EVALUATION OF
SHOULDER PAIN
SHOULDER BASIC
PAIN
EVALUATION
KNOWLEDGE
OF ANATOMY
POSTERIOR VIEW
Rotator cuff muscles
EVALUATION
OF
SHOULDER
PAIN
Shoulder Pain-Causes
1. Non-traumatic
I. Intrinsic Causes
A. Glenohumeral
Rotator cuff tendinopathy, Rotator cuff tear, Subacromian bursitis,
Glenohumeral arthritis, Glenohumeral instability, Labral tear
B. Extra-Glenohumeral
Bicipital tendinopathy, Acromioclavicular arthritis, Subscapular bursitis,
Distal clavicle osteolysis
II. Extrinsic Causes
Disc herniation with C4, C5 radicular pain, Cervical spinal canal
stenosis/myelopathy, Long thoracic and suprascapular neuralgia, Post-
herpetic neuralgia involving C4, C5 nerve root, CRPS involving upper
arm and shoulder (Shoulder-Hand syndrome), Referred pain
(Myofascial pain, Diaphragm irritation, Myocardial ischemia,
Intrathoracic tumors)
2. Traumatic
Fracture clavicle, Fracture humerus, Glenohumeral dislocation,
Acromioclavicular ligament sprain
Red flags
1. Tumour like pan coast tumour
2. Acute rotator cuff tear
3. Unreduced dislocation
4. Infection
5. Unexplained sensory and motor deficit
6. Pulmonary or vascular compromise
7. Myocardial infarction
History –general
Chief complaints:
Pain in shoulder with duration, Stiffness of shoulder
H/O present illness
1. Quantity of pain – severity
2. Quality of pain- nociceptive, neuropathic etc
3. Aggravating & Relieving factors
4. Radiation
5. Diurnal variation
Family history
Occupational history
Medical history
History special
Shoulder Joint Examination: at a glance
Inspection Palpation Range of Neurological Special
1st step
2nd step
3rd step
4th step
5th step
movements examinations tests
including
muscle
power
Special tests
Tests for Rotator cuff Tests for Tests for AC Tests for
impingement tests instability joint Bicipital
• Neer’s test • Drop arm test • Apprehension • Local tenderness Tendon
• Hawkin’s • External rotation test • O’Brien test • Speed test
Kennedy test lag sign • Relocation test • Yergason test
• Anterior release
test
I. INSPECTION
INSPECTION
ANTERIOR ASPECT
•CLAVICLE– Fracture is common in the middle 1/3 rd
•STERNOCLAVICULAR JOINT– Dislocation, Enlargement due to
degenerative changes
•ACROMIOCLAVICULAR JOINT--Enlargement due to degenerative
changes or, acute injury
•DELTOID -- atrophy increases visibility of under lying bones
POSTERIOR ASPECT
•SCAPULA – medial border is clearly visible… protrusion of medial
border that is Winging of Scapula can occur due to weakness or
denervation of Serratus Anterior Muscle because of Long Thoracic
Nerve injury
ALIGNMENT
•Viewed anteriorly or posteriorly both shoulders should appear
symmetric
II. PALPATION- bones & joints
Bones:
•CLAVICLE –Tenderness …if there is a fracture
•ACROMION -- Os Acromionale (a second ossification centre fails to unite
with the main body of the acromion).. Tenderness maybe present
Joints:
•STERNOCLAVICULAR JOINT – tenderness may be present due to injury
•ACRMIOCLAVICULAR JOINT- tenderness may be present in AC joint arthritis
•GLENOHUMERAL JOINT- tender may be present in arthritis
•CERVICAL FACET JOINTS- there might be referred pain around shoulder
PALPATION– muscles-tendons-bursa
Bicipital tendon & bursa
Supraspinatus & subscapularis muscles and bursa
Subacromian/subdeltoid bursa
Infraspinatus muscle and bursa
Trigger points at trapezius, deltoid, supra/infraspinatus muscle
III. Range of Motion (ROM) Tests
• ROM tests : both active & passive
•Pain or/and restriction of movements
•Flexion- Extension-Abduction-Adduction(horizontal adduction)-
Internal/External Rotation (at adducted & 90 degree abducted
position)
•Apley’s scratch test
Apley’s scratch test
IV. Neurological examinations
Sensory-
Motor-
1. Power
2. Tone
3. Reflexes
Sensory
Motor power Belly press test
Empty can test
External rotation
against resistance
Biceps C5
Reflexes Brachioradialis C6
Triceps C7
1. Tests for supraspinatus
impingement
Neer’s Test Hawkin’s-Kennedy Test
2. Rotator cuff tests
Drop arm Test
External Rotation Lag sign
3. Tests for shoulder instability
Apprehension test Relocation test
Anterior release test
4. Tests for AcromioClavicular Joint
AC joint tenderness test
O’Brien test
5. Tests for Bicipital tendon
Speed test Yergason test
1. X-ray helpful mostly in traumatic pain
Fractures of the proximal humerus, clavicle, and scapula
Glenohumeral dislocations & osteoarthritis
AC joint arthritis or injury
2. MRI
Rotator cuff tear & tendinopathy,
Avascular necrosis
Investigations Biceps tendinopathy and rupture
Tumors
3. Ultrasonography
Rotator cuff tears
Labral tears
Biceps tendon tears
Dislocations
4. Blood tests: Infections, inflammatory arthritis, coagulopathy
Trigger point inj (Myofascial pain)
Stellate ganglion/T2-T3 Sympathetic
(CRPS/Shoulder-hand syndrome)
Diagnostic Selective nerve root block (radicular
pain)
interventions
Local anaesthetic inj for
impingement
Suprascapular nerve block (for
treatment plan)
Shoulder Pain Algorithm
Shoulder Pain Algorithm
Shoulder Pain Algorithm
Thank
you
