Evaluation and Treatment ofShoulder Pain

Deborah L. Greenberg, MD

KEYWORDS

� Rotator cuff disease � Subacromial impingement syndrome � Adhesive capsulitis� Painful arc

KEY POINTS

� Shoulder pain can have a significant impact on function.

� A thorough examination of the shoulder is a necessity.

� Most shoulder pain is due to the structure supporting the shoulder joint.

� Pain relief and exercises are the mainstays of therapy.

INTRODUCTION

Shoulder pain is a common presenting concern in outpatient medical practice. Shoul-der problems can significantly affect a patient’s ability to work and other activities ofdaily life such as driving, dressing, brushing hair, and even eating. “The shoulder” con-sists of a complex array of bones, muscles, tendons, and nerves, making the cause ofpain seem difficult to decipher. Shoulder pain can be caused by structures within theshoulder or can arise from problems external to the shoulder. Fortunately, most shoul-der pain falls into one of several patterns.The rotator cuff provides stabilization to the glenohumeral joint, and contributes to

mobility and strength of the shoulder. Disease of the rotator cuff is the most commoncause of shoulder pain seen in clinical practice. The prevalence of rotator cuff diseaseincreases with age, obesity, diabetes, and chronic diseases that affect the strength ofthe shoulder such as stroke.1 An experienced practitioner can often recognize thecause of a patient’s shoulder pain with a few questions and a focused examination.Treatment of shoulder pain can be successfully managed by a primary care providerin most cases. Referral to a physical therapist can be important to help improve thepatient’s mechanics and strength. Early use of imaging studies and specialist referralsare overutilized by primary care providers, and should be limited to specific indica-tions.2 Consultation with an orthopedic surgeon for fractures and tendon tears willbe necessary in some cases.

The author declares no financial disclosures or conflict of interest.Division of General Internal Medicine, University of Washington School of Medicine, 4245Roosevelt Way Northeast, Seattle, WA 98105, USAE-mail address: debbiegr@u.washington.edu

Med Clin N Am 98 (2014) 487–504http://dx.doi.org/10.1016/j.mcna.2014.01.016 medical.theclinics.com0025-7125/14/$ – see front matter � 2014 Elsevier Inc. All rights reserved.

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When evaluating patients with shoulder pain, it is important to understand the anat-omy of the region. The major anatomic structures of interest include (Fig. 1)3:

� Four main bony structures: proximal humerus, clavicle, scapula, and ribs. Theacromion, the superior, anterior extension of the scapula, forms the roof of theshoulder.

� Three main joints: glenohumeral, acromioclavicular (AC), sternoclavicular.� Four rotator cuff muscles/tendons (SITS): supraspinatus (abduction), infraspinatus(external rotation), teres minor (external rotation, adduction), and subscapularis(adduction, internal rotation). The supraspinatus and infraspinatus tendons passthrough the subacromial space to insert on the greater tubercle of the humerus.

Fig. 1. Muscles: back and scapula region. From Netter illustration from www.netterimages.com. � Elsevier Inc. All rights reserved.

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� Bursa: the subacromial bursa provides a cushion as the rotator cuff tendonsmove below the acromion.

� Surrounding musculature: biceps, deltoid, pectoralis, latissimus dorsi,rhomboids.

� Neurovascular: suprascapular nerve and vessels.

Important Terms

Rotator cuff diseaseRotator cuff disease (RCD) is a term encompassing tendinopathy, partial-thicknesstear, or complete tear of one or more of the rotator cuff tendons. RCD also includessubacromial bursitis. In general, the term RCD is used synonymously with subacromialimpingement syndrome (SIS).

Subacromial impingement syndromeSIS is an umbrella term that encompasses rotator cuff tendinopathy and partial tears,as well as subacromial bursitis. The term is meant to convey the proposed etiology ofthese conditions. Inflammation and pain are caused by compression or impingementof the supraspinatus tendon (most common), infraspinatus tendon, subacromialbursa, biceps tendon, or other structures as they pass through the space betweenthe lateral aspect of the acromion and the humeral head. Functional impingementcan occur when there are problems with the mobility and stability of the rotator cuffmuscles or the position and movement of the scapula.4 Risk factors for impingementinclude repetitive activity above the head, increasing age, and conditions such asstroke and Parkinson disease. These risk factors are related to poor mechanics ordecreased strength and stability of the rotator cuff and other supporting muscles.The natural history of SIS is often chronic or with recurrent pain and dysfunction.

Adhesive capsulitis (frozen shoulder)Chronic pain and reduced active and passive mobility in the glenohumeral joint isassociated with a variety of shoulder problems or occur as a primary problem of un-known cause. Adhesive capsulitis typically is seen in patients in their 40s to 60s, but ismore common in diabetics in whom it is likely to present at a younger age. Adhesivecapsulitis may resolve spontaneously over a period of years, but causes significantpain and functional limitations in the meantime.5

SYMPTOMS

Symptoms should be evaluated in the context of the patient as a whole. Age, under-lying medical conditions, body habitus and overall strength, and smoking status are allimportant considerations. A systematic approach to history taking is crucial to avoidmissing historical information. The most important factors include:

� Prior condition of shoulder� Location of current pain:

Localized or diffuseAnterior, lateral, or posterior

� Radiation patterns (clue: radiation past the elbow suggests a neurologiccomponent)

� Timing of pain onset: sudden onset or developed gradually? (clue: came on all atonce suggests a tear)6

� Associated factors: repetitive stress or recent or prior injury� Duration: acute (<6 weeks), subacute (6–12 weeks), chronic (>3 months)

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� Quality of pain: sharp, dull� Associated symptoms: weakness, stiffness, crepitus, swelling (clue: fear ofrecurrence suggests shoulder instability)

� Alleviating and exacerbating factors: pain at night, pain worse with overheadactivities (pain at night is a classic symptom for tear but likelihood ratios [LRs]are not significant in systematic review)7

� Systemic factors: fever, numbness, weight loss, fatigue, dyspnea, chest pain

Common Symptom Patterns

Subacromial impingement: lateral pain, subacute, worse with movement overheadRotator cuff tear: sudden onset, weakness, pain at nightAdhesive capsulitis: distant injury or chronic pain, progressive inability to reach overhead, decreased mobility

DIAGNOSTIC TESTS AND IMAGING STUDIESPhysical Examination

The physical examination is used to diagnose the cause of the patient’s pain but alsoto assess functional abilities. Elderly patients in particular may not be able to performactivities of daily living and may require assistance at home. A systematic approach tothe examination is essential. The initial physical examination for shoulder pain shouldfocus primarily on the musculoskeletal complex. Additional components of the exam-ination can be performed if there is concern about an extrinsic cause of the patient’sshoulder pain.

Observing Both Shoulders for Comparison

Further specific testing can be done based on the results of the initial examination.There are many tests for shoulder mobility and strength. None of the maneuvershas been found to be the ideal test for diagnosis of a particular syndrome or lesion.8

Abduction maneuvers are recommended, given their better performance in system-atic reviews in the diagnosis of specific pathologic conditions of the shoulder.

1. General appearance (Fig. 2): Symmetry, bulk, deformities, atrophy above or belowthe scapular spine. Atrophy in the space below the scapular spine suggests RCD(positive LR 2.0, negative LR 0.61)7 or injury to the suprascapular nerve.6

2. Palpation: Sternoclavicular joint, clavicle, acromioclavicular joint, lateral acromion,biceps tendon in the groove between the greater and lesser tubercle of the humer-us. Remember: some patients can be tender at many points but you are trying torecreate the pain that they have been experiencing at home. The anterior jointline can be palpated.

3. General range of motion (ROM)/pain provocation testing: ROM testing identifieslimitations in ROM and localizes pain. Start with these basic ROM tests with thepatient standing. Test active ROM first and add passive ROM if the patient haspain or limited motion. All maneuvers start from the anatomic position with armsat the side and palms facing forward.

AbductionAsk the patient to raise the arm from the side (0�) to overhead (Fig. 3). Normal ROM is180�. If the patient has limitation in active ROM, assist with passive ROM. Standbehind the patient and place a hand on the unaffected shoulder. With the otherhand support the patient’s affected arm just above the elbow. The patient’s arm

Fig. 2. General appearance of the shoulder. (A) Anterior; (B) Posterior.

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should remain within the horizontal plane. Raise the arm until limited by pain. If painoccurs with active or passive ROM, specify the location (0�–180�).Pain in the lateral shoulder between 60� and 120� abduction is known as the painful

arc, and suggests disease in the rotator cuff or subacromial bursa,9–11 also known assubacromial impingement. The painful arc is one of the most helpful physical exami-nation findings when considering RCD (positive LR 3.7, negative LR 0.50).7

Pain between 120� and 180� suggests a problem with the AC joint.

External rotationStand in front of the patient. Ask the patient to hold the arms in front of the body withelbows bent to 90�, palms facing in; ask the patient to hold the elbows against thesides and move the hands outward, parallel to the floor. Normal external rotation isat least 55� and up to 80�. For passive ROM grasp the affected arm proximal to thewrist and externally rotate. Pain or decreased ROM suggests a problem with the teresminor or infraspinatus muscle.

Internal rotationStand in front of the patient. Ask the patient to hold the arms in front of the body withelbows bent to 90�, palms facing in; ask the patient to hold the elbows against the

Fig. 3. Abduction.

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sides and move the hands inward, parallel to the floor. Normal internal rotation is atleast 45�. For passive ROM, grasp the affected arm proximal to the wrist and internallyrotate. Pain or decreased ROM suggests a problem with the subscapularis muscle.

Cross-body adductionCross-body adduction is also known as the scarf test (Fig. 4). The patient reaches theaffected arm across the body to the opposite shoulder. Pain in the front of the shouldersuggests AC joint abnormality.

Fig. 4. Cross-body adduction.

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� If the basic examination and ROM testing are normal, STOP and consider prob-lems external to the shoulder itself. Pursue more generalized examination: neuro-vascular examination of the upper extremity, cardiac, pulmonary, abdominal,and neurologic examinations.

� If you are concerned about adhesive capsulitis or glenohumeral arthritis, poorlylocalized pain, limited range of all active and passive ROM, STOP.

� If you are concerned about AC joint disease, pain over AC joint, pain on abduc-tion, STOP.

� If you are concerned about RCD, further testing for impingement (Fig. 5) andstrength testing (Fig. 6) is required.

� If you are concerned about instability, biceps tendinopathy, or posterior pain,further tests as shown in Fig. 7 should be considered.

Anteroposterior and Axillary Plain Radiographs of the Shoulder

Radiographs are useful in the setting of trauma, in particular:

� Fall on outstretched arm: fracture of the proximal humerus� Fall on lateral shoulder: AC joint separation, clavicular or humeral fracture

Radiographs are also useful in evaluating:

� Presence and extent of glenohumeral arthritis, or to differentiate glenohumeralarthritis from adhesive capsulitis in a patient with limited passive ROM

� Presence and extent of AC arthritis� Shoulder pain in patients with rheumatoid arthritis

Ultrasonography of the Shoulder

Ultrasonography of the shoulder can be used to assess:

� Shoulder dislocation.� Biceps disorder. Compared with arthroscopy, ultrasonography performs well inthe diagnosis of dislocation or subluxation of the long head of the biceps (sensi-tivity 96%, specificity 100%). Ultrasonography is also reliable for detecting com-plete tears of the biceps tendon, but may not be adequate for the detection ofpartial tears (sensitivity 49%, specificity 97%).12

� Rotator cuff tears. This modality is operator dependent, but in the hands of agood technician can be as good as magnetic resonance imaging (MRI) fordetecting full-thickness tears (sensitivity 92%, specificity 94%) and partial-thickness tears (sensitivity 67%, specificity 94%).13,14 Summary data for detect-ing any tear is sensitivity 91% and specificity 85%.15 Ultrasonography is lessexpensive than MRI, and is better tolerated and preferred by patients.16

Magnetic Resonance Imaging

MRI of the shoulder is indicated for:

� Possible labral tear (trauma, repetitive overhead throwing or playing tennis,catching, or locking)

� Possible rotator cuff tear when quality ultrasonography not available (weakness)

As with ultrasonography, performance characteristics are better for full-thicknesstears (sensitivity 84%–96%, specificity 93%–98%) than for partial-thickness tears(sensitivity 35%–44%, specificity 85%–97%).13 For diagnosing any rotator cuff tear,sensitivity is 98% and sensitivity 79%.15 MRI allows a better look at the shoulder asa whole, and can be useful if a surgical procedure is planned.

Fig. 5. Additional range of motion/pain provocation tests for suspected impingement. (A)Hawkins-Kennedy Impingement Sign:10 Patient holds arm at 90� flexion with elbow at 90�

flexion. Place downward pressure on the forearm and passively internally rotate the arm.(positive LR 1.5, negative LR 0.51).7 (B) Neer’s Impingement Sign: The patient internallyrotates their hand (thumb toward the ground). Place your hand on the back of the patient’sshoulder to stabilize the scapula. Forward flex the patient’s straight arm by grasping justbelow the elbow and lifting. (positive LR 1.3).7 Full ROM 180�.

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Magnetic resonance arthrography (MRA) is better than either ultrasonography orMRI in detecting rotator cuff tears,17 especially partial-thickness tears. MRA is gener-ally ordered by sports medicine or orthopedic consultants on referral for possible sur-gical repair in a patient who has not improved with conservative therapy or who hassignificant strength lost on examination, but in whom a tear was not detected on initialimaging.

Fig. 6. Strength testing of rotator cuff. (A) Empty Can Test: Patient starts with a straight armat 90� abduction. The arm is then brought forward 30� toward center on the horizontalplane and the thumb rotated toward the floor. Apply gentle pressure downward abovethe elbow while patient attempts to resist this pressure. Pain suggests impingement ofthe supraspinatus. Weakness suggests a partial- or full-thickness tear.6 (B) Resisted isometricexternal rotation: Patient flexes their arm to 90� and attempts to externally rotate armagainst resistance. (positive LR for RCD 2.6, negative LR 0.49).7 (C) Internal Rotation lagtest*: similar to lift-off test. One of the best tests when considering complete tear of subsca-pularis. Patient places hand on back with elbow at 90�. The examiner lifts the hand off theback. Failure to hold this position is a positive test. (positive LR for full thickness tear 5.6,negative LR 0.04).7

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Bottom Line

Check radiograph if: trauma or possible arthritisCheck sonogram or MRI if: concern for labral or rotator cuff tear

DIFFERENTIAL DIAGNOSIS

The differential diagnosis is broad and can be aided by the primary location of the pain.

Lateral Shoulder Pain

SIS, rotator cuff tendonitis, subacromial bursitis, full-thickness or partial-thicknesstears of the rotator cuff tendons, adhesive capsulitis, multidirectional instability, cervi-cal radiculopathy, proximal humeral fracture, glenohumeral osteoarthritis (Table 1).

Fig. 7. Further testing if suspecting something other than subacromial impingementsyndrome. (A) Apprehension Test- patient lies on the table. With their arm positioned offthe side of table it is abducted 90� and externally rotated 90� (positive LR 17.2).11 A positivetest is patient apprehension in this position. (B) Speed’s Test: The patient flexes their arm to90� with palm facing upward. Press downward as the patient resists arm movement. A posi-tive test is pain in area of bicipital groove. (C) Yergason’s Test: The patient flexes their elbowto 90�. Provide resistance to supination. A positive test is pain in area of bicipital groove.

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Anterior Shoulder Pain

RCD, glenohumeral osteoarthritis, AC arthritis, AC separation, biceps tendonitis,adhesive capsulitis, anterior instability, biceps tendon rupture (sudden-onset pain,weakness and swelling), proximal humeral fracture, labral tear (Table 2).

Posterior Shoulder Pain

Posterior instability/dislocation, suprascapular nerve entrapment, RCD, labral tear,glenohumeral osteoarthritis, cervical radiculopathy, proximal humeral fracture.

Nonspecific Shoulder Pain

� Polymyalgia rheumatica: older patient, bilateral shoulder pain, full ROM, noweakness, may have hip pain, claudication, fatigue

Table 1Common causes of lateral shoulder pain

SIS/RCDComplete Rotator CuffTear Adhesive Capsulitis

Associated factors Repetitive movementStrokeParkinson disease

Long history of shoulderproblems

Trauma

DiabetesAge

Onset Subacute to chronic Acute or chronic withsudden worsening

Subacute to chronic

Other findings Tenderness belowlateral edge ofacromion

Pain at nighta

WeaknessCatching sensation

StiffnessSignificant functional

limitations

Range of motion Full passive ROM Limited active ROM dueto weakness

Full passive ROM

Decreased active andpassive ROM

Pain with rangeof motion

aPainful arc� External rotation� Internal rotation

Often in setting ofimpingement, thussimilar findingspossible

Pain with ROM onmultiple maneuvers

Weakness No YesDrop-arm testOther tests (see Fig. 6)

No

Atrophy No Maybe Maybe

Acute: �6 weeks; subacute: 6–12 weeks; chronic: �3 months.Abbreviations: RCD, rotator cuff disease; ROM, range of motion; SIS, subacromial impingement

syndrome.a Classic symptom but likelihood ratios not significant in systematic review.7

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� Cervical radiculopathy: pain below the elbow, numbness or weakness,decreased reflexes

� Glenohumeral osteoarthritis� Rheumatoid arthritis: stiffness and other joint involvement� Consider pulmonary, gastrointestinal, and cardiac causes of diaphragm irritationor referred pain

TREATMENT

The goal of treatment is to reduce pain and improve ROM, thus restoring function tothe shoulder.

General Measures

� Analgesics: Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonlyrecommended for the treatment of shoulder pain because of their anti-inflammatory effects. Experience suggests that any commonly used oral analge-sics can be used for the treatment of shoulder pain thought to be due to RCD,SIS, AC joint disease, or adhesive capsulitis. There have been no studiescomparing oral over-the-counter or prescription acetaminophen with NSAIDs.Thus either can be used, depending on coexistent disease and provider andpatient preference.

� Should patients put ice or heat on their shoulder? Ice has traditionally beenrecommended for painful muscles and joints.18 There is little evidence to show

Table 2Differential of anterior shoulder pain

Biceps Tendonitis AC Separation AC ArthritisProximal HumeralFracture Adhesive Capsulitis Labral Tear OA

Associatedfactors

AgeAssoc with SIS

Fall onto lateralshoulder

Repetitive lifting AgeFall on shoulder oroutstretched arm

Chronic progressivepain/stiffness

Repetitiveoverheadthrowing

Trauma

AgePrior trauma

Onset Subacute to chronic Acute Chronic Acute Subacute to chronic Acute Chronic

Specificfindings

Tenderness inbicipital groovewith internal andexternal rotation

Unilateral deformityand tenderness ofAC joint

Tenderness overAC joint

Bruising Decreased passive/active ROM

Deep shoulderpain

Joint-linetenderness

StiffnessCrepitusJoint-line

tenderness

ROM Normal Normal exceptadduction

Normal exceptadduction

Reluctant to attempt Decreased passive/active ROM

Normal Decreasedpassive/activeROM

Maneuver SpeedYergason

Cross-arm adduction Cross-armadduction

None Forward flexionreduced

None None

Initialevaluation

None Radiograph Radiograph Radiograph None MRI Radiograph

Abbreviations: AC, acromioclavicular joint; MRI, magnetic resonance imaging; OA, osteoarthritis; ROM, range of motion; SIS, subacromial impingement syndrome.

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whether ice is effective or even counterproductive in the treatment of soft-tissueinflammation. Ice does produce analgesia. Recommend ice for 20 to 30 minutesas often as every 2 hours if it provides relief to the patient. Ice should not be usedbefore vigorous exercise. If ice is not helpful, the patient can try heat.

� Activity and work modification: Patients should limit activities that exacerbatetheir discomfort, especially overhead movements.

Menu of Additional Therapeutic Options

� Physical therapy: Therapists often use a combination of modalities, which canincludemanualmobilization, ice, heat, ultrasonography,massage, supervisedpro-gressive resistance exercises, electric stimulation, acupuncture, and stretching.

� Exercise therapy: Exercise therapy is generally initiated by a physical therapist.The patient is given instruction on strengthening exercises with movementsagainst gravity and then progressive resistance exercises. The patient thenfollows a self-management plan at home.

� Manual therapy: Joint and soft-tissue mobilization and manipulation. Manualtherapy is thought to break down the adhesions that form between differentlayers of soft tissue and allow unimpeded movement of the muscle. It can beused alone or in combination with exercises.

� Acupuncture: Needles are placed into specific acupuncture points. Sessionstypically last 30 to 60 minutes and are performed 1 to 2 times a week for 4 to8 weeks. Acupuncture can reduce pain,19,20 allowing the patient to participatein exercise therapy.

� Subacromial corticosteroid injection: The injection can be guided by ultrasoundor by clinical landmarks. There is no difference in safety or efficacy with eitherapproach.21 The routine use of ultrasound-guided glucocorticoid injection isdiscouraged, given the excess cost. Patients should not engage in heavy liftingfor 2 weeks following an injection.

� Platelet-rich plasma injection: Injection of autologous platelet-rich plasma intothe subacromial space. There is no evidence that platelet-rich plasma injectionsin addition to exercise improve pain or function of the shoulder to a greater extentthan exercise alone.22

� Immobilization should be avoided unless directed by a surgeon for fracture.� Botulinum toxin: Intramuscular injection of botulinum toxin A, which may be use-ful in reducing shoulder pain after stroke and in osteoarthritis of the shoulder.23

� Surgical intervention.

Condition-Specific Treatment

SIS/RCD, subacromial bursitis

Bottom Line1. General measures: ice/heat, oral analgesic, avoid exacerbating activities.2. Patient should have exercise therapy as part of a home self-management plan or as

part of a physical therapist treatment plan.3. The addition of manual therapy, acupuncture, or a subacromial steroid injection

can have added benefit. Consider based on availability, cost, and patientpreference.

4. If symptoms fail to improve after 3 months of conservative therapy, referral forsurgical intervention can be considered.

The cause of this syndrome is dysfunctional mechanics, primarily of the scapula orrotator cuff muscles, leading to inflammation and pain as tendons and other structure

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are compressed between the acromion and humeral head. Treatment is designed toreduce pain, allowing sufficient strengthening exercises to correct the mechanicaldeficiencies.Exercise therapy is universally recommended for the treatment of SIS and RCD.

Exercise can significantly reduce pain and improve function.24,25 Recommendedexercises run the gamut from nonspecific shoulder strengthening to exercisesdesigned to correct the mechanical issues leading to impingement. In one studyof patients awaiting surgery for impingement, exercise focusing on eccentricstrengthening of the rotator cuff muscles and eccentric/concentric strengtheningof the shoulder stabilizers substantially reduced the need to for surgery in compar-ison with nonspecific shoulder exercises (odds ratio 7.7, 95% confidence interval3.1–19.4; P<.001).26

Exercise therapy can be supervised as part of regular visits to a physical therapist,or done independently by the patient at home as part of a self-management plan. Pa-tients willing to participate in self-training typically meet with the therapist initially andthen attend 1 to 3 follow-up visits to adjust the exercise plan. Both supervised and in-dependent exercise programs improve symptoms in patients with shoulder pain.25

Self-management involves fewer visits with the therapist and thus, lower cost. Patientswho are willing to adhere to a home program likely have better improvement in painand function than patients who participate in a more traditional physical therapyprogram.27

Exercise therapy can be combined with manual therapy or acupuncture, or startedafter a subacromial steroid injection. Manual therapy in addition to exercise may bemore effective than exercise alone in reducing pain.28 Subacromial steroid injectionor acupuncture plus home exercise therapy are equally effective at reducing painand improving function in patients with SIS both short term and after 1 year.20 Initiationof exercise should be delayed for 2 weeks after a steroid injection.Surgical decompression, either arthroscopically or as an open procedure, is

designed to reduce compression in the subacromial space. Studies have not showna benefit of surgery over conservative therapy for the reduction of pain or improvementof function in patients with impingement syndrome.29,30 Given the risks of surgery, thismodality should be considered only after conservative therapy has failed.

Rotator cuff tearRotator cuff tears can be asymptomatic or can cause significant pain and disability.Patients with a rotator cuff tear who are surgical candidates should be referred toan orthopedic surgeon to discuss the risks and expected benefits of surgical repair.Some patients will recover sufficient pain relief and function without surgery, but theoutcome in an individual patient is difficult to predict.31 Because delayed surgerycan cause complications in some patients owing to atrophy and scarring of tissue,patients should be fully informed of their options.

Adhesive capsulitisReduction of pain followed by improved ROM is the goal of therapy. Pain reductioncan be achieved with a subacromial corticosteroid injection or oral analgesics. Ran-domized trials have shown that steroid injections and oral NSAIDs, when accompa-nied by therapeutic exercise, are equally effective in improving pain and functionover a period of 6 months.32 The choice of therapy should be based on patient pref-erence, comorbidities, and availability of treatment options. It is unclear whethermanual therapy in addition to other treatments improves outcomes.28 If the patientis in significant pain, declines injection, and has contraindications to other oral

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analgesics, oral steroids can reduce pain and improve ROM in the short term, butare unlikely to improve long-term function.33 Patients should be educated on thetime course of recovery. Full recovery can often take as long as 6 to 18 months. Ad-hesive capsulitis may be self-limited in some patients over a period of months toyears.5 Patients who fail to respond to 3 months of therapy or are unable to partic-ipate in therapy because of significant pain can be referred for consideration ofimaging-guided capsular distention, manipulation under anesthesia, or other surgi-cal options.

Osteoarthritis of the glenohumeral jointInitial conservative therapy can include pain relief with analgesics and exercise ther-apy, although there is limited evidence that these modalities improve function or out-comes. Limited evidence suggests that injectable viscosupplementation can behelpful for some patients.34 Patients who fail conservative therapy can undergo totalarthroplasty of the shoulder joint with hopes of reducing pain and improving function.There are no randomized trials comparing surgical treatment with continued conser-vative measures in these patients.35

Nonspecific shoulder pain/dysfunctionMassage therapy helps improve pain and ROM in short-term studies, especially in pa-tients with posterior shoulder pain and limited internal ROM.36 There is little evidencethat it helps improve function of the shoulder over the long term.28

MANAGEMENTEducation

In addition to the specific treatment of shoulder pain, patients should be educated onthe cause of their problem and the role of each of the modalities used in treatment.Failure to engage in self-management, particularly rehabilitation exercises, can signif-icantly delay or prevent full return to function.

Prevention

Many shoulder problems are due to repetitive motion with the arms or the lack ofstrength and mobility. Patients with work-related symptoms should undergo an ergo-nomic review at work to reduce the risk of persistent problems.37 All patients shouldbe encouraged to incorporate upper extremity ROM and strengthening to their overallfitness routine.

CASESCase 1

A 58-year-old man with a history of obesity and diabetes reports pain in his rightshoulder over the last several months. He does not remember a specific injury, butis now having difficulty performing his job as a house painter and putting on andtaking off his shirt. He has difficulty laying on his right side to sleep. When askedto locate the pain he places his hand over the lateral aspect of his right shoulder.On physical examination he has tenderness below the lateral edge of the acromion.His active ROM is limited to 100� abduction because of the pain, but he has fullpassive ROM. He has pain with external rotation but no evidence of weakness inhis right arm. Hawkins and Neer tests are positive. He has tried ice, a 2-week trialof ibuprofen, and then a 2-week trial of acetaminophen without significantimprovement.

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DiscussionThis patient has a history and examination consistent with SIS. Review his dosing ofanalgesics to ensure that he tried adequate doses. Further NSAIDs may be contrain-dicated if he has renal dysfunction. He should be prescribed ice, heat, and then spe-cific exercises with manual therapy, acupuncture, or a subacromial bursa injection.

Case 2

A 63-year-old woman has had pain in her left shoulder for the last 6 months. Painbegan while trimming some plum trees in her yard. Initially she had difficulty puttingdishes into an overhead cabinet. She has been avoiding all overhead activities forthe last 3 months. She finds that her shoulder is stiff and she has difficulty brushingher hair. She is not able to localize her pain to one spot. On examination she haslimited active and passive ROM with forward flexion, abduction, internal rotation,and external rotation of her left arm. She does not have weakness.

DiscussionThis patient most likely has adhesive capsulitis. If you were concerned about gleno-humeral arthritis, a radiograph would be reasonable to exclude this possibility. Oral an-algesics and referral to a physical therapist for exercises is the appropriate initial step.

Case 3

A 74-year-old woman lost her balance while boating. She fell and hit her right shoulderagainst the seat in the boat. She had immediate pain in her right shoulder, and hasbeen holding her arm against her side in the 3 hours since the accident, as any move-ment is uncomfortable. Her arm is bruised and she is reluctant to move it. Her pulsesand neurologic testing in that arm are intact.

DiscussionNo further examination is needed at this point. A radiograph to assess for fractureshowed a proximal nondisplaced humeral fracture. After discussion with an orthope-dist, she was placed in an arm sling and followed up in the clinic.

FUTURE CONSIDERATIONS AND SUMMARY

Shoulder pain is a common symptom in the adult population. The most commoncause of shoulder pain is SIS, reflecting a problem with the rotator cuff or subacromialbursa. Determining the cause of a patient’s pain is usually a clinical diagnosis basedon careful history taking and physical examination. Limited use of imaging studies willbe needed in the setting of trauma, possible glenohumeral arthritis, or when a com-plete tendon tear is suspected. Therapy is based on pain control and therapeuticexercises in almost all cases. Despite the prevalence of shoulder pain, there is noconsensus on the best way to achieve pain control or on the type of exercise mostlikely to achieve speedy recovery.

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