Shoulder pain

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Shoulder pain is "unilateral or bilateral pain of the shoulder. It is often caused by physical activities such as work or sports participation, but may also be pathologic in origin."[1]

Cause/etiology

A careful history is essential in diagnosis. While some shoulder pain is of gradual onset, sudden onset of pain, and the patient's activity at the time (i.e., mechanism of injury) is key information.

Two-thirds of shoulder pain is due to rotator cuff lesions.[2] Rotator cuff strengthening and stretching should be part of athletic training programs, but the specific but simple exercises are not often done, predisposing to injury.

Shoulder impingement syndrome

Shoulder impingement syndrome is "compression of the rotator cuff tendons and subacromial bursa between the humeral head and structures that make up the coracoacromial arch and the humeral tuberosities. This condition is associated with subacromial bursitis and rotator cuff (largely supraspinatus) and bicipital tendon inflammation, with or without degenerative changes in the tendon. Pain that is most severe when the arm is abducted in an arc between 40 and 120 degrees, sometimes associated with tears in the rotator cuff, is the chief symptom."[3]

Shoulder joint tear

Injury to the labrum, the fibrous ring that holds the head of the humerus, the upper bone of the arm, in its socket (i.e., the glenoid) in the shoulder joint, can come from repetitive motion, or specific trauma such as:[4]

  • "Falling on an outstretched arm
  • A direct blow to the shoulder
  • A sudden pull, such as when trying to lift a heavy object
  • A violent overhead reach, such as when trying to stop a fall or slide"
  • Hard throwing movements

Diagnosis

History and physical examination

The history and physical examination has limited ability to diagnose the causes of shoulder pain according to a systematic review[5] and more recent research studies[6][7][8] of the topic.

A more recent study suggests the Gerber test can diagnose subacromial-subdeltoid bursitis with greater than 90% sensitivity.
In Gerber's lift-off test, the patient is asked to place the hand against the back at the level of the waist with the elbow in 90° flexion. The examiner pulls the hand to about 5–10 cm from the back while maintaining the 90° bend in the elbow. The patient is then asked to hold the position without the examiner's help. The test is considered positive if the hand cannot be lifted off the back without feeling the pain. [7]

Treatment

Exercise

Strengthening exercises with rubbed bands may help.[9]

Medications

Several meta-analyses have addresses intra-articular injections:

  • In 2009, a review of 20 trials concluded that injections with corticosteroids and oral non-steroidal anti-inflammatory agents have similar effect.[10]
  • In 2005, a review of 7 trials concluded "Subacromial injections of corticosteroids are effective for improvement for rotator cuff tendonitis up to a 9-month period. They are also probably more effective than NSAID medication."[11]
  • In 2003, the Cochrane Collaboration reviewed 26 trials and concluded "there is little overall evidence to guide treatment".[12]

Acupuncture

Acupuncture may help.[13]

Extracorporeal shock wave therapy

Extracorporeal shock wave therapy (ESWT) may help calcific tendonitis of the shoulder.[14]

Surgery

The role of surgery for rotator cuff injury is not clear according to a systematic review.[15]

The role of surgery for frozen shoulder is not clear according to a systematic review.[16]

References

  1. Anonymous (2015), Shoulder pain (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. Vecchio P, Kavanagh R, Hazleman BL, King RH (May 1995). "Shoulder pain in a community-based rheumatology clinic". Br. J. Rheumatol. 34 (5): 440–2. PMID 7788173[e]
  3. Anonymous (2015), Shoulder impingement syndrome (English). Medical Subject Headings. U.S. National Library of Medicine.
  4. Shoulder Joint Tear (Glenoid Labrum Tear), American Academy of Orthopedic Surgeons
  5. Hegedus EJ, Goode A, Campbell S, et al (2007). "Physical Examination Tests of the Shoulder: A Systematic Review with Meta-analysis of Individual Tests". Br J Sports Med. DOI:10.1136/bjsm.2007.038406. PMID 17720798. Research Blogging.
  6. Oh JH, Kim JY, Kim WS, Gong HS, Lee JH (2008). "The evaluation of various physical examinations for the diagnosis of type II superior labrum anterior and posterior lesion". Am J Sports Med 36 (2): 353–9. DOI:10.1177/0363546507308363. PMID 18006674. Research Blogging.
  7. 7.0 7.1 Silva L, Andréu JL, Muñoz P, et al (May 2008). "Accuracy of physical examination in subacromial impingement syndrome". Rheumatology (Oxford) 47 (5): 679–83. DOI:10.1093/rheumatology/ken101. PMID 18375403. Research Blogging.
  8. Michener LA, Walsworth MK, Doukas WC, Murphy KP (2009). "Reliability and diagnostic accuracy of 5 physical examination tests and combination of tests for subacromial impingement.". Arch Phys Med Rehabil 90 (11): 1898-903. DOI:10.1016/j.apmr.2009.05.015. PMID 19887215. Research Blogging.
  9. Holmgren T, Björnsson Hallgren H, Oberg B, Adolfsson L, Johansson K (2012). "Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study.". BMJ 344: e787. DOI:10.1136/bmj.e787. PMID 22349588. PMC PMC3282676. Research Blogging.
  10. Gaujoux-Viala C, Dougados M, Gossec L (2009). "Efficacy and safety of steroid injections for shoulder and elbow tendonitis: a meta-analysis of randomised controlled trials.". Ann Rheum Dis 68 (12): 1843-9. DOI:10.1136/ard.2008.099572. PMID 19054817. PMC PMC2770107. Research Blogging.
  11. Arroll B, Goodyear-Smith F (2005). "Corticosteroid injections for painful shoulder: a meta-analysis.". Br J Gen Pract 55 (512): 224-8. PMID 15808040. PMC PMC1463095[e]
  12. Buchbinder R, Green S, Youd JM (2003). "Corticosteroid injections for shoulder pain.". Cochrane Database Syst Rev (1): CD004016. DOI:10.1002/14651858.CD004016. PMID 12535501. Research Blogging.
  13. Vas J, Ortega C, Olmo V, et al (June 2008). "Single-point acupuncture and physiotherapy for the treatment of painful shoulder: a multicentre randomized controlled trial". Rheumatology (Oxford) 47 (6): 887–93. DOI:10.1093/rheumatology/ken040. PMID 18403402. Research Blogging.
  14. Gerdesmeyer L, Wagenpfeil S, Haake M, et al (November 2003). "Extracorporeal shock wave therapy for the treatment of chronic calcifying tendonitis of the rotator cuff: a randomized controlled trial". JAMA 290 (19): 2573–80. DOI:10.1001/jama.290.19.2573. PMID 14625334. Research Blogging.
  15. Seida JC, Leblanc C, Schouten JR, Mousavi SS, Hartling L, Vandermeer B et al. (2010). "Systematic Review: Nonoperative and Operative Treatments for Rotator Cuff Tears: A Comparative Effectiveness Review.". Ann Intern Med. DOI:10.1059/0003-4819-153-4-201008170-00263. PMID 20621893. Research Blogging.
  16. Rookmoneea M, Dennis L, Brealey S, Rangan A, White B, McDaid C et al. (2010). "The effectiveness of interventions in the management of patients with primary frozen shoulder.". J Bone Joint Surg Br 92 (9): 1267-72. DOI:10.1302/0301-620X.92B9.24282. PMID 20798446. Research Blogging.