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Shoulder pain

  • Common ddx

    • rotator cuff tendonopathy, impingement, bursitis, adhesive capsulitis, cervical strain
  • Serious ddx

    • rotator cuff tear, dislocation, cspine fracture, neuro issue, anything trauma related, referred pain from cardio or GI issues
  • Labs

    • MRI for rotator cuff tear
    • xray for trauma, calcific tendonitis or osteoarthritis
    • CBC, Chem
    • ANA, ESR if autoimmune
    • EKG if suspect cardiac
  • Tx for simple pain without weakness, paresthesia or deformities

    • ice pack
    • avoid aggravating activities such as overhead throwing
    • physical therapy
    • NSAIDs
    • consider subacromial glucocorticoid injection
  • Gross deformity ddx

    • glenohumeral dislocation, posterior shoulder disclocation, biceps tendon rupture, clavicular fracture, AC separation, long thoracic nerve, shoulder instability
  • Pain on active motion only

    • subacromial bursitis, rotator cuff tear
  • Pain on passive motion

    • adhesive capsulitis, labral tear, osteoarthritis, rheumatoid arthritis, PMR, gout, septic arthritis
  • Nerve ddx

    • axillary nerve, brachial plexus neuropraxia, cervical nerve root irritation, syringomyelia
  • Vascular ddx

    • coronary insufficiency, thoracic outlet syndrome, upper extremity DVT, axillary vein thrombosis
  • Referred pain ddx

    • cholecystitis, pancreatitis, MI, cspine
  • Skin ddx

    • cellulitis, shingles
  • Posterior pain ddx

    • subscapular bursitis
  • Muscle atrophies ddx

    • suprascapular nerve, chronic rotator cuff tear, axillary nerve
  • HPI

    • onset
    • triggering events
    • location: unilateral vs bilateral
    • quality: radiation to arms, neck
    • severity
    • aggravates, alleviates
  • ROS

    • fever, weight loss
    • trauma
    • temple pain, vision loss
    • chest pain, dyspnea
    • nausea, vomiting, diarrhea, abdominal pain
    • muscle weakness, numbness, tingling, burning
    • arm pain, neck pain
  • PMH

    • shoulder injury, surgery
    • pinched nerve
  • FH

  • SH

    • work, activities, posture
  • Meds

  • Allergies

  • Px

    • vitals
    • gen impression
    • neck: cspine palpation, ROM
    • cardio, pulm, abd
    • inspection: posture, guarding, symmetry/atrophy, bruises, deformities, scapula
    • palpation: acromion, AC joint, clavicle, SC joint, scapular spine, supraspinatus, infraspinatus, bicipital groove.
    • ROM (active and passive), strength, sensation (deltoid, fingers), reflex
    • impingement tests
    • elbow: ROM, strength, pain, popeye biceps
  • Cheatsheet

    • simple tendinopathy: pain without weakness or paresthesia
    • tear: weakness
    • glenohumeral dislocation: abduction + external rotation, held with opposite hand
    • posterior shoulder dislocation: seizure, internal rotation + adduction
    • adhesive capsulitis: stiffness, frozen shoulder, chronic immobility
    • labral tear: overhead throwing, swimming, catching sensation, crepitus
    • neuropathy: paresthesia, arm radiation
    • axillary nerve: loss of deltoid sensation, deltoid atrophy
    • brachial plexus neuropraxia: football players
    • cervical nerve root irritation: aggravated with neck extension or rotation toward affected side
    • coronary insufficiency: intermittent arm cramps
    • thoracic outlet syndrome: arm weakness, paresthesia
    • subscapular bursitis: thin build, scapula pain
    • suprascapular nerve: overhead throwing, posterior shoulder pain, supraspinatus atrophy
    • chronic rotator cuff tear: supraspinatus atrophy
    • rotator cuff muscles: supraspinatus, infraspinatus, teres minor, subscapularis
    • winged scapula (long thoracic nerve), sulcus sign (shoulder instability)
  • Impingement tests

    • Neer's (supraspinatus impingement): abduct 30 deg then flexion all the way upward.
    • Hawkin's (supraspinatus impingement, bursa): arm wrestle position, then internally rotate.
    • painful arc (impingement): pain with abduction > 90deg
  • Shoulder tests

    • empty can test (supraspinatus tear): thumb's down position (90 deg abduction, 30 deg forward flexion), arm extended, resist downward push.
    • Drop arm test (supraspinatus tear): unable to drop arm down smoothly from 90 deg abduction
    • apprehension test (shoulder instability): empty can test, but with external rotation instead of downward push. Positive if pt less apprehensive when you stabilize the humeral head.
    • Nerve root test (Spurling's position): neck extension + rotation toward affected side triggers pain
  • ROM

    • external rotation: Infraspinatus
    • internal rotation: Subscapularis
    • abduction: Supraspinatus

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