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Shoulder Pain

BASICS

  • Commonality: Affects all ages, accounts for 16% of all MSK complaints; lifetime prevalence ~70%.
  • Etiology varies with age:
  • <30: Instability, overuse
  • 30–60: Rotator cuff (RTC) disorders, impingement, partial tears

  • 60: Full-thickness tear, glenohumeral OA

EPIDEMIOLOGY

  • Incidence: 7–25/1,000 patients/year; peak in 4th–6th decades.

ETIOLOGY & PATHOPHYSIOLOGY

  • Trauma: Fracture, dislocation, ligament/tendon tear, AC separation.
  • Overuse: RTC pathology, biceps tenosynovitis, bursitis, strain, labral injuries.
  • RTC impingement progression:
    • Stage I: Tendinopathy
    • Stage II: Partial tear
    • Stage III: Full-thickness tear
  • Age-related:
  • Young: Instability, physeal injuries
  • Older: OA, adhesive capsulitis, RTC tear
  • Other: Rheumatologic (RA, PMR, fibromyalgia), infection, referred pain (cervical, gallbladder, diaphragm).

RISK FACTORS

  • Repetitive overhead activity/sports
  • Weightlifting (AC joint)
  • Rapid training increases/improper technique
  • Muscle imbalance/weakness
  • Trauma/falls
  • Adhesive capsulitis: DM, thyroid, autoimmunity, female, age 40–60

PREVENTION

  • Maintain strength/ROM
  • Avoid repetitive overhead activity (especially in youth)
  • Use proper technique

DIAGNOSIS

HISTORY

  • Location:
  • Superior: AC, trapezius
  • Lateral: RTC, deltoid
  • Anterior: Biceps tendinosis, labrum
  • Diffuse: RTC, adhesive capsulitis, OA
  • Descriptors:
  • Night pain, worse lying on side: RTC, adhesive capsulitis, OA
  • Stiff/limited ROM: adhesive capsulitis, OA
  • Aggravating movements:
  • Cross-body adduction (scarf test): AC
  • Abduction/external rotation: instability, RTC, OA
  • Overhead: RTC, AC, labrum, OA
  • Neck movement, pain past elbow: cervical
  • Mechanism:
  • Abduction/external rotation trauma: instability/dislocation
  • FOOSH: separation/fracture
  • Overuse: RTC

PHYSICAL EXAM

  • Inspection: Malalignment, atrophy, asymmetry, swelling
  • ROM: Decreased active & passive (adhesive capsulitis); decreased active only (RTC tear)
  • Strength: SITS muscles (supraspinatus, infraspinatus, teres minor, subscapularis)
  • Special tests:
  • Neer, Hawkins: RTC impingement
  • Drop-arm: RTC tear
  • Cross-arm adduction: AC pathology
  • Speed/Yergason: biceps
  • Apprehension/relocation: instability
  • Sulcus sign: inferior instability
  • O'Brien/clunk: labral
  • Spurling: cervical

DIFFERENTIAL DIAGNOSIS

  • Fracture (clavicle, humerus, scapula), contusion
  • RTC disorder: impingement, tear, calcific tendonitis
  • Subacromial bursitis
  • Scapulothoracic dyskinesis
  • AC joint (separation, OA, osteolysis)
  • Biceps tendinosis/tear
  • Glenohumeral OA, instability, adhesive capsulitis
  • Labral tear, muscle strain
  • Cervical radiculopathy
  • Autoimmune, referred pain, infection

DIAGNOSTIC TESTS & INTERPRETATION

  • Plain X-ray: AP, scapular Y, axillary views
  • MRI: Soft tissue/RTC, biceps, labrum
  • MR arthrogram: Labral pathology
  • US: RTC, biceps, AC pathology (good technician = MRI for full-thickness tear)
  • EMG: Distinguish cervical/brachial plexus
  • Labs: Autoimmune serology if indicated
  • ECG: Cardiac suspicion

TREATMENT

  • Conservative:
  • Activity modification
  • Analgesics/NSAIDs/acetaminophen
  • Physical therapy (essential for full recovery)
  • Corticosteroid injections (RTC, capsulitis, OA, scapulothoracic)—US guidance preferred
  • Surgical Referral:
  • Full-thickness RTC tears >1cm in <65 years or functional loss
  • Refractory or complicated/displaced fractures
  • Dislocation/multidirectional instability in <20 years

ADDITIONAL THERAPIES

  • Physical/manual therapy
  • Acupuncture (short-term benefit in RTC impingement)
  • Chiropractic/osteopathic MMT (manual manipulative therapy)
  • Platelet-rich therapies: not routinely recommended

ONGOING CARE & PATIENT EDUCATION

  • Limit overhead activity if symptomatic
  • Recovery may be slow; recurrence/persistent pain in 40–50% at 12 months
  • Refer to specific diagnosis for detailed prognosis

PROGNOSIS

  • Generally favorable with conservative care
  • RTC disorders: most common cause in >30 years
  • Instability: most common in <30 years
  • Diabetes: increased risk for adhesive capsulitis

ICD-10

  • M25.519: Pain in unspecified shoulder

CLINICAL PEARLS

  • RTC disorders are the top cause of shoulder pain >30 years old.
  • Instability is the most common in <30 years old.
  • Adhesive capsulitis: High risk in diabetes.
  • Most cases improve with structured rehab and pain control.