Shoulder Pain

Differential Diagnosis

Acute Pain (Obvious/Emergent)

• Acute shoulder injury

  • Clavicle

    • Acromioclavicular injury

    • Clavicle fracture

  • Glenohumeral dislocation

  • Proximal humerus fracture

• Less common: Referred shoulder pain

  • Left shoulder/arm: Cardiac involvement, e.g. pericarditis, myocardial infarction

  • Right shoulder: Hepatobiliary, e.g. gallstones, pancreatitis

  • Intra-abdominal hemorrhage (rare): Phrenic nerve (diaphragm) irritation referred to C5, e.g. pneumonia, perforated peptic ulcer, ruptured ovarian cyst/ectopic pregnancy

Acute or Chronic Pain

• Rotator cuff injury (impingement and tear)

• Superior labral tear from anterior to posterior (SLAP) tear

• Thoracic outlet syndrome (less common): Compression of vessels/nerves by clavicle produces referred numbness/pain when arms are lifted to shoulder level. Arm weakness and numbness may be present on exam. Refer to physical therapy and consider surgery for refractory cases.

Chronic Pain

• Common

  • Shoulder pathology

    • Adhesive capsulitis (frozen shoulder)

    • Pediatrics: Little league shoulder

  • Cervical radiculopathy

• Less common

  • Glenohumeral instability

  • Calcific tendonitis

  • Shoulder arthritis: Rare without history of shoulder trauma

    • Acromioclavicular arthritis

    • Glenohumeral osteoarthritis

  • Autoimmune (rare)

    • Polymyalgia rheumatica

    • Polymyositis

Shoulder Exam

1. Assess for musculoskeletal instability from front, side and back

2. Palpate clavicle and acromioclavicular joint

   • Assess for muscle tenderness and instability

   • Sulcus sign: Indicates shoulder instability

3. Test range of motion:

   • Abduction (jumping jack)

   • Adduction (X across the body)

   • Elevation through forward flexion (judo chop without bending elbow)

   • Extension (swan dive)

   • External rotation (robot arms rotate outward): Decreased ROM or pain indicates adhesive capsulitis

   • Internal rotation (back scratch with the thumb)

4. Rotator cuff

   • Empty can test (supraspinatus): Patient holds arms directly in front and pretends to empty two cans

   • Neer test (subacromial impingement): Place fully pronated arm in forced flexion

   • Hawkins-Kennedy (supraspinatus impingement syndrome): Arm bar and rotate downward

   • External lag (infraspinatus/teres minor): Resistance against external rotation and/or inability to hold arm in external rotation

   • Internal lag/Gerber Lift-off (subscapularis)

     • Resistance against internal rotation

     • Place hands behind back and lift off with/without resistance

5. Biceps tendon and labral/SLAP tear

   • Physical exam

     • Speed test: Straight arm with palm up “asking for candy”

     • Crank test: Indicates labral/SLAP tear, especially if Speed test is positive

   • Note: Physical exam for a biceps tear can be unreliable. If suspected, obtain an MRI of the elbow for definitive diagnosis.