Non-Traumatic Shoulder Injuries
I. Normal Shoulder Exam
A. Referred Pain
i. Cervical radiculopathy
-Suggested by pain radiating below shoulder or to upper back
-decreased range of motion in neck due to pain,
-positive Spurling's test (radicular pain with head compression)
-normal shoulder exam
ii. Lung (apical lung tumor, pleural disease)
iii. Heart (MI)
iv. Subdiaphragmatic (gallbladder disease)
v. Vascular (Thoracic Outlet Sy)
II. Point Tenderness
1. Rotator Cuff
Injury: 90% chronic arms overhead
Diag:
-result of extreme overuse in young adults (e.g. pitchers) or minor
trauma in older adults
-sudden "pop" while lifting overhead
-lateral pain
-worse at night
-abduct arm pain after 20deg
-relief of pain w/ lido inject
(pain free weakness = full tear)
PE: -loss of active BUT NOT passive ROM (due to pain)
-positive impingement signs
-weakness with drop arm test
Rx: Acute --> sling, PT, ortho f/u
Chronic --> PT, ortho
Next: MRI, surgery for younger pts with big tear, rehab
PT: arm dangle at side, circle 5-10wt
2. Adhesive Capulitis (Frozen Shoulder)
Diag:
-diffuse/dull ache
-result of prolonged immobilization of shoulder
-loss of active AND passive ROM
-pain at extremes of motion
Rx: PT, ortho f/u
-rehab for 18 mo, manipulation under anesthesia if no improvement
3. Bicipital Tendinitis
-result of repetitive flexion-extension or pronation-supination of elbow
-PE: anterior shoulder pain with flexion at elbow (curling) or
resisted forearm supination, tenderness over bicipital groove
4. Subacromial Bursitis and Supraspinatus Tendinitis
-result from repetitive overhead arm movement (e.g. serving in tennis
or throwing baseball), gradual onset
-PE: positive impingement signs, pain but no weakness with drop arm test
5. Impingement Syndrome
-definition: narrowing of impingement interval (space between superior
aspect of humeral head and inferior aspect of acromion)
(supraspinatus tendon runs through this space, also subacromial and
subdeltoid bursae are there)
Diag:
-pain exacerbated by overhead arm movements
-nocturnal pain exacerbated by sleeping on affected shoulder
-weakness
-loss of motion
PE:
-positive impingement signs
-pain with elevation of arm with elbow flexed (like military salute)
against resistance
-positive drop arm test
-point tenderness at impingement interval
causes: abduction of arm (normal), structural variations of acromion
(types II and III), osteoarthritic spurs of acromioclavicular (AC)
joint, calcification and thickening of coracoacromial ligament, loss
of rotator cuff strength resulting in superior migration of humerus,
among others
Other
-osteoarthritis (usually acromioclavicular joint), rheumatoid
arthritis, septic arthritis, gout, lyme disease, SLE,
spondyloarthropathy
Source
8/07 DONALDSON (adapted from Miller, Mistry)