What history should be taken in a patient with shoulder pain?

History Taking in Shoulder Pain

A systematic history for shoulder pain should document mechanism of injury, pain characteristics, functional limitations, age-related risk factors, and red flag symptoms to guide diagnosis and imaging decisions.

Essential History Components

Mechanism and Timing of Injury

• Document the exact mechanism of injury, including how any fall or trauma occurred, height of fall, landing position, and whether the injury was related to work 1, 2, 3
• Record the time of injury and evolution of symptoms since onset, distinguishing acute (<2 weeks) from chronic (>6 months) presentations 1, 4
• Determine if pain is traumatic (directly attributed to a specific event) or atraumatic in nature 1, 3
• Note any history of previous similar injuries, including prior shoulder dislocations, fractures, or rotator cuff repairs 1, 2

Pain Characteristics and Location

• Assess pain location precisely: anterior shoulder suggests rotator cuff or biceps pathology; superior shoulder indicates acromioclavicular joint disease; scapular region may indicate referred pain from cervical spine or rotator cuff 1, 5, 6
• Document pain severity using appropriate pain scales and identify aggravating factors (overhead activities, cross-body adduction, throwing motions) and alleviating factors 2, 4
• Determine if pain is present at rest, at night, or only with specific movements 7, 4

Functional Limitations and Instability

• Inquire about specific functional deficits: difficulty with overhead activities, reaching behind back, lifting objects, or activities of daily living 4
• Ask about history of shoulder instability, including any dislocation or subluxation events, particularly in patients under 40 years 1, 4
• Document any sensation of shoulder "giving way" or feeling unstable during activities 1

Age-Specific Considerations

• For patients over 35-40 years: focus on rotator cuff disease, degenerative changes, and arthritis as predominant causes 1, 8, 4
• For patients under 35 years: prioritize questions about instability, labral tears, and sports-related injuries 1
• In elderly patients, inquire about minimal trauma or falls that could cause osteoporotic fractures 8

Associated Symptoms and Red Flags

• Screen for neurological symptoms: numbness, tingling, weakness, or radiation of pain down the arm suggesting cervical radiculopathy or nerve compression 5, 6
• Ask about systemic symptoms including fever, chills, or constitutional symptoms that may indicate septic arthritis 1
• Document any associated medical conditions: diabetes and thyroid disorders (associated with adhesive capsulitis), inflammatory conditions 4

Neurovascular Assessment History

• Inquire about any changes in sensation, motor function, or color/temperature changes in the affected extremity 2
• Ask about any swelling or visible deformity noted by the patient 3

Common Pitfalls to Avoid

• Do not assume absence of trauma means absence of fracture, especially in elderly patients where osteoporotic fractures can occur with minimal or unrecognized trauma 8
• Avoid focusing solely on the shoulder joint without considering referred pain from cervical spine disorders, which commonly cause shoulder pain 6
• Do not overlook work-related injury history, as over 20% of injury-related shoulder pain is work-related 9
• Failing to distinguish between intrinsic shoulder pathology and extrinsic causes (cervical spine, postural problems) leads to inappropriate management 6