Comprehensive Shoulder Examination and Management of Shoulder Pain
A thorough shoulder examination should include assessment of tone, strength, soft tissue changes, joint alignment, pain levels, and orthopedic changes, followed by appropriate imaging and targeted treatment based on the specific diagnosis. 1
Initial Assessment
- Begin with inspection for asymmetry, muscle atrophy, and deformity while obtaining a detailed history of the mechanism of injury 2
- Palpate key anatomical structures including the acromioclavicular joint, rotator cuff tendons, and biceps tendon to identify areas of tenderness 2, 3
- Assess range of motion both actively and passively, including forward flexion, abduction, external and internal rotation, with comparison to the unaffected side 3
- Evaluate strength using a dynamometer if available, particularly for rotator cuff muscles (supraspinatus, infraspinatus, subscapularis) 3
Special Tests
- Perform impingement tests (Neer's sign, Hawkins-Kennedy) to evaluate for subacromial impingement 4
- Include rotator cuff integrity tests (empty can test, external rotation lag sign, lift-off test) 3
- Assess for instability using apprehension test, relocation test, and load and shift test 4
- Evaluate labral pathology with O'Brien's test, biceps load test, and other specific labral tests 4
- Test for scapular dyskinesis during arm elevation and lowering 2
Imaging Recommendations
- Standard radiographs should be the initial imaging study for traumatic shoulder pain, including anteroposterior views in internal and external rotation, plus axillary or scapula-Y view 1
- For suspected rotator cuff pathology, MRI without contrast, MR arthrography, or ultrasound are all appropriate depending on local expertise 1
- CT is superior for characterizing fracture patterns but inferior to MRI for soft tissue injuries 1
- For suspected septic arthritis, ultrasound or x-ray guided arthrocentesis is recommended 1
- In patients under 35 years with instability, MR arthrography is generally recommended 1
Management Approach
- For limitations in range of motion, implement gentle stretching and mobilization techniques, focusing on external rotation and abduction 1
- Gradually increase active range of motion while restoring alignment and strengthening weak shoulder girdle muscles 1
- For pain management, use analgesics such as acetaminophen or ibuprofen if no contraindications exist 1
- Consider corticosteroid injections for subacromial pain related to rotator cuff or bursa inflammation 1
- For spasticity-related shoulder pain, botulinum toxin injections into the subscapularis and pectoralis muscles may be beneficial 1
- Implement a multidisciplinary approach including physiotherapy and occupational therapy for chronic shoulder pain 5
Special Considerations
- For hemiplegic shoulder pain following stroke, assess tone, strength, soft tissue changes, joint alignment, and pain levels 1
- To prevent Complex Regional Pain Syndrome (CRPS), utilize active, active-assisted, or passive range of motion exercises 1
- For suspected CRPS, look for pain and tenderness of metacarpophalangeal and proximal interphalangeal joints, edema, trophic skin changes, hyperesthesia, and limited range of motion 1
- Consider early oral corticosteroids for CRPS management (30-50 mg daily for 3-5 days with tapering over 1-2 weeks) 1
- Refer patients with acute injuries, failed non-surgical treatment, or "red flag" diagnoses for specialist care 5