The Painful Shoulder: - A Practical Approach
The Painful Shoulder: - A Practical Approach
What set off the pain? Is it attributable to bursitis, tendinitis, arthritis, a torn rotator cuff, or something more unusual? Does the patient need diagnostic imaging, a specialist referral, physical therapy?
Persistent shoulder pain is a very common problem in adult patients. More than 9% of men and 12% of women over age 15 will be affected at some time during their lives. A recent survey in the Netherlands found that the prevalence of shoulder pain was 21% in adults; in those aged 60 to 64 years, it increases to more than 40%. Most studies tend to show a higher prevalence among women than men.
Shoulder complaints are associated with marked interference with daily functioning and are a common presenting complaint in acute care settings. In certain occupations that involve a lot of pushing and pulling with the arms, shoulder pain is a frequent work-related injury. Many recreational activities, such as canoeing or baseball, are also associated with shoulder injuries. Given the great mobility of the shoulder joint, many activities, such as combing one's hair, reaching for something in a cabinet, or putting on a shirt can be problematic in the presence of shoulder pain.
In many cases of shoulder pain, there is an obvious trigger to the pain, such as a recent fall on an outstretched arm. However, older patients often present with an insidious onset of pain without any obvious recent injury.
Consider the following case:
A 67-year-old man presents with a two- to three-month history of left shoulder pain. The pain is localized mostly over the deltoid region, worsens with overhead movement, and bothers the patient at night. The patient states that he has tried ibuprofen and also glucosamine/chondroitin without much relief. There is no history of recent trauma, although the patient reports that lately he has been working in his yard. He has no history of prior shoulder problems but does have some osteoarthritis in both knees.
EXTENSIVE DIFFERENTIAL DIAGNOSIS
We will revisit the above patient at various points in this article, but first the differential diagnosis for shoulder pain, which is extensive and includes both acute and chronic conditions that directly involve the shoulder (see box below), as well as referred pain, will be discussed. Studies of large numbers of adults with persistent shoulder pain have found that about 60% will have subacromial bursitis or supraspinatus tendinitis; 12%, adhesive capsulitis; 10%, supraspinatus tear or rupture; 7%, acromioclavicular (AC) arthritis; 5%, bicipital tendinitis; and 7%, other causes. To complicate matters, more than one condition can occur simultaneously.
MOST COMMON CAUSES
As mentioned earlier, rotator cuff and supraspinatus tendinitis and subacromial bursitis are the most common causes of persistent shoulder pain in adults. The pain occurs mostly on lifting an arm over the head, reaching for a wallet in a back pocket, or combing one's hair. It is especially problematic at night and often disrupts sleep, because it is difficult to put the shoulder in a neutral position without strain during sleep. During the night, patients may sleep with their arm in a position of abduction and rotation, which can be painful. During the day, they are more likely to avoid such positions and so have less discomfort.
Older patients often have rotator cuff tendinitis in the absence of any overt trauma. The mechanism is thought to relate to a combination of repetitive low-grade injury and relative ischemia of the tendons. In the younger patient, there is usually a history of trauma—typically, a fall on an outstretched arm or excessive use of the shoulder during a sports activity such as pitching a baseball. The underlying trigger in most cases is impingement, which results from compression of the rotator cuff tendons between the greater tuberosity of the humeral head and the lateral edge of the acromion when the arm is abducted. Repetitive compression is thought to contribute to inflammation.
Rotator cuff tears may be full or partial. Acute full thickness tears in younger individuals (under age 40) are normally the result of repetitive use or trauma, such as a fall on an outstretched arm, but they are relatively uncommon. Elderly patients may have full tears that are more chronic or subacute in presentation and often the end result of impingement and tendinitis. There may be an initial injury, but the symptom complex is usually chronic lateral shoulder pain, sometimes with a catching sensation, and often with weakness on overhead lifting and nocturnal pain.
Bicipital tendinitis can occur by itself or in combination with rotator cuff tendinitis. The patient usually reports a more anterior location as the site of the pain than is typical with rotator cuff inflammation.
In the older patient, the clinician always needs to consider referred pain as a possible cause of persistent shoulder discomfort. Potential sources for referred shoulder pain include cervical spine disease, diaphragmatic irritation, coronary disease, pericardial disease, and intrathoracic neoplasms and inflammation. With referred pain, the patient will often have painless active and passive range of motion in the shoulder.
Acromioclavicular joint problems such as arthritis and separation are also common causes of shoulder pain. Typically, patients are able to identify the site of the pain with one finger over the AC joint. The joint will more commonly involve a history of direct trauma, such as being tackled while playing football, or it will result from an occupation that involves weight-bearing with the arm, such as painting.
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Originally Posted by trimurtulu
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