SHOULDER PAIN

It is possible for patients of all ages to have shoulder pain, sometimes due to trauma, this joint is also susceptible to development of arthritis, rotator cuff tear and less commonly, collagen vascular disease, and infection.

Differential Diagnosis:

• Prior trauma

• Acromioclavicular joint (AC) separation , Sternoclavicular Joint injury
• Rotator cuff tear--more common in the elderly.
• Fractures (clavicle, humerus, scapula)
• Shoulder dislocation.
• Complex Regional Pain Syndrome Type I (RSD), Type II (Causalgia)

• No prior trauma

• Bursitis (subacromial, subdeltoid)
• Adhesive capsulitis (frozen shoulder)
• Rotator cuff inflammation
• Arthritis ( glenohumeral, acromioclavicular, sternoclavicular)
• Glenohumeral instability
• Biceps tendinitis or rupture
• Neurologic disorders (cervical spine, brachial plexus)
• Neuropathic Pain
• Infection
• Neoplastic process (primary or metastatic)

HISTORY:

• Age
• Trauma
• Work activities
• Recreational activities
• Crepitation
• Weakness
• Decreased range-of-motion
• Type of Pain (burning, stinging, lancinating etc.)
• Night pain (type)
• Sensation of slipping or instability
• Constitutional or other symptoms

CLINICAL FINDINGS:

• Inspection
• Palpation
• Range-of -motion (ROM)

• passive (ROM)
• active (ROM)

• Testing with resistance

• Supraspinatus (abduction, external rotation)
• Subscapularis (internal rotation)
• Teres minor and infraspinatus (external rotation)
• Biceps (flexion of elbow)

• Neurologic testing

• DTR’s ( biceps, triceps, brachioradialis)
• Sensory (touch and pinprick, vibratory)
• Intrinsic muscle strength (arm and hand)
• Skin temperature

TESTS:

• Radiographs of shoulder
• MRI
• CT arthrogram
• Nerve conduction studies (EMG)
• CT or MRI of cervical spine if indicated by other tests.
• Sympathetic block
• Laboratory (CBC, sedimentation rate, antibody testing)

MANAGEMENT:

• Fractures (appropriate reduction and immobilization; open or closed)
• Rotator cuff injury or inflammation

• Nonsteroidal anti-inflammatories
• Corticosteroid injections (intracapsular)
• Arthroscopic surgery

• Dislocations (depending on age, surgical or conservative)
•  Acromioclavicular and sternoclavicular inflammation

• Symptomatic treatment of pain
• Corticosteroid injections (acromioclavicular, sternoclavicular
  joint)
• Surgical

• Tendinitis (supraspinatus, infraspinatus, subscapularis, bicipital)

• Symptomatic treatment of pain
• Corticosteroid injections

• Bursitis (subdeltoid, subcoracoid)

• Symptomatic treatment of pain
• Corticosteroid injections

• Frozen shoulder

• Symptomatic treatment of pain
• Corticosteroid injection shoulder joint
• Physical therapy, including local heat and range-of-motion exercises (passive and moderate active)

• Cervical nerve root abnormalities

• Steroid injections (Cervical Epidural Steroid Injections)
• Physical therapy
• Surgical decompression 

• Complex Regional Pain Syndrome 

• Sympathetic Blocks
• Physical Therapy
• Antidepressants (Amitriptyline, Imipramine Clomipramine, Nortriptyline, Desipramine, Maprotiline)
• Anticonvulsants (Carbamazine, Gabapentin, Phenytoin, Lamotrigine, Valproate)
• Antispasticity agents ( Baclofen)
• Analgesics (Tramadol, Oxycodone)

• Neuropathic Pain

• Sympathetic blocks
• Physical Therapy
• Antidepressants
• Anticonvulsants
• Antispasticity agents
• Analgesic’s

• Lytic bone lesions

• Search for underlying cause.