6 Common Shoulder Conditions Every Physician Should Know

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6 Common Shoulder Conditions Every Physician Should Know

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

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 2 . Posterior view of the rotator cuff

Image 2. Posterior view of the rotator cuff

Image 1 . Anterior view of the rotator cuff.

Image 1. 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

Image 3. Illustration of adhesive capsulitis

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 OA.

Image 4. AP Radiograph of shoulder demonstrating severe glenohumeral OA.

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 . Illustration of rockwood classification for AC joint injuries.

Image 5. Illustration of 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 demonstrating AC joint OA which can preclude osteolysis.

Image 6. AP radiograph 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.

References

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  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

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  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.

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  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.