Chronic Shoulder Pain

Shoulder pain is considered chronic when present for > 6 months. Common conditions resulting in chronic shoulder pain include rotator cuff disorders, adhesive capsulitis, shoulder instability, and joint arthritis. Shoulder pain can be intrinsic or extrinsic to the joint. The potential of serious causes of referred pain to the shoulder such as cardiovascular and abdominal etiologies should be considered. A focused history and physical examination is essential and should include inspection, palpation, range of motion (ROM), and provocative testing. Imaging often includes plain radiographs occasionally supplemented with MRI. Management varies related to specific disorders and frequently requires physical therapy.

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Overview

Epidemiology

  • Shoulder pain is responsible for approximately 10%–20% of all musculoskeletal complaints.
  • Annual incidence: 15 per 1,000 individuals in the primary care setting
  • In 2000, shoulder complaints in the United States totaled $7,000,000,000.

Etiology

  • Risk factors:
    • Age: 
      • < 40: overuse injuries, instability, or labral tear
      • > 40: rotator cuff tear, adhesive capsulitis, osteoarthritis (OA), or bicep disorders
    • Vocation or recreational activities
    • History of previous trauma
  • Intrinsic causes: pain originates from the shoulder complex:
    • Most common: rotator cuff related disorders (e.g., rotator cuff tears, tendinopathy, bursitis, impingement)
    • Common:
      • Glenohumeral joint disorders (e.g., glenohumeral OA, adhesive capsulitis)
      • Biceps tendinopathy or rupture
      • Acromioclavicular joint OA
      • Labral tears
    • Less common: inflammatory disorders (e.g., rheumatoid arthritis, gout, pseudogout, septic arthritis, polymyalgia rheumatica)
  • Extrinsic causes:
    • Neurologic:
      • Cervical radiculopathy
      • Brachial plexopathy
      • Herpes zoster
      • Thoracic outlet syndrome (TOS)
    • Cardiovascular/pulmonary:
      • Myocardial infarction
      • Angina pectoris
      • Aortic dissection
      • Pulmonary embolism (PE)
      • Pancoast tumor (apical lung tumor)
      • Other malignancies
      • Vascular thrombosis
    • Abdominal:
      • Radiates to left shoulder: splenic rupture (Kehr sign)
      • Radiates to right shoulder: 
        • Gallbladder
        • Hepatic disorders (e.g., cholecystitis, abscess)
      • Radiates to either shoulder:
        • Abdominal (e.g., abscess, hemorrhage, ruptured viscus, pancreatitis)
        • Esophageal disorders

Anatomy of the shoulder joint

  • The shoulder complex is made up of multiple joints, bones, ligaments, and tendons.
  • The glenohumeral joint has the most mobility of any joint in the body.
  • Glenohumeral joint: 
    • Passive restraints:
      • Joint capsule
      • Glenohumeral ligaments
      • Glenoid labrum
    • Active stabilizers:
      • Rotator cuff muscles
      • Periscapular muscles
  • Rotator cuff muscles (active stabilizers):
    • Supraspinatus, infraspinatus, teres minor, subscapularis
    • Form a cuff around the head of the humerus
    • Stabilize the joint while allowing motion
    • Supraspinatus is the most commonly torn rotator cuff tendon.
  • Shoulder complex also includes:
    • Acromioclavicular
    • Sternoclavicular joints
    • Scapulothoracic articulation
    • Long head of the bicep tendon
  • Cervical spine evaluation is included in the assessment of shoulder pain.
  • A thorough neurovascular examination is essential after trauma to the upper extremity.

Mnemonic:

SITS: Supraspinatus, Infraspinatus, Teres minor, Subscapularis

Evaluation of Chronic Shoulder Pain

History

  • Pain > 6 months
  • Previous shoulder injury, trauma, or surgery
  • History and pain patterns are important in the diagnosis of shoulder pathology.
  • Location of pain:
    • Lateral: rotator cuff disease, impingement
    • Anterior: biceps tendon
    • Superior: acromioclavicular joint pathology
  • Pain at night: rotator cuff disease
  • Cervical spine etiology:
    • Periscapular pain
    • Pain or numbness below the elbow

Physical exam

  • Exposure of shoulder
  • Compare to unaffected side
  • Inspection/observation:
    • Atrophy/asymmetry:
      • Atrophy may be seen with chronic rotator cuff tears.
      • Atrophy of supraspinatus and infraspinatus may be secondary to suprascapular nerve palsy.
    • Winging of the scapula (long thoracic nerve palsy)
  • Cervical spine exam: Always consider associated injury.
  • Active and passive range of motion (ROM):
    • ROM can be evaluated either sitting or supine.
    • Lack of passive ROM: adhesive capsulitis versus OA
    • Assessment of scapular motion: Look for winging and scapular dyskinesis (asymmetry of motion).
  • Palpation:
    • Palpation of the cervical spine, sternoclavicular joint, acromioclavicular joint, glenohumeral joint, and proximal humerus
    • Assess for warmth and swelling.
  • Neurologic and vascular exam:
    • Evaluation of brachial plexus
    • Testing for TOS
    • Evaluation for vascular effort thrombosis (i.e., overhead athletes/workers)

Imaging

Imaging studies might be helpful to support or confirm the diagnosis:

  • Plain radiographs: AP shoulder, AP glenoid, scapular Y view, and axillary view
  • MRI or ultrasound for more difficult cases

Important Causes and Management of Chronic or Subacute Shoulder Pain

Rotator cuff pathology

  • Rotator cuff tendinopathy or tendinitis:
    • One of the most common causes of shoulder pain
    • The rotator cuff tendons (especially the supraspinatus due to the anatomical position) undergo compression in the subacromial space with abduction of the shoulder.
    • Features similar to impingement syndrome: 
      • Pain with abduction and overhead reaching
      • Often associated with night pain
    • Diagnosis is clinically based.
    • X-rays are often normal and may include calcification of the tendon.
    • MRI may be indicated to exclude significant rotator cuff tear.
    • Management:
      • Modification of activities: PT for rotator cuff strengthening, ROM, and balance of the shoulder
      • Consider steroid injections for pain management and surgical evaluation for recalcitrant cases.
  • Shoulder impingement syndrome:
    • Etiology: 
      • Repetitive overhead motions
      • Calcification of the coracoacromial ligament
      • Subacromial bursitis
      • Supraspinatus tendonitis or tendinosis
      • Any condition further narrowing the subacromial space
    • Features similar to rotator cuff tendinopathy: 
      • Pain with abduction and overhead reaching
      • Often associated with night pain
    • Diagnosis is clinically based.
    • X-ray is often normal and may include calcification of the tendon.
    • MRI is generally not indicated.
    • Management:
      • Modification of activities: PT for rotator cuff strengthening and ROM
      • Consider steroid injection for pain management.
      • Surgical evaluation for recalcitrant cases
  • Rotator cuff tendon tears:
    • Generally, age is helpful in classifying the tear:
      • Younger individuals commonly have acute tears.
      • Older individuals often have degenerative tears.
      • Important: A significant number of individuals > 60 years of age have asymptomatic degenerative rotator cuff tears on MRI studies.
    • Supraspinatus is the most commonly torn rotator cuff.
    • Features:
      • Shoulder weakness with similar pain when reaching overhead or behind
      • Often bothersome at night
    • Perform physical examination and muscle strength testing specific to the location of the rotator cuff tendon tear.
    • Initial diagnosis is based on clinical examination.
    • MRI is used to confirm the diagnosis.
    • Management:
      • Based on multiple factors: age, duration of symptoms, partial versus full tear, and comorbidities
      • A full thickness tear generally requires surgical repair.
      • A partial thickness tear may be treated with PT.
Shoulder motion with rotator cuff

Function of the supraspinatus muscle

Image: “Shoulder motion with rotator cuff” by Young Lae, Moon M.D. Chair of 3D Based Medical Application Working group. Chairman and Professor of Orthopaedics, Chosun University Hospital, Korea. License: CC BY 3.0

Other shoulder pathology

Biceps tendinopathy or rupture:

  • A degenerative condition affecting the long head of the biceps tendon
  • Repetitive lifting and overhead reaching → irritation, microtears, tendinopathy → damage to bicep tendons
  • The individual complains of anterior shoulder pain and weakness.
  • Aggravated by lifting and carrying
  • Resultant swelling appears like a “Popeye” muscle on exam.
  • Management:
    • The majority are nonsurgical.
    • Surgical repair may be done in younger individuals or for cosmetic reasons.

Acromioclavicular joint pain:

  • The acromioclavicular joint is a common site of degenerative joint disease (DJD) with ↑ age or previous trauma.
  • Examination: pain to palpation of joint, positive cross-arm test 
  • Plain X-ray: DJD of the acromioclavicular joint
  • Management: steroid joint injections and surgical evaluation

Sternoclavicular joint pathology:

  • Presentation may include subluxation or DJD.
  • Management is symptomatic.

Adhesive capsulitis (frozen shoulder):

  • Painful shoulder with often disabling loss of ROM
  • Self-limited, but can be prolonged (2–3 years)
  • Most common in the 5th and 6th decade of life; women > men
  • Exact pathophysiology is not definitively understood.
  • Associated with diabetes, hypothyroidism, or immobilization
  • Painful restriction of both active and passive movement of the shoulder 
  • Diagnosis is clinical.
  • 3 phases:
    • Initial phase: pain and loss of motion
    • Intermediate phase: stiffness, severe loss of ROM, ↓ in pain
    • Recovery phase: motion gradually improves
  • Examination:
    • Painful ↓ ROM of both active and passive shoulder movement
    • Marked ↓ in external rotation
  • Radiology:
    • X-ray (usually normal)
    • MRI (usually not necessary) may show minimal signs of edema and ligament thickening.
  • Management:
    • Lack of consensus on the optimal management
    • PT, glucocorticoids, injections, and surgical management are all used with varying effect.

Glenohumeral OA:

  • Uncommon site for primary OA
  • Often related to distant trauma or large rotator cuff tears: In the absence of any previous trauma, consider metabolic abnormalities.
  • Gradual onset of anterior or deep shoulder pain and ↓ ROM
  • Examination:
    • ↓ ROM often with crepitus
    • Shoulder atrophy often develops
  • Diagnosis:
    • Plain X-ray is used to confirm the diagnosis.
    • Laboratory evaluation may be needed to exclude other diagnoses.
  • Management:
    • PT, NSAIDs, topical therapy
    • Injection therapy
    • Surgical management: joint replacement 

Chronic instability of the shoulder:

  • Can be secondary to previous traumatic dislocation/subluxations
  • Frequently present with symptoms of instability
  • Episodes of “dead arm”
  • Diagnosis:
    • Signs of generalized hyperlaxity
    • Positive sulcus sign
    • Signs of excessive mobility
  • Management:
    • PT is the cornerstone of therapy.
    • Surgery evaluation in recalcitrant cases

Superior Labral tear from Anterior to Posterior (SLAP) lesion:

  • Injury to the glenoid labrum (SLAP)
  • Etiology: most commonly in overhead athletes or trauma
  • Clinical manifestations: dull pain or discomfort (especially with overhead activities or a change in velocity) in overhead athletes
  • Imaging:
    • Plain X-rays to rule out other causes
    • MRI to confirm diagnosis
  • Classification:
    • Type I: degenerative fraying of labrum with intact biceps insertion
    • Type II: detachment of the biceps insertion
    • Type III: bucket-handle tear with intact biceps insertion
    • Type IV: bucket-handle tear with detachment of the biceps insertion
  • Management:
    • The majority of type I injuries are nonoperative (i.e., NSAIDs and PT).
    • Consider surgical evaluation with persistent pain.
    • Additional factors: age of the individual, overhead athlete, functional requirements

Clinical Relevance

  • Thoracic outlet syndrome (TOS): a broad term used for a spectrum of syndromes related to the general region of the thoracic outlet involving the compression or irritation of elements of the brachial plexus, the subclavian artery, or the subclavian vein. The diagnosis is clinically based and supported by radiography and a number of provocation maneuvers. Management can be medical and surgical.
  • Acute shoulder pain: commonly caused by acute shoulder injuries, including acromioclavicular joint injuries, clavicle fractures, glenohumeral dislocations, proximal humerus fractures, and rotator cuff tears. Management includes pain control and varies based on the diagnosis.
  • Hypothyroidism: a condition characterized by the deficiency of thyroid hormones. Thyroid hormones are integral in metabolic processes and the development of the brain and other organs. Diagnosis is by obtaining thyroid function tests. Elevated thyroid stimulating hormone and a low free thyroxine (T4) are noted. Management is with synthetic T4. Hypothyroidism is also associated with adhesive capsulitis.
  • Ehlers-Danlos syndrome: a heterogenous group of inherited connective tissue disorders characterized by hyperextensible skin, hypermobile joints, and fragility of the skin and connective tissue. The syndrome is due to genetic defects affecting collagen processing and synthesis. The diagnosis is clinical but confirmed via genetic testing. No curative treatment exists.
  • Osteoarthritis: the most common form of arthritis due to cartilage destruction and changes of the subchondral bone. Individuals develop gradual joint pain, stiffness, and decreased ROM. The diagnosis is clinical and supported with radiographic joint findings. Management includes conservative measures, analgesic medications, glucocorticoid intra-articular injections, and surgery for advanced disease. 

References

  1. Burbank, K.M., Stevenson, J.H., Czarnecki, G.R., Dorfman, J. (2008). Chronic shoulder pain: part I. Evaluation and diagnosis. Am Fam Physician. 77(4), 453–60. https://pubmed.ncbi.nlm.nih.gov/18326164/
  2. Meislin, R.J., Sperling, J.W., Stitik, T.P. (2005). Persistent shoulder pain: epidemiology, pathophysiology, and diagnosis. Am J Orthop (Belle Mead NJ). 34(12 Suppl), 5–9. https://pubmed.ncbi.nlm.nih.gov/16450690/
  3. Van der Windt, D.A., Koes, B.W., de Jong, B.A., Bouter, L.M. (1995). Shoulder disorders in general practice: incidence, patient characteristics, and management. Ann Rheum Dis. 54(12), 959–964. https://pubmed.ncbi.nlm.nih.gov/8546527/
  4. Iannotti, J.P., Kwon, Y.W. (2005). Management of persistent shoulder pain. a treatment algorithm. Am J Orthop. 34(12 suppl), 16–23. https://pubmed.ncbi.nlm.nih.gov/16450692/
  5. Woodward, T.W., Best, T.M. (2000). The painful shoulder: part I. Clinical evaluation. Am Fam Physician. 61(10), 3079–3088. https://pubmed.ncbi.nlm.nih.gov/10839557/
  6. Woodward, T.W., Best, T.M. (2000). The painful shoulder: part II. Acute and chronic disorders. Am Fam Physician. 61(11), 3291–3300. https://pubmed.ncbi.nlm.nih.gov/10865925/
  7. Ebell, M.H. (2005). Diagnosing rotator cuff tears. Am Fam Physician. 71(8), 1587–1588. https://pubmed.ncbi.nlm.nih.gov/15864899/

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