So, I'm excited to talk to you about shoulder pain today.
It's one of the more common
things I see in my practice.
And the interesting thing about shoulder pain is
it really requires a good
So, we’re going to be discussing the epidemiology
and differential diagnosis of
common causes of shoulder pain today,
but we’ll also spend a
lot of time on physical exam
and then therapeutics as well.
Let's get underway
and let’s start with a case.
I’ve got a 50-year-old right-handed woman.
She reports a four-week history
of right shoulder pain.
She works as a housecleaner
and her shoulder feels worse after work.
A little bit more history.
She feels the shoulder has
grown stiff in the past week.
And she tried acetaminophen and ibuprofen for pain
and they had a modest effect.
This isn't that atypical a history.
notice a few things, though, in the history.
Whenever you're talking about a unilateral
symptom in the upper extremities,
always include whether the
patient's right or left hand.
That's going to tell me something.
So, maybe in my patients,
and working as a housecleaner,
she’s vacuuming a lot
or doing a lot of repetitive motion with that right arm
because that’s her dominant arm.
So, always include her hand in this as
part of the history of present illness.
It’s worse after work.
So, that’s not surprising.
There’s a lot of inflammatory
conditions that can be.
And then, now her
shoulder is growing stiff.
Is that because it hurts so much
or is it because she inherently is lacking
range of motion of the joint?
And then, it's important to know
she’s already tried acetaminophen
and ibuprofen too, obviously.
That’s going to inform us as we
think about therapeutics for her.
So, some things we want to know
about that are elucidated in this case,
what is the duration of pain?
How long has it been going on?
Was there an inciting
event such as a trauma?
That's going to be very different
if you're tackled playing football
versus you’ve noticed the pain
slowly developing over the
course of a month cleaning houses.
The degree of disability.
Any time we talk about musculoskeletal pain
and really any type of pain,
it should include an assessment for
how disabled the patient is as well.
It’s not just about treating the pain.
If this is interfering with her
ability to do her job,
that interferes with her livelihood.
So, that could become a lot more
serious than just pain alone.
Other joint pain.
in combination with other forms of pain,
could indicate some rare
Even more rarely,
some type of infection.
But if it’s just sticking to her shoulder,
you can be pretty sure it's probably related,
in this case, to her overuse at work.
And then, as I mentioned,
it can be hard to elucidate
just on history alone
what is pain and what is
truly immobility of the arm
because patients will use their upper extremity less
as the pain increases,
which increases the sensation
that they’re not moving it as much.
So, what are the major causes
of shoulder pain to consider?
The major causes in my practice,
and all primary care,
include rotator cuff tendinitis,
acromioclavicular joint disease,
and glenohumeral arthritis
Really, those are the six most common causes.
They account for the vast majority of cases in my practice.