bone, joint, and muscle belly/tendon insertion)
  • Active and passive ROM
  • Provocative testing
  • Curious how to perform a telemedicine exam of the shoulder? Check out this article by the Mayo Clinic!

Rotator Cuff

  • Pain all of the time
  • Weakness
  • Real trauma in younger patients, without real trauma in older patients
  • Drop test, empty can test, lift off or bear hug, resisted external rotation

Consider MRI if you are concerned for an acute rotator cuff tear!


Impingement

  • Pain at night, especially with sleeping on that side
  • Pain with ROM especially flexion >90º
  • Usually no weakness, can do ADLs
  • Neer’s test, Hawkin’s test, painful arc 60-120º


Biceps


AC joint

  • Point precisely to AC joint as site of pain
  • Cross arm test, painful arc >120º


Adhesive capsulitis

  • Pain all the time
  • Loss of ROM (can start with pain with ROM)
  • No real trauma
  • Associated with diabetes
  • Differentiate from OA with XR
  • Limited ROM in capsular pattern (external rotation > abduction > internal rotation)

ROM


The Boyd Test*


Further Reading!

  • Çalış, Mustafa, et al. “Diagnostic values of clinical diagnostic tests in subacromial impingement syndrome.” Annals of the rheumatic diseases 59.1 (2000): 4447.
  • Hegedus, Eric J., et al. “Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests.” British journal of sports medicine 42.2 (2008): 80-92.
  • Hermans, Job, et al. “Does this patient with shoulder pain have rotator cuff disease?: The Rational Clinical Examination systematic review.” JAMA 310.8 (2013): 837-847.
  • Jain, Nitin B., et al. “The diagnostic accuracy of special tests for rotator cuff tear: the ROW cohort study.” American journal of physical medicine & rehabilitation 96.3 (2017): 176.

Blog post based on Med-Peds Forum talk by Chelsea Boyd, PGY2