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Painful Shoulder syndromes

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Version Jan 2023

Examination

Palpation
Contours of shoulder look for asymmetry
Palpate from sternoclavicular joint along clavicle
Acromioclavicular joint to acromium
Humeral head to the acromion

Movements

Abduction: supraspinatus
External rotation: infraspinatus/teres minor
Internal rotation: subscapularis

Integrity

Depends on the muscles and associated tendons and ligaments
Joint is shallow and plate-like and so surrounding muscles provide stability

Cause Details

Rotator cuff tear The rotator cuff can become compressed in the subacromial space when arm elevated. Can be worsened by osteophytes or muscle or ligamentous issues such as calcification. Seen in Elderly, trauma, marked nocturnal pain, weakness of resisted abduction. Pain when lying on the affected shoulder is key. The painful arc with active abduction from 90 to 120 degrees. Impingement can lead to a frozen shoulder, rupture long head of biceps or rupture of local tendons. Manage with NSAIDs, analgesia and steroid injection and surgery may be considered to remove osteophytes.

Adhesive capsulitis/Frozen shoulder Nocturnal Shoulder pain occurs when the patient has not been lying on the shoulder. Fibrosis and retraction of the lower glenohumeral joint capsule. Seen in those aged 50+. Associated with diabetes and glycosylation of collagen. May also be seen post-MI, Stroke. Thyroid disease and TB and lung cancer. Initial inflammatory phase with nocturnal pain and restricted movements for up to 9 months then pain settles but shoulder remains stiff and then there is recovery with improved mobility. Analgesia. The joint injection may help. Arthroscopy may be considered. Oral steroids have short term benefit.

Inflammatory arthopathy Swelling of the shoulder and pain, anterior bulge due to subacromial bursa

Glenohumeral OA Morning stiffness and pain on use and chronic symptoms. Changes seen on X-Ray.

Cause	Details
Rotator cuff tear	The rotator cuff can become compressed in the subacromial space when arm elevated. Can be worsened by osteophytes or muscle or ligamentous issues such as calcification. Seen in Elderly, trauma, marked nocturnal pain, weakness of resisted abduction. Pain when lying on the affected shoulder is key. The painful arc with active abduction from 90 to 120 degrees. Impingement can lead to a frozen shoulder, rupture long head of biceps or rupture of local tendons. Manage with NSAIDs, analgesia and steroid injection and surgery may be considered to remove osteophytes.
Adhesive capsulitis/Frozen shoulder	Nocturnal Shoulder pain occurs when the patient has not been lying on the shoulder. Fibrosis and retraction of the lower glenohumeral joint capsule. Seen in those aged 50+. Associated with diabetes and glycosylation of collagen. May also be seen post-MI, Stroke. Thyroid disease and TB and lung cancer. Initial inflammatory phase with nocturnal pain and restricted movements for up to 9 months then pain settles but shoulder remains stiff and then there is recovery with improved mobility. Analgesia. The joint injection may help. Arthroscopy may be considered. Oral steroids have short term benefit.
Inflammatory arthopathy	Swelling of the shoulder and pain, anterior bulge due to subacromial bursa
Glenohumeral OA	Morning stiffness and pain on use and chronic symptoms. Changes seen on X-Ray.

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. The official launch will be at the end of 2018. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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