Approach to Taking a History in a Patient with Atraumatic Shoulder Pain
A comprehensive history for atraumatic shoulder pain should focus on identifying the specific cause through systematic questioning about pain characteristics, functional limitations, and risk factors, which guides appropriate imaging and treatment decisions.
Key Components of History Taking
Pain Characteristics
- Location and radiation: Ask patient to point to the exact location of pain and whether it radiates to neck, arm, or elsewhere
- Onset and duration: When symptoms began and whether they've been constant or intermittent
- Quality: Sharp, dull, aching, burning, or throbbing
- Severity: Use visual analog scale (0-10)
- Aggravating factors: Specific movements or activities that worsen pain (overhead activities, reaching behind, sleeping positions)
- Alleviating factors: Rest, medications, positional changes, or other interventions that provide relief
Functional Assessment
- Impact on activities of daily living
- Effect on sleep patterns
- Work-related limitations
- Sports or recreational activity limitations
- Simple Shoulder Test can be used to systematically assess functional limitations 1
Associated Symptoms
- Weakness
- Stiffness or limited range of motion
- Instability or sensation of the shoulder "giving way"
- Catching, locking, or clicking sensations
- Numbness or tingling in the arm or hand (suggesting possible neurological involvement)
Past Medical History
- Previous shoulder injuries or problems
- History of degenerative joint disease
- Inflammatory conditions (rheumatoid arthritis, polymyalgia rheumatica)
- Diabetes (associated with adhesive capsulitis)
- Thyroid disorders
- Cervical spine pathology
Previous Treatments
- Physical therapy (type and duration)
- Medications (NSAIDs, corticosteroids, analgesics)
- Injections (corticosteroid, hyaluronic acid)
- Prior surgeries
- Response to previous treatments
Differential Diagnosis Considerations
Based on the history, consider these common causes of atraumatic shoulder pain:
Rotator cuff disorders: Most common cause of shoulder pain 2
- Ask about overhead activities, gradual onset, night pain
Adhesive capsulitis (frozen shoulder):
- Progressive stiffness and pain
- Risk factors: diabetes, thyroid disorders, prolonged immobilization
Biceps tendon abnormalities:
- Anterior shoulder pain
- Pain with overhead activities or lifting
Labral tears:
- Mechanical symptoms (catching, locking)
- Overhead athletes or repetitive overhead activities
Glenohumeral arthritis:
- Gradual onset, progressive pain
- Morning stiffness, decreased range of motion
Acromioclavicular joint disorders:
- Pain localized to the AC joint
- Pain with cross-body adduction
Subacromial/subdeltoid bursitis:
- Pain with overhead activities
- Night pain when lying on affected side
Red Flags to Identify
- Night pain unrelated to position (possible malignancy)
- Unexplained weight loss
- History of cancer
- Fever or systemic symptoms
- Progressive neurological symptoms
- Pain unrelated to movement
Pitfalls to Avoid
Failing to consider referred pain: Always assess for cervical spine pathology, which can refer pain to the shoulder 3
Overreliance on imaging before clinical evaluation: Studies show that routine pre-evaluation MRI does not significantly affect treatment outcomes and should not be used as a screening tool before comprehensive clinical evaluation 1
Missing non-musculoskeletal causes: Cardiac, pulmonary, or abdominal pathologies can present as shoulder pain
Not assessing psychological factors: Chronic pain can have psychological components that affect presentation and treatment response
Inadequate documentation of prior treatments: Understanding previous treatment failures is crucial for developing an effective management plan
By systematically gathering this information, you can develop a focused differential diagnosis that will guide your physical examination and appropriate selection of imaging studies, ultimately leading to better treatment decisions and outcomes for patients with atraumatic shoulder pain.