I don't routinely do plain radiographs or other
imaging studies on that first patient visit.
A lot times, those provocative tests
will lead me towards a probable diagnosis.
And many of these disorders do work out over time,
so therefore I'm just going to provide
supportive care until it does.
When the pain becomes more chronic,
if this patient gets –
for example, who's had
pain for four weeks,
does not get better on our initial
certainly I’ll recommend x-rays for her next time.
And in general,
when we talk about musculoskeletal medicine,
I think MRI is a great tool,
but I use it really when we’re thinking about intervening
in a case with some kind of active intervention.
So, that’s referring on to a procedure such as injection
therapy in or around the joint and/or surgery.
So, what about just the general
management of shoulder pain?
So, modification activity is really important.
Should not keep your –
your shoulder should not be raised above your –
like above 90° in abduction or flexion when working.
And if patients do a lot of overhead activity,
they work cleaning houses,
they work in a stock room,
they need a ladder
because working over your head all day
will give you shoulder pain every time eventually.
Simple analgesics, whether this patient
chose ibuprofen and acetaminophen,
they are more similar than they are different.
Again, I always am concerned with the
safety of NSAIDs used over time.
Over a couple of weeks,
particularly in a young healthy patient,
is not going to make a difference.
Used over two years,
there's a big separation between
acetaminophen being more safe than NSAIDs.
Injections, commonly used.
I do them.
I approve them.
We use corticosteroids.
There is very little data to support the practice,
but they've been used for many, many years.
It's important to give a probable diagnosis because
there are some different sites you can inject,
the most common being a subacromial bursa injection
which will take care of particularly adhesive capsulitis fairly well,
but also can improve rotator cuff tendinitis.
But if you really are suspecting biceps tendinitis,
different area for injection,
here in the interior and the bicipital groove.
Or if – particularly if you demonstrate
acromioclavicular joint arthritis,
different form of injection,
again into the AC joint.
So, think about that as you’re forming your differential
because it's going to dictate where you might put in injections.
And overall, the best evidence for injections
in terms of what I think they can improve
most effectively is adhesive capsulitis.
That loss of range of motion
that this patient probably –
if we think back to our case,
she had had four weeks of pain in her shoulder,
started with just pain.
Now, she's having stiffness
and she’s probably developing adhesive capsulitis
on top of what I would guess would be a rotator cuff tendinitis.
If these things don't work,
there’s physical therapy.
There’s also surgical referral.
And I'll probably think about an MRI
if it's that severe that she needs to go to surgery.
So, hopefully, you’ve gained an appreciation for the
common differential diagnosis of the pain in the shoulder joint.
We went through some of the physical exam,
particularly the provocative testing.
And then the therapy isn't that dissimilar
from other forms of musculoskeletal medicine,
with an important focus on limitation of exacerbating activities,
particularly working overhead,
and thinking of using injections
based on what you found on