From the Guidelines
A comprehensive shoulder pain assessment should begin with a thorough clinical evaluation, including radiography as the preferred initial imaging study, particularly in cases of traumatic shoulder pain, as recommended by the American College of Radiology 1. When assessing shoulder pain, it is essential to evaluate the location, onset, duration, and quality of pain, along with aggravating and relieving factors. The assessment should include:
- Evaluating range of motion by having the patient perform active movements (forward flexion, abduction, external and internal rotation) followed by passive movements to identify limitations and pain triggers
- Special tests like the Neer impingement test, Hawkins-Kennedy test, and empty can test to help identify specific conditions such as rotator cuff tears or impingement syndrome
- Palpation to locate tender areas, particularly at the acromioclavicular joint, biceps tendon, and rotator cuff insertion
- Evaluating strength through resisted movements of the shoulder muscles
- Assessing for neurological symptoms including numbness, tingling, or weakness that might indicate nerve involvement
- Documenting any previous shoulder injuries, treatments, and their effectiveness
In terms of imaging, radiography of the shoulder is the most appropriate initial study for traumatic shoulder pain, as it can effectively demonstrate shoulder malalignment and most shoulder fractures 1. However, in cases of nonlocalized shoulder pain and negative radiographs, MRI of the shoulder without IV contrast may be the most appropriate study 1. It is crucial to consider the clinical findings and the specific condition being assessed when determining the most appropriate imaging study.
The assessment approach should be systematic, considering the complex anatomy of the shoulder and the wide variety of potential pathologies, as noted in the American College of Radiology's guidelines on acute shoulder pain 1. This systematic approach helps identify the underlying cause of shoulder pain and guides appropriate treatment planning.
From the Research
Shoulder Pain Assessment
- Shoulder pain is a common complaint, and it is the third most common musculoskeletal complaint after back and neck pain 2
- The causes of shoulder pain can be diverse, ranging from trauma to chronic conditions such as impingement syndrome, adhesive capsulitis, and glenohumeral osteoarthritis 2, 3
- A thorough history and physical examination are essential for diagnosing the cause of shoulder pain, including the time and character of the pain, range of motion, and ability to perform everyday activities 2, 4
Diagnostic Tools
- Imaging modalities such as X-ray, ultrasound, and magnetic resonance imaging can be used to aid in diagnosis 2
- A focused history and physical examination can help identify the cause of shoulder pain, including the mechanism of injury, type of dysfunction, and nature of the pain 4
Treatment Options
- Most causes of shoulder pain can be treated non-surgically with physiotherapy, anti-inflammatory medication, and local corticosteroid injections 2
- Exercise and manual therapy (EMT) have similar outcomes to corticosteroid injections in the management of patients with subacromial pain syndrome 5
- Corticosteroid therapy and physiotherapy have been compared in terms of their effect on pain, mobility, and function in shoulder impingement, with some studies suggesting that corticosteroid injections may provide short-term improvements in shoulder function, but no long-term superiority over physiotherapy 6
Key Considerations
- The physician's ability to correctly diagnose and recommend appropriate treatment is crucial for successful outcomes and patient satisfaction 2
- A solid understanding of the anatomy and unique features of the shoulder is important for adequately assessing any injury 4
- The combination of corticosteroid injections and EMT does not appear to provide better results than either intervention alone 5