#124 The Shoulder – Simplify Your Approach

November 12, 2018 | By Molly Heublein

Shoulder pain made simple. Develop your confidence and skills with tips from sports medicine specialist Dr. Carlin Senter MD. We discuss her simplified approach to the basic shoulder exam, including when and how to do special tests, high yield exam maneuvers, when to refer shoulder pain patients to orthopedic surgery, and who can be managed conservatively.

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Credits

Written and produced by: Molly Heublein MD and Nora Taranto MS4
Editor: Matthew Watto MD
Hosts: Molly Heublein, MD, Paul Williams MD, Matthew Watto MD
Guest: Carlin Senter, MD

Shoulder Pain Pearls

1. In patients with reduced active and passive range of motion, the differential narrows down to frozen shoulder or glenohumeral arthritis.
2. Frozen shoulder will resolve on its own, but can take 2-3 years to completely resolve.
3. In patients with full passive range of motion, special testing is important to help rule out full thickness rotator cuff tears, which should be referred to orthopedic surgeons since they require surgical repair.
4. Other shoulder pathology such as partial rotator cuff tears, impingement syndrome, bursitis, and tendonitis can improve with time, physical therapy, NSAIDS, or steroid injections. Surgical intervention is not needed.

Shoulder Pain In-Depth Show Notes

Evaluating Shoulder Pain: The Basics

The History

Craft your differential based on age.  

Dr Senter recommends crafting a shoulder pain differential based on age. A younger person (under 40 years old) likely has tendonitis, whereas a middle aged person is more likely to have rotator cuff disease or frozen shoulder.  In patients over 50 years old, atraumatic tears are common. Patients with a remote history of shoulder dislocation have an increased risk of glenohumeral arthritis.

Typical shoulder pain

Typical pain initiates laterally on the shoulder, deep to the deltoid.  Acromioclavicular (AC) joint pain will be on the top of the shoulder.  If a patient complains of posterior shoulder pain in the back of the neck or close to the scapula or rhomboids, think about cervical spine etiology.

Posterior shoulder pain

N.b. Patients may complain of “shoulder pain” which is actually cervicogenic.  If the pain is posterior, it is more likely neck related. If at all unsure, examine the neck.  Typical shoulder pain will worsen when reaching overhead, compared to cervical radiculopathy, which improves when the hand is placed on top of the head (by decreasing tension on nerve roots).  Dr Senter notes that any pain radiating past the elbow would be not related to the shoulder.

Shoulder Exam

HIPROT

History, Inspection, Palpation, Range of motion, Other Tests.  See our YouTube video for a visual review of this.

Inspection

This will usually be normal. Evaluate for abnormalities (both on history and physical exam) that suggest a clavicle fracture, separated AC joint, winged scapula (with posterior pain), or ipsilateral scalloping below scapula due to chronic massive rotator cuff tear.  

Palpation

Palpate two areas in particular: the Acromioclavicular (AC) joint (common site for Osteoarthritis) and the long head of the biceps tendon (common site of tendonitis) for tenderness.   

The AC Joint Exam

For the AC joint, palpate across the collar bone to the distal clavicle, feeling for a small divot.   AC joint arthritis is common with increasing age and can cause pain with many exam maneuvers described below. Osteoarthritic changes of the AC joint are a frequent X-ray finding, but if you haven’t palpated the AC joint to evaluate for tenderness, it’s hard to know if the x-ray finding of arthritis is significant or incidental. To further evaluate acromioclavicular arthritis after palpation, perform cross body adduction: Bring straight arm across patient’s upper body like a nice stretch this forces the AC joint together and can illicit pain.

Biceps Tendon Exam

Feel the long head of the biceps by pushing with your thumb into the area where the shoulder joins chest wall and feeling for a “ropey string”.  Tenderness localized along the tendon suggests biceps tendonitis.

Range of Motion

If active and passive ROM are decreased, then consider two diagnoses 1) glenohumeral joint arthritis or 2) frozen shoulder.  

Active external rotation

Dr. Senter’s #1 most useful physical exam maneuver = active external rotation. Have the patient hold their elbows bent to 90 degrees, with arms tight at their waist.  Keeping the elbows tucked in, have them wing out hands, for active shoulder external rotation. Limitation of this rotation is quite sensitive for identifying reduced glenohumeral ROM.

Abnormal Passive ROM

You do not need to perform additional exam maneuvers if you find abnormal passive range of motion (evaluating the health of the rotator cuff in clinic with further exam is less important with abnormal ROM because the recovery of the rotator cuff first requires recovery from frozen shoulder or glenohumeral joint arthritis–Dr. Senter’s expert opinion). If you find reduced ROM, order an x-ray.  The x-ray will rule out other serious pathology causing inhibited motion (e.g. rheumatoid arthritis, which would show inflammatory arthritis; glenohumeral arthritis which would show osteoarthritis findings of osteophytes, subchondral cysts, subchondral sclerosis, and/or joint space narrowing).  Frozen shoulder will have a normal x-ray.

A caution about shoulder pain

N.b. Even in the specialist clinic, the exam can sometimes be difficult to interpret and to differentiate true limitation of ROM versus an exam limited by pain. It is important to evaluate recovery, with follow-up within 6 weeks.

Processes producing limited Shoulder ROM

Frozen Shoulder (adhesive capsulitis)

It is quite common, but interestingly we know relatively little about its pathogenesis. Frozen shoulder is more common in women and diabetics, typically presenting around age 50-60.  

Natural history of frozen shoulder

Classic history

The patient wakes up with terrible shoulder pain, but not so severe that the patient goes to the emergency room. Typically, it will be in this painful phase for 6-9 months. During this time, the patient starts to lose range of motion.  Next, is the frozen stage, which again lasts 6-9 months.  During the frozen phase, ROM is maximally decreased, but the patient is in less pain.  Finally comes the thawing phase, in which the patient will slowly improve to normal function (Rizk 1982).   This whole process can take 2-3 years to improve. The good news is that it fully resolves and doesn’t tend to happen to the same shoulder ever again.

Regarding treatment

It is most important to counsel patients about the long recovery and to offer a variety of options including PT, injection, or watchful waiting are all reasonable–Dr. Senter’s expert opinion. Ultrasound guided steroid injection into the glenohumeral joint may be more effective than US guided injection into subacromial space for pain relief, but does not clearly expedite recovery.  Data around physical therapy is limited. There is no “right answer” as to how to treat frozen shoulder (Page 2014, Buchbinder 2003).  

Glenohumeral arthritis

This typically affects older patients, around 80-90 years old.  Regarding treatment: it depends on functional status, and generally is similar to knee osteoarthritis.  Steroid injections may relieve pain (Do these under ultrasound guidance into the glenohumeral joint (Sibbitt 2009)).   Physical therapy may help regain ROM and strengthen muscles around the joint. In some cases, the joint can be replaced if the functional limitations indicate it.  It is important to think about the urgency of the situation.  If the person is not doing well (not sleeping, not functioning), it is more important to treat aggressively (ie injection, surgery). –Dr. Senter expert opinion.

Other considerations for shoulder pain

Calcific Tendonitis

Dr Senter urges us to consider calcific tendonitis when a patient presents with extremely severe shoulder pain. This has a remarkably acute onset, and can be so bad that patients first present to the emergency department. Calcific tendonitis resolves promptly with NSAIDs and/or steroid injections.

Rotator Cuff Tears

The classic history will be in a middle-aged person with a low velocity trauma. Rotator cuff disease is so common that it’s the right answer most of the time in primary care!  Pain will be worse with overhead activity and worse at night. It often wakes patients from sleep. The mission of the primary care clinician evaluating rotator cuff disease is to detect and refer the full thickness tear to the surgeon.  Everything else can go to PT –Dr Senter’s expert opinion.

Anatomy of the Rotator Cuff

The rotator cuff consists of 4 muscles, all connected to the humerus.  Starting from the front of the shoulder and moving posteriorly is the subscapularis, which internally rotates the humeral head. If you reach behind your back and lift your hand off your belt, that’s your subscapularis in action.  Next moving posteriorly, at the top of the shoulder, is the supraspinatus, which sits above the scapular spine, and abducts your humerus. It helps to raise the arm from the side of the body.  Below that, beneath the scapular spine, is the infraspinatus, which inserts on the back side of the humerus and allows external rotation.  Lastly, is the Teres Minor. Dr. Senter tells us that it is “ok to forget about teres minor- nothing ever happens there”.  ***The majority of tears are tears of the supraspinatus.

Our job in primary care

The primary job of the primary care provider is to rule out a big tear. The sooner a full thickness tear is identified and surgically repaired, the better the outcome (Mukovozov 2013).   Over time, the tendon can retract and the muscle may become atrophic or infiltrated with fat.

Special Exam Maneuvers for Rotator Cuff Tear

Empty Can Test/Jobe’s test

This test is positive if the examiner elicits weakness, which suggests a  full-thickness tear–or pain, which suggests tendonitis.  The patient abducts their arms, a little bit forward (at 10 and 2 o’clock).  Have the patient push upward while the examiner pushes down. Dr. Senter notes that it does not actually matter if patient holds a full or empty can (thumbs up or down); these positions will just activate different part of the same supraspinatus muscle.   

Internal and External Rotation Lag Tests

These have a high sensitivity/specificity for rotator cuff tear.  

Internal rotation lag test

It has a high positive predictive value for a full-thickness tear.  To test the subscapularis, position the patient’s hand internally rotated around the back, and lift off the beltline.  If the patient falls out of position, this is a positive internal rotation lag test.  

External rotation lag test

Position the elbow hugged against the hip with the elbow bent at 90 degrees. Then passively move the patient’s arm into external rotation.  If patient is unable to maintain that position (arm drifts inward), then this represents a positive external rotation lag test and a high risk of full thickness tear.  These can be passive/against gravity tests, and not testing strength.

Arm Drop/Drop Arm Test.  

Have the patient abduct their arm.  If the patient is unable to control the return from abduction and the arm just drops, the patient likely has rotator cuff disease.  Dr. Senter cautions that this test is not perfectly predictive for cuff tears because sometimes pain can cause a positive test rather than true weakness.

Painful arc maneuver.

This valuable test can suggest rotator cuff disease.  The examiner passively abducts the arm. Pain elicited between 60 and 120 degrees of abduction suggests rotator cuff pathology, since this is the area where the rotator cuff starts to pinch.  

Impingement syndrome

Impingement syndrome, aka bursitis, is an imprecise diagnosis, similar to diagnosing someone with “back pain”.  **Many things (e.g. tendonitis, rotator cuff pathology, etc.) can cause impingement.  The typical patient is younger and complains of acute shoulder pain.

Tests for impingement

Hawkins Test

Think “hawk, like the bird” because you are “flapping the patient’s wing”.  Bring shoulder into 90 degrees of forward flexion. Bend the elbow passively to 90 degrees. Then, gently perform passive internal rotation.  Pain that localizes to the deep deltoid is consistent with impingement.

Neer’s test – “near by the ear”

Bring the arm into rapid, passive forward flexion.  Pronate the forearm (palm down). The test is positive, and consistent with impingement, if the patient experiences pain deep to the deltoid.

Management of shoulder pain

Who needs referral?

Patients with full-thickness tear (e.g. positive internal or external rotation lag test) warrant referral. Most patients don’t need referral. If there is no evidence of a full-thickness tear (and symptoms are consistent with impingement, tendonitis, or a partial tear), then there is NO need to see a surgeon.  

Non-surgical treatment of shoulder pain

Treat with NSAIDS and/or physical therapy as first line therapy. Dr. Senter notes that severe pain may warrant a trial of steroid injection.  A 2014 study out of the VA compared physical therapy vs. injections, and almost everyone got 50% better over the course of a year (Rhon 2014). It may not matter what you offer as first treatments.

The latest on injections in shoulder pain

They’re probably not great for tissues (looking at studies related to the knee, steroid injections may be harmful for cartilage (McAlindon 2017). One systematic review and meta-analysis found that shoulder injections were similar to NSAIDS for short-term pain relief (up to 8 weeks), but seem to have no long term benefit (up to 48 weeks later) (Gaujoux-Viala 2009). Dr. Senter notes that older studies of poorer quality show that people who had had multiple injections may not do as well after tendon repair as those who had fewer injections. Roberts et al  mention this concern in an article title “Joint aspiration or injection in adults: Complications” on UpToDate. Weakening of the rotator cuff was seen in a recent rat model (Maman 2015). The overall trend is towards fewer injections. But, for short term pain relief, injection can be helpful –Dr. Senter’s expert opinion.

Follow-up for shoulder pain

It is essential to check back in 6-8 weeks to make sure the patient is improving, as you can miss something more serious.  If the patient is not improving at follow-up, refer to sports medicine or orthopedics. It’s often advisable to refer a patient without an MRI because the surgeon may prefer specific imaging techniques.

Take Home Points

1. Remember the importance of testing active and passive range of motion.
2. If you feel confident in your ability to test range of motion, you should feel confident triaging problems to two big buckets: Reduced range of motion (glenohumeral arthritis vs frozen shoulder) and Full range of motion (Everything else, including Cuff disease: impingement (bursitis); tendonitis, partial thickness tear, full thickness tear).  
3. If you find reduced range of motion, order an x-ray.
4. Once you’ve triaged to the full range-of-motion category, the main goal is to identify full-thickness rotator cuff tears, which necessitate surgery.
5. It is essential to follow up with patients within 6-8 weeks to evaluate improvement. If the patient is not improving, refer to sports medicine or orthopedics (with or without MRI).

Goals and Learning Objectives

Goal

Listeners will be able to do a thorough shoulder exam and identify conditions requiring surgical intervention versus conservative management.

Learning objectives

1. To develop a thorough differential for shoulder pain.  
2. To perform exam maneuvers that will test range of motion.
3. To learn tests specific for cuff tears and other shoulder pathology.
4. To know when to treat conservatively and when to refer for surgical intervention  

Disclosures

Dr. Senter reports no relevant financial disclosures. The Curbsiders report not relevant financial disclosures.

Time Stamps

• 00:00 Disclaimer, intro, and guest bio
• 03:15 Guest one liner, book recommendation, career advice, and some picks of the week
• 13:20 Clinical case of shoulder pain; helpful historical features
• 18:54 Differentiating referred pain from c-spine pathology from shoulder pathology
• 21:00 A framework for shoulder pain, HIP-ROT, and using ROM to generate a differential
• 27:40 Frozen shoulder aka adhesive capsulitis
• 31:57 Glenohumeral joint arthritis
• 33:52 Rotator cuff disease
• 40:53 Specific testing for rotator cuff tears
• 51:45 Impingement syndrome versus bursitis
• 56:25 Counseling patient with shoulder pain or injury
• 59:03 Steroid injections, topical therapy, and AC joint arthritis
• 65:18 When to refer to surgery and some take home points

Book recommendations and Picks of the Week:

• God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine
  by Victoria Sweet
• Matt’s pick of the week: TRX straps
• Paul’s pick of the week: Cryptonomicon, by Neal Stephenson

Links

Links from the show are included above.

Citation for guest CV:

Senter, Carlin. Guest expert. “#124 The Shoulder: Simplify Your Approach.” The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com.

More reading and references, if you’d like them!

1. Buchbinder R, Green S, Youd JM. Corticosteroid injections for shoulder pain.
   Cochrane Database Syst Rev. 2003;(1):CD004016. Review. PubMed PMID: 12535501.

2. Gaujoux-Viala C et al. Efficacy and safety of steroid injections for shoulder and elbow tendonitis: a meta-analysis of randomised controlled trials. Ann Rheum Dis. 2009 dec; 68(12):1843-1849. doi:  [10.1136/ard.2008.099572]

3. Hermans J, Luime JJ, Meuffels DE, Reijman M, Simel DL, Bierma-Zeinstra SMA. Does This Patient With Shoulder Pain Have Rotator Cuff Disease?The Rational Clinical Examination Systematic Review. JAMA.2013;310(8):837–847. doi:10.1001/jama.2013.276187

4. McAlindon T et al. Effect of Intra-articular Triamcinolone vs. Saline on Knee Cartilage Volume and Pain in Patients with Knee Osteoarthritis: A Randomized Clinical Trial. JAMA. 2017; 317(19):1967-1975. doi:10.1001/jama.2017.5283

5. Mikolyzk DK et al. Effect of corticosteroids on the biomechanical strength of rat rotator cuff tendon

6. J Bone Joint Surg Am, 91 (2009), pp. 1172-1180. http://dx.doi.org/10.2106/JBJS.H.00191

7. Mukovozov, I et al. “Time to surgery in acute rotator cufftear: A systematic review” Bone & joint research vol. 2,7 122-8. 1 Jul. 2013, doi:10.1302/2046-3758.27.2000164

8. O’Kane JW, Toresdahl BG. The evidenced-based shoulder evaluation. Curr Sports Med Rep. 2014 Sep-Oct;13(5):307-13.

9. Page MJ, Green S, Kramer S, Johnston RV, McBain B, Chau M, Buchbinder R.
   Manual therapy and exercise for adhesive capsulitis (frozen shoulder). Cochrane
   Database Syst Rev. 2014 Aug 26;(8):CD011275. doi: 10.1002/14651858.CD011275.
   Review. PubMed PMID: 25157702.

10. Rizk T, Pinals R.  Frozen Shoulder. Seminars in Arthritis and Rheumatism.  Volume 11, Issue 4, May 1982, Pages 440-452. https://doi.org/10.1016/0049-0172(82)90030-0Get

11. Rhon DI, Boyles RB, Cleland JA. One-Year Outcome of Subacromial Corticosteroid Injection Compared With Manual Physical Therapy for the Management of the Unilateral Shoulder Impingement Syndrome: A Pragmatic Randomized Trial. Ann Intern Med. Aug 2014 ;161:161–169.doi: 10.7326/M13-2199

12. Sibbitt WL Jr, Peisajovich A, Michael AA, Park KS, Sibbitt RR, Band PA, Bankhurst AD. Does sonographic needle guidance affect the clinical outcome of  intraarticular injections? J Rheumatol. 2009 Sep;36(9):1892-902. doi:10.3899/jrheum.090013. Epub 2009 Jul 31. PubMed PMID: 19648304.