History

Fact Explanation
Shoulder pain. [1,2] Inflammation of the supraspinatus tendon
Onset of pain possibly in relation to specific injury or it may be a pain of gradual onset [1] Injury to the muscle-fibers and tendon due to an acute insult or due to overuse, leading to inflammation
Pain is located on the anterolateral aspect of the shoulder [2] The anterolateral portion of the tendon is the part that is initially affected [1]
Pain worsens on flexion and abduction Impingement of the swollen tendon on the anteroinferior part of the Acromion [1]
References
  1. KAMINENI, Srinath. Upper limb- pathology, assessment and management. In: WILLIAMS, Norman S., ed., BULSTRODE, Christopher J.K., ed., O’CONNELL, P. Ronan, ed. Bailey & Love’s Short Practice of Surgery. 25th ed. London: Hodder Arnold, 2008, pp. 486-488
  2. WOODWARD, Thomas W., BEST, Thomas M., The Painful Shoulder: Part II. Acute and Chronic Disorders. American Family Physician, 2000, 61(11),3291-3300
  3. WILSON, John J., BEST, Thomas M., Common Overuse Tendon Problems: A Review and Recommendations for Treatment. American Family Physician, 2005, 72(5), 811-818

Examination

Fact Explanation
Swelling and erythema of the affected shoulder [1] Due to the inflamed tendon
Asymmetry will be noted on the affected side when comparing both shoulders [1] The inflamed tendon leading to swelling of the affected shoulder
Well-localized tenderness on palpation over the supraspinatus muscle [1,2] Pressure over the inflamed tendon leads to pain
Active movements- limited abduction and flexion. [2,3] Active abduction and flexion are limited because of worsening of the pain
Active movements- the pain is at its worst during the middle of the range of abduction (60-120 degrees i.e. the painful arc) and then reduces as the arm is fully raised [2,3] The supraspinatus muscle supports the deltoid in abduction along this arc.
Passive movements- not restricted [2] The articulation itself is usually not compromised.
"Full can test" to assess the supraspinatus muscle- abduction of the shoulders to 90 degrees in forward flexion with the thumbs pointing upwards and the elbows fully extended. The patient then attempts to elevate the arms against the examiner's resistance. There will be pain and weakness on the affected side. [5,6] The inflamed tendon leads to pain and the pain will lead to inhibition of the action of the muscle
Neer's test- place the arm in forced flexion with the arm fully pronated. Pain with this maneuver indicates a positive test [6] Sub-acromial impingement of the inflamed supraspinatus tendon [6]
Hawkins' test- elevate the patient's arm to 90 degrees while forcibly internally rotating the shoulder. Pain with this maneuver indicates a positive test [6] Sub-acromial impingement of the inflamed supraspinatus tendon [6]
References
  1. WILSON, John J., BEST, Thomas M., Common Overuse Tendon Problems: A Review and Recommendations for Treatment. American Family Physician, 2005, 72(5), 811-818
  2. KAMINENI, Srinath. Upper limb- pathology, assessment and management. In: WILLIAMS, Norman S., ed., BULSTRODE, Christopher J.K., ed., O’CONNELL, P. Ronan, ed. Bailey & Love’s Short Practice of Surgery. 25th ed. London: Hodder Arnold, 2008, pp. 486-488
  3. SHIPLEY, M., RAHMAN, A., O’GRADAIGH, D., COMPSTON, J.E. Rheumatology and bone disease. In: KUMAR, Parveen, ed., CLARK, Michael, ed. Kumar & Clark’s Clinical Medicine. 7th ed. Elsevier Limited, 2009, p. 507
  4. HUNTLEY, Jim S., GIBSON, Jane, SIMPSON, A. Hamish R. W. The musculoskeletal system. In: DOUGLAS, Graham, ed., NICOL, Fiona, ed., ROBERTSON, Colin, ed. Macleod’s Clinical Examination. 12th ed. Elsevier Limited, 2009, p. 385
  5. FONGEMIE, Allen E., BUSS, Daniel D., ROLNICK, Sharon J., Management of Shoulder Impingement Syndrome and Rotator Cuff Tears. American Family Physician, 1998, 57(4),667-674
  6. WOODWARD, Thomas W., BEST, Thomas M., The Painful Shoulder: Part I. Clinical Evaluation. American Family Physician, 2000, 61(10),3079-3088

Differential Diagnoses

Fact Explanation
Shoulder girdle pain(Muscular neck pain) [1] Presents as a shoulder pain. Does not radiate to upper arm [1]
Rotator-cuff tears [2,3] Presents as shoulder pain. Weakness and atrophy of the affected shoulder [2,3]
Biceps tendon rupture [2] There is shoulder pain. There will be a bulge in the distal humerus ("Popeye" muscle). In addition, there will be weakness in supination and elbow flexion [2]
Adhesive capsulitis (Frozen shoulder) [2,3] Severe shoulder pain with limitation of all active and passive movements, including rotation. Usually secondary to pain from a previous shoulder problem [1,2,3]
Biceps tendonitis (Bicipital tendonitis) [3] Pain in the area of the bicipital groove. Tenderness over the bicipital groove [3]
Glenohumeral dislocation [3] Most shoulder dislocations are anterior. They present with shoulder pain and the affected arm will be held in an abducted and externally rotated position. The humeral head is palpable anteriorly and there will be a dimple in the skin beneath the acromion [3]
Clavicular fractures [3] Most fractures are located in the middle third of the clavicle. There will be shoulder pain and tenderness over the fracture site [3]
Impingement syndrome [2,3] In impingement syndrome stage ll, there is tendinitis and subsequent fibrosis of the supraspinatus tendon [2,3]
Sternoclavicular(SC) joint sprain and separation [3] Shoulder pain particularly with adduction. Localized tenderness and deformity may be present. The patient's head may be tilted towards the side of the lesion & the discomfort is exacerbated when lying supine [3]
Acromioclavicular(AC) joint sprain and separation [3] Shoulder pain with well-localized swelling and tenderness over the AC joint. A "stepped" deformity is palpable between the acromion and clavicle in complete joint disruption [3]
Labral injury (SLAP lesion & other glenoid labral tears) [3] Painful shoulder that clicks or pops with motion. There is a positive "clunk" test. Tenderness to deep palpation over the anterior glenohumeral joint. Signs of instability may be present [3]
Acute calcific tendinitis [2] There is very severe, acute shoulder pain. Movements are very painful and restricted. Tenderness over the greater tuberosity [2]
Acromioclavicular arthritis [2] Shoulder pain and swelling at the acromioclavicular joint. It is usually associated with tendon impingement [2]
Glenohumeral arthritis [2,3] Shoulder pain with activity, loss of passive motion and stiffness. There may be disuse atrophy with chronic disease [2,3]
Cervical radiculopathy [1,2] Radiating pain below the shoulder with associated pins and neeedles sensation and/or neurological signs on the affected arm [1,2]
Acute coronary syndrome/ Angina pectoris [4] Shoulder and upper arm pain with an associated ischemic-type chest pain [4]
Perforated peptic ulcer [5] Shoulder pain occurs due to diaphragmatic irritation. There is associated abdominal pain. Patient may give a history suggestive of peptic ulcer disease
References
  1. SHIPLEY, M., RAHMAN, A., O’GRADAIGH, D., COMPSTON, J.E. Rheumatology and bone disease. In: KUMAR, Parveen, ed., CLARK, Michael, ed. Kumar & Clark’s Clinical Medicine. 7th ed. Elsevier Limited, 2009, p. 507
  2. FONGEMIE, Allen E., BUSS, Daniel D., ROLNICK, Sharon J., Management of Shoulder Impingement Syndrome and Rotator Cuff Tears. American Family Physician, 1998, 57(4),667-674
  3. WOODWARD, Thomas W., BEST, Thomas M., The Painful Shoulder: Part II. Acute and Chronic Disorders. American Family Physician, 2000, 61(11),3291-3300
  4. CAMM, A. J., BUNCE, N. Cardiovascular disease. In: KUMAR, Parveen, ed., CLARK, Michael, ed. Kumar & Clark’s Clinical Medicine. 7th ed. Elsevier Limited, 2009, p. 688
  5. SCHWARTZ, Shepard, EDDEN, Yair, ORKIN, Boris, ERLICHMAN, Matityahu, Perforated peptic ulcer in an adolescent girl. Pediatric Emergency Care, 2012, 28(7), 709-711

Investigations - for Diagnosis

Fact Explanation
Plain radiograph- Antero-posterior(AP) view of the shoulder (with the arm at 30-degrees external rotation) [1,2] To assess the gleno-humeral joint, subacromial osteophytes and sclerosis of the greater tuberosity [1,2]
Plain radiograph- Outlet Y-view of the shoulder [1,2] To assess the subacromial space and to differentiate between the different anatomic variations of the acromion process [1,2]
Plain radiograph- Axillary view of the shoulder [1,2] To visualize the acromion and coracoid process. Also, in order to visualize coracoacromial ligament calcifications [1]
Ultrasonography of the shoulder [1,3,4] Shows characteristic changes of tendinosis. Also useful if a rotators cuff tear is suspected [1,3]
Magnetic resonance imaging(MRI) of the shoulder [1,3,4] Best imaging modality for rotators cuff pathology. Shows characteristic changes of tendinosis [1,3]
References
  1. FONGEMIE, Allen E., BUSS, Daniel D., ROLNICK, Sharon J., Management of Shoulder Impingement Syndrome and Rotator Cuff Tears. American Family Physician, 1998, 57(4),667-674
  2. WOODWARD, Thomas W., BEST, Thomas M., The Painful Shoulder: Part II. Acute and Chronic Disorders. American Family Physician, 2000, 61(11),3291-3300
  3. WILSON, John J., BEST, Thomas M., Common Overuse Tendon Problems: A Review and Recommendations for Treatment. American Family Physician, 2005, 72(5), 811-818
  4. KAMINENI, Srinath. Upper limb- pathology, assessment and management. In: WILLIAMS, Norman S., ed., BULSTRODE, Christopher J.K., ed., O’CONNELL, P. Ronan, ed. Bailey & Love’s Short Practice of Surgery. 25th ed. London: Hodder Arnold, 2008, pp. 486-488

Management - General Measures

Fact Explanation
Relative rest of the shoulder with avoidance of aggravating activities (Avoid complete immobilization) Relative rest reduces pain, prevents further damage and may promote tendon healing [1]
Application of ice on the affected shoulder Effective for short-term pain relief. Application of ice may blunt the inflammatory response and thus reduce the pain and swelling [1]
Physiotherapy (Strengthening and stretching exercises- once the pain has subsided) Prevents joint stiffness and promotes the formation of new collagen [1]
Technique modification In order to minimize the repetitive stresses placed on tendons in order to reduce pain and promote healing [1]
Sub-acromial injection of local anesthetic (e.g. lidocaine) Temporary improvement of symptoms [2,3,4]
References
  1. WILSON, John J., BEST, Thomas M., Common Overuse Tendon Problems: A Review and Recommendations for Treatment. American Family Physician, 2005, 72(5), 811-818
  2. KAMINENI, Srinath. Upper limb- pathology, assessment and management. In: WILLIAMS, Norman S., ed., BULSTRODE, Christopher J.K., ed., O’CONNELL, P. Ronan, ed. Bailey & Love’s Short Practice of Surgery. 25th ed. London: Hodder Arnold, 2008, pp. 486-488
  3. WOODWARD, Thomas W., BEST, Thomas M., The Painful Shoulder: Part II. Acute and Chronic Disorders. American Family Physician, 2000, 61(11),3291-3300
  4. FONGEMIE, Allen E., BUSS, Daniel D., ROLNICK, Sharon J., Management of Shoulder Impingement Syndrome and Rotator Cuff Tears. American Family Physician, 1998, 57(4),667-674

Management - Specific Treatments

Fact Explanation
Nonsteroidal anti-inflammatory drugs(NSAIDs)- oral and topical [1,3,4,5] Anti-inflammatory and analgesic properties [1,2,3,4,5]
Corticosteroid injections- once a surgically repairable tendon tear is excluded (steroids can be combined with local anesthetics) Anti-inflammatory and analgesic properties [1,2]
Therapeutic ultrasonography Reduces pain and increases the rate of collagen synthesis [1]
Extracorporeal shock wave therapy (ESWT) Induces structural and neurochemical alterations in order to reduce pain and promote tendon healing [1]
Iontophoresis and phonophoresis Delivers topical NSAIDs and corticosteroids to symptomatic subcutaneous tissues (by using electronic and ultrasonographic impulses) [1]
References
  1. WILSON, John J., BEST, Thomas M., Common Overuse Tendon Problems: A Review and Recommendations for Treatment. American Family Physician, 2005, 72(5), 811-818
  2. KAMINENI, Srinath. Upper limb- pathology, assessment and management. In: WILLIAMS, Norman S., ed., BULSTRODE, Christopher J.K., ed., O’CONNELL, P. Ronan, ed. Bailey & Love’s Short Practice of Surgery. 25th ed. London: Hodder Arnold, 2008, pp. 486-488
  3. SHIPLEY, M., RAHMAN, A., O’GRADAIGH, D., COMPSTON, J.E. Rheumatology and bone disease. In: KUMAR, Parveen, ed., CLARK, Michael, ed. Kumar & Clark’s Clinical Medicine. 7th ed. Elsevier Limited, 2009, p. 507
  4. WOODWARD, Thomas W., BEST, Thomas M., The Painful Shoulder: Part II. Acute and Chronic Disorders. American Family Physician, 2000, 61(11),3291-3300
  5. FONGEMIE, Allen E., BUSS, Daniel D., ROLNICK, Sharon J., Management of Shoulder Impingement Syndrome and Rotator Cuff Tears. American Family Physician, 1998, 57(4),667-674