Acute Shoulder Pain

00:01 So, I'm excited to talk to you about shoulder pain today.

00:04 It's one of the more common things I see in my practice.

00:07 And the interesting thing about shoulder pain is it really requires a good physical examination.

00:12 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.

00:22 Let's get underway and let’s start with a case.

00:25 I’ve got a 50-year-old right-handed woman.

00:27 She reports a four-week history of right shoulder pain.

00:30 She works as a housecleaner and her shoulder feels worse after work.

00:35 A little bit more history.

00:36 She feels the shoulder has grown stiff in the past week.

00:40 And she tried acetaminophen and ibuprofen for pain and they had a modest effect.

00:45 This isn't that atypical a history.

00:47 Right away, notice a few things, though, in the history.

00:50 Whenever you're talking about a unilateral symptom in the upper extremities, always include whether the patient's right or left hand.

00:58 That's going to tell me something.

00:59 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.

01:08 So, always include her hand in this as part of the history of present illness.

01:14 It’s worse after work.

01:15 So, that’s not surprising.

01:17 There’s a lot of inflammatory conditions that can be.

01:19 And then, now her shoulder is growing stiff.

01:22 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.

01:32 That’s going to inform us as we think about therapeutics for her.

01:36 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.

01:55 The degree of disability.

01:56 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.

02:03 It’s not just about treating the pain.

02:05 If this is interfering with her ability to do her job, that interferes with her livelihood.

02:09 So, that could become a lot more serious than just pain alone.

02:13 Other joint pain.

02:14 Shoulder pain, in combination with other forms of pain, could indicate some rare rheumatologic condition.

02:21 Even more rarely, some type of infection.

02:24 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.

02:32 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.

02:49 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, adhesive capsulitis, acromioclavicular joint disease, biceps tendinitis, and glenohumeral arthritis or instability.

03:06 Really, those are the six most common causes.

03:09 They account for the vast majority of cases in my practice.