Shoulder ache is often a common symptom in primary care. This can be caused by an intrinsic shoulder problem such as calcific tendonitis. However, pain can also be referred to other structures like the diaphragm, neck, or heart. Common shoulder issues share overlying clinical features. It is essential to look for any red flags that mean investigation and diagnosis need a more focused or urgent approach when assessing shoulder pain.
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Epidemiology
- Shoulder ache is the 3rd most frequent reason for musculoskeletal consultations in primary care.
- 1% of adults suffering from new shoulder pain see their general practitioners (GP) every year.
- The self reported prevalence of shoulder ache is between 16% to 26%.
Risk factors
- Occupation-related physical factors, including repetitive exposure and movements to vibrations from machine tools.
- Work-related psychosocial factors may also be risk factors for including stress, shoulder pain, job satisfaction, social support, and job pressure.
- Shoulder pain is common in athletes who engage in overhead activities or contact sports.
- Occupations particularly prone to shoulder pain syndromes include garment makers, meat/food-processing workers, decorators, assembly/production line workers, cashiers, bricklayers/construction workers, hairdressers, plasterers, pneumatic tool operators, welders, and painters workers using keyboards for long periods. For example, IT, secretarial.
Causes
Patients presenting to primary care usually have a combination of various shoulder problems.
- Rotator cuff disorders
- Intrinsic shoulder pain
- Rotator cuff tears
- Calcific tendonitis
- Subacromial pain is caused by impingement if the humeral heads are not sufficiently depressed to slide under the acromion on the elevation of the arm. Sometimes, it is also called tendonitis, tendinopathy, or subacromial bursitis.
- Glenohumeral disorders: frozen shoulder (adhesive capsulitis), arthritis.
- Biceps tendinopathy.
- Acromioclavicular joint problems.
- Infection (rare)
- Extrinsic shoulder pain
- Shoulder instability - associated with hypermobility, involves dislocation or subluxation.
- Referenced pain: Myocardial ischaemia, neck pain, referred diaphragmic pain (e.g., subphrenic abscess, gallbladder disease).
- Malignancy: metastases, apical lung cancers.
- Polymyalgia rheumatica.
Primary care is dominated by four main causes of shoulder pain or disability: acromioclavicular joint disease, glenohumeral disorders, rotator cuff disorders, and referred neck pain.
Assessment
When assessing shoulder pain, Take a history of your shoulder pain and conduct an exam with these questions in mind.
- Is the pain appear from the neck, shoulder, or elsewhere?
- Are there any red flag signs & symptoms?
- Is the pain confined to the acromioclavicular joints: the pointing sign? If so, you have an acromioclavicular joint disease.
- Are there symptoms such as global pain, restricted movement, restriction in all activities, and passive? If so, it could be a glenohumeral disorder, either frozen shoulder or arthritis.
- Does the patient show a wide region of pain: a grasping sign suggestive of subacromial pain?
History
Some points to cover in history are mentioned below.
Nature of the pain involved:
- Any particular injury
- How the pain began
- Whether it is chronic or acute.
- Any effect on daily activities or functions.
- It doesn't matter if the pain is on either side of the dominant arm.
- It doesn't matter if there is a pain in motion or at rest.
- It doesn't matter if there is night pain that affects sleep.
- Any pain associated with it - such as chest, neck, or any other upper joint pain or limb pain.
- Any history of shoulder pain/dislocation/instability.
- The occupation of the patient
- Sports activities of the patient.
- Any symptoms or signs of systemic disease.
- Your past medical history, especially any history of diabetes, cancer, or coronary heart disease.
- Adverse drug reactions and drug history.
Examination
Although there are more than 100 specific "Orthopaedic Special Testings" that can detect shoulder pathology, only a few of them are specific or sensitive enough to be diagnostically discriminatory.
- Examine the axilla, neck, and chest wall.
- Assess the range of motion and examine the cervical spine.
- For muscle wasting, swelling, deformity, or bruising, inspect the sides, front, and back.
- Acromioclavicular, and palpate the sternoclavicular glenohumeral joints. Look for tenderness, warmth, swelling, and crepitus.
- As an initial screening test, ask the person if they would like to place their palms at the base of their neck with their elbows pointing laterally. Next, ask them to lower their arms and to try to get their backs between the shoulder blades. Be aware, however, that this can also affect other joints, e.g., elbow, wrist.
- Both shoulders should assess the power, range of motion, and stability, active, passive, and resisted.
- Look for sharp pain in the arc between 70 and 120deg of abduction.
- Test the passive external winding at 'Frozen Shoulder' Low. Keeping the elbow at the side, bend the arm out as far as possible.
- Passively abduct the patient's shoulder and perform the drop arm test. Ask the patient to slowly lower the abducted hand to the waist. This can identify a huge rotator cuff tear. They may be able to gradually lower the arm to 90 degrees as this mainly uses the deltoid muscle, but below 90 degrees, the arm will drop to the side.
- The cross arm test is used to isolate the acromioclavicular joints. Ask the patient to lift the arm to 90 degrees straight in front of them. Next, ask the patient to adduct the arm across the chest. If there is an acromioclavicular joint problem, there will be pain in the joint area.
Investigations
- If there are any red flags, symptoms, or signs, blood tests such as ESR/CRP, FBC, and radiology like CXR are usually not required
- Ultrasonography is the most preferred imaging test for the shoulder.
- A plain X-ray is rarely helpful, except for the confirmation of shoulder dislocation or shoulder arthritis.
- Magnetic resonance arthrogram is helpful in shoulder instability.
- X-ray of the cervical spine may be helpful if referred neck pain is suspected. However, the diagnosis is always clinical.
Treatment And Management
There is a paucity of well-designed clinical trials in managing shoulder disorders. Primary care management is typically conservative. It involves reducing or avoiding overhead activities, paying attention to any contributing factors, and taking medication for pain relief, including corticosteroid injections. Physiotherapy focused on the specific cause of symptoms is indicated if symptoms don't resolve quickly or become severe initially.
Rotator Cuff Disorders
- Recommend modifications to activities, such as reducing precipitating movement, e.g., reaching overhead.
- Provide analgesia with paracetamol or codeine. Or, an oral NSAID (non-steroidal anti-inflammatory drug) can be used.
- Refer to physiotherapy for the purpose of optimizing shoulder function using an evidence-based rehabilitation program.
- If the person cannot do strengthening or stabilizing exercises due to pain, a subacromial injection of corticosteroid may be an option. These may have a short-term benefit.
Rotator Cuff Tears
- Steroid injections and physiotherapy can be useful for minor tears.
- Suspicious large tears, which are symptomatic, can benefit from early referrals for orthopedic input.
- Surgical treatment often involves the repair of the arthroscopic rotator cuff tendon.
Muscle Strains
- A very common shoulder muscle strains include the trapezius, rhomboid strains.
- The treatment of muscle strains involves R.I.C.E. Method rest, ice, compression, elevation (sitting up), massage and NSAIDs (topical and oral), and any additional analgesia required.
- Physiotherapy may be required for severe or persistent strains.
It is not proof of good quality to say whether acupuncture works to treat shoulder pain for some reason or if it is harmful.
Glenohumeral Disorders
In the short-term, glucocorticoid injections seem to be more effective than physiotherapy or exercises.
Acromioclavicular Disease
- The acromioclavicular injury usually responds to relaxing and simple analgesia unless there is a significant interruption in the joint, in which the orthopedic referral is necessary.
- If an acromiocloveler is suspected of joint injury, consider providing a sling for 5-7 days.
- If the patient is not responding well to rest and analgesia, physiotherapy may be recommended.