6 Common Shoulder Conditions Every Physician Should Know
Shoulder pain is a common complaint in the family practice setting. In fact, the incidence of shoulder complaints is approximately 11.2 cases per 1000 patients per year [1]. This article reviews 6 of the more common causes of shoulder pain; rotator cuff tendinitis, adhesive capsulitis, osteoarthritis, bursitis, acromioclavicular joint disorder and clavicular disorders including osteolysis and fractures. For each condition, a brief review of pathophysiology together with an evidence-based approach to treatment will be provided.
Image 1. Posterior view of the rotator cuff.
Image 2. Anterior view of the rotator cuff.
Rotator cuff disease often occurs along a continuum, starting with subacromial bursitis secondary to impingement and progressing to tendinopathy with partial or full thickness rotator cuff tears. Patients with rotator cuff tendinopathy present with pain and weakness particularly over the lateral deltoid [2]. Pain arising from subacromial bursitis usually occurs over the anterolateral aspect of the shoulder, often with radiation to, but not usually beyond, the elbow [3]. Repetitive overhead activity, whether in sport or work, is a major risk factor for impingement and rotator cuff tendinopathy [4]. Radiography may be normal but can show concomitant pathology such as glenohumeral or AC joint osteoarthritis and calcific tendinitis. Magnetic resonance imaging without contrast media is the current imaging modality of choice [5, 6] although ultrasonography is becoming more popular. Nonoperative management of impingement and rotator cuff injuries consists of physical therapy, NSAIDS, and glucocorticoid injections. Other modalities such as platelet rich plasma are promising however there is insufficient evidence to its support at present [7]. Surgery is rarely indicated.
Image 3. Illustration of adhesive capsulitis (frozen shoulder)
Adhesive capsulitis, also known as ‘’frozen shoulder’, is characterized by thickening and contraction of the capsule around the glenohumeral joint with resultant loss of motion and pain [8]. There is an association with diabetes and hypothyroidism [9]. The mainstay of treatment includes physical therapy, nsaids, oral or intraarticular corticosteroid therapy, acupuncture and hydrodilation [9]. Patients with no improvement after 6 to 12 weeks who cannot tolerate their pain may be candidates for surgical referral [ 10]
Image 4. AP radiograph of shoulder demonstrating severe glenohumeral osteoarthritis
Osteoarthritis of the glenohumeral joint occurs secondary to progressive mechanical and biochemical breakdown of the articular cartilage [16]. Physical examination may reveal positive impingement signs; thus, the physician must consider coexisting rotator cuff disease. Radiography may show only subtle changes to the bone until there is more advanced disease. Non-operative management includes acetaminophen, physical therapy, strength training, aerobic exercise and injections with glucocorticoid or sodium hyaluronate [ 13, 14, 15]. Surgical intervention is warranted with a loss of function that is unresponsive to conservative treatment [11].
Image 5. Rockwood classification for AC joint injuries
Acromioclavicular (AC) joint injuries often occur with a fall onto a shoulder with the arm in an adducted position [12]. Exam findings may range from normal appearing AC joint (Type I injury) or a deformity at the AC (Types II-VI). Regardless, patients typically report joint tenderness to palpation with a positive cross arm test. Injuries are classified as Type I-VI depending on radiographic findings. These injuries can be treated nonoperatively with a sling for comfort, ice application, early physical therapy and over-the-counter pain medication as needed [17]. Referral to an orthopedist for type III-VI injuries is recommended.
Image 6. AP radiograph of shoulder demonstrating AC joint OA which can preclude osteolysis.
Distal clavicular osteolysis is caused by repetitive microtrauma to the distal clavicle. It is common in weight lifters and presents with pain and tenderness over the distal clavicle. Plain films usually confirm the diagnosis. Treatment consists of discontinuing load-bearing activity and physical therapy [4]. Surgical referral is individualized and depends on functional demands and severity of symptoms [4]]. Finally, clavicle fractures are usually caused by a fall directly on the shoulder. Radiographs help determine whether the patient has a displaced fracture which may require referral for orthopedic care [8]. Nondisplaced clavicle fractures generally can be treated conservatively in a sling for two to six weeks with physical therapy and avoidance of aggravating activities.
– More Shoulder Pain from Sports Medicine Review: https://www.sportsmedreview.com/by-joint/shoulder/
– Read More: https://wikism.org/Shoulder_Pain_(Main)
Authors
Stephen Henry DO MS CAQSM
- Assistant Professor Department of Orthopedics and Department of Family Medicine and Community Health
- Team Physician – U of Miami Department of Intercollegiate Athletics
- Team Physician – Miami Marlins
- University of Miami Miller School of Medicine
Thomas M Best, MD, PhD, FACSM, CAQSM
- Professor of Orthopedics, Family Medicine and Community Health, Biomedical Engineering, Kinesiology
- Research Director – U of Miami Sports Medicine Institute
- Director – Primary Care Sports Medicine Fellowship
- Team Physician – U of Miami Department of Intercollegiate Athletics
- Team Physician – Miami Marlins
- U of Miami Miller School of Medicine
References
1. Ann Rheum Dis. 1995 Dec;54(12):959-64. Shoulder disorders in general practice: incidence, patient characteristics, and management. van der Windt DA, Koes BW, de Jong BA, Bouter LM.
2. Cowderoy GA, Lisle DA, O’Connell PT. Overuse and impingement syndromes of the shoulder in the athlete. Magn Reson Imaging Clin N Am. 2009;17(4):577-593, v.
3. Todd Derrick, Isaac Zacharria, Ramirez Curtis, MD, Bursitis: An overview of clinical manifestations, diagnosis and management. www.uptodate.com accessed 3.10.19
4. Silverstein BA, Vilkari-Juntura E, Fan ZJ, Bonauto DK, Bao S, Smith C, Natural Course of nontraumatic rotator cuff tendinitis and shoulder symptoms in a working population. Scand J work Environ Health. 2006;32(2):99.
5. Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am. 1995;77(1):10–15.
6. Roy JS, Braën C, Leblond J, et al. Diagnostic accuracy of ultrasonography, MRI and MR arthrography in the characterization of rotator cuff disorders: a systematic review and meta-analysis. Br J Sports Med. 2015;49(20):1316–1328.
7. Moraes VY, Lenza M, Tamaoki MJ, Faloppa F, Belloti JC. Platelet-rich therapies for musculoskeletal soft tissue injuries. Cochrane Database Syst Rev. 2013;(12):CD010071.
8. Thomas W. Woodward MD, and Thomas M Best M.D. PH.D., University of Wisconsin Medical School, Madison Wisconsin, The Painful Shoulder: Part II. Acute and Chronic Disorders, Am Fam Physician 2000 Jun ;61(11):3291-3300
9. Adhesive Capsulitis: Diagnosis and Management, Jason Ramirez MD, University of Maryland School of Medicine Balitmore, Maryland American Family Physician, March 1, 2019 Volume 99 Number 5.
10. Adhesive Capsulitis: Diagnosis and Management, Jason Ramirez MD, University of Marlyand School of Medicine, Baltimore Marlyand AFP March 1,2019, Volume 99, Number 5
11. Sperling JW, Cofield RH, Rowland CM. Neer hemiarthroplasty and Neer total shoulder arthroplasty in patients fifty years old or less. Long-term results. J Bone Joint Surg Am. 1998;80(4):464–473.
12. Korsten K, Gunning AC, Leenen LP. Operative or conservative treatment in patients with Rockwood type III acromioclavicular dislocation: a systematic review and update of current literature. Int Orthop. 2014;38(4):831–838.
13. Anderson Bruce, Tugwell Peter, Ramirez Curtis Monica, Glenohumeral osteoarthritis, www.uptodate.com accessed 3.10.19.
14. O’Reilly SC, Muir KR, Doherty M. Effectiveness of home exercise on pain and disability from osteoarthritis of the knee: a randomized controlled trial. Ann Rheum Dis. 1999;58(1):15–19.
15. Miceli-Richard C, Le Bars M, Schmidely N, Dougados M. Paracetamol in osteoarthritis of the knee. Ann Rheum Dis. 2004;63(8):923–930.
16. Peter J Millet, Ruben Gobeize, Robert E Boykin, Shoulder Osteoarthritis: Diagnosis and Management. Am Fam Physician. 2008 Sep 1;78(5):605-611
17. James Monica, MD; Zachary Vrendenburgh, MD; Jeremy Korsh, MD; Charles Gatt, MD, Acute Shoulder Injuries in Adults Rutgers University Robert Wood Johnson Medical School, New Brunswick, New Jersey. Am Fam Physician. 2016 Jul 15;94(2):119-127.
