Shoulder Pain: Evaluation and Management
Gaetano P. Monteleone, Jr., M.D.
Dept. of Family Medicine
West Virginia University School of Medicine
monteleoneg@rcbhsc.wvu.edu
www.thesportsmedicinecenter.com
I.

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




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The Shoulder
A.
Anatomy
Muscles/tendons-rotator cuff
(supraspinatus, infraspinatus, teres minor,
subscapularis), biceps, triceps, deltoid,
serratus anterior, latissimus dorsi,
pectoralis major and minor, trapezium.
Ligaments- inferior, middle, and superior
glenohumeral ligaments (the capsule);
coracoacromial ligament,
coracoclavicular ligament,
acromioclavicular ligament.
Bursa- subacromial, inferior scapular.
Bones- humerus, scapula, clavicle.
Joints- glenohumeral, sternoclavicular,
acromioclavicular, "scapulothoracic".
Cartilage- glenoid cartilage, labrum
(fibrocartilage).
Nerves- brachial plexus.
Vascular- subclavian, axillary, and brachial
arteries and veins.
B.
Biomechanics
1. Capsule
The capsule creates the glenohumeral joint space. There
are four ligaments that are really just thickenings of the
capsule. These thickenings, however, have individual
functions in the stability of the glenohumeral joint.
Relative to the hip and the acetabulum, the
glenohumeral joint allows for more motion and, therefore, results in less stability.
The capsule: Superior glenohumeral ligament
Middle glenohumeral ligament
Inferior glenohumeral ligament complex
Coracohumeral ligament
2. The structures that create stability at rest are different than those that stabilize
during motion. The static stabilizers include the capsule, GH ligaments and the fibrocartilaginous
labrum. The dynamic stabilizers of the shoulder include the rotator cuff (RC) musculature, long
head of the biceps, and the scapular rotators (serratus anterior, rhomboids and levator scapulae).
3. The surface of the humeral head has been reported to be 2-4 times that of the
glenoid. As a result, only 25-30% of the humeral head is in contact with the glenoid fossa. The
Shoulder Pain: Evaluation and Management
Gaetano P. Monteleone, Jr., M.D.
Dept. of Family Medicine
West Virginia University School of Medicine
monteleoneg@rcbhsc.wvu.edu
www.thesportsmedicinecenter.com
fibrous, meniscus-like glenoid labrum increases the
congruity between the two structures. The tendon of the long head of the biceps inserts in the
superior portion of the labrum. The inferior glenohumeral ligament complex attaches to the
inferior portion of the labrum. Vascularity is limited to the peripheral region of the labrum, and
like the meniscus of the knee, decreases with advancing age. The average depth of the glenoid
is doubled from 2.5 to 5.0 mm by the labrum.
C.
History
1. Chief Complaint
-Dislocation
-Subluxation
-Apprehension
-Pain
-Weakness
2.Age- Younger age favors instability, with the ligamentous structures tightening with aging. As
the patient ages, there is increasing chance for tendinitis, bursitis and degenerative changes of
the acromion (spurring) leading to subacromial impingement or RC tear.
3. Arm Dominance- assess effects on job and sport.
4. Occupation/Sport/Activities- overhead activities such as house painting, carpentry, volleyball,
baseball, tennis, etc. may lead to RC tendinitis, bursitis and impingement.
5. Mechanism of Injury- external rotation with abduction or hyperextension favors instability,
while overhead activities (brushing hair, jars/cans in cupboard) cause symptoms of impingement.
In addition, note any history of paresis or paresthesias (dead arm syndrome) which can be seen
in instability.
6. Current and Previous Treatment- information regarding the duration of dislocation, duration
of symptoms, whether reduction was required, duration of immobilization, rehabilitation,
medicines (NSAID's/narcotics), etc.
7. Recurrences?- frequency, activity during recurrences, voluntary/involuntary, and treatment.
D.
Physical Exam
A careful physical exam must be performed both to confirm the suspected diagnosis and
to rule out any other causes of symptoms (such as cervical radiculopathy). Thus a complete
exam must include examination of the cervical spine and the entire upper extremity not just the
glenohumeral joint. It is essential to examine both sides to serve as a basis of comparison.
1. Inspection
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Attitude
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Muscle features - tone/atrophy/hypertrophy of dominant side
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Bony deformity - AC joint, SC joint
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Erythema
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Skin manifestations/ecchymosis
Shoulder Pain: Evaluation and Management
Gaetano P. Monteleone, Jr., M.D.
Dept. of Family Medicine
West Virginia University School of Medicine
monteleoneg@rcbhsc.wvu.edu
www.thesportsmedicinecenter.com
•
2. Palpation
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Local tenderness
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Edema
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Temperature changes
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Deformities
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Muscle characteristics - tone, consistency
3. Joint Motion
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Glenohumeral:scapulothoracic normal 2:1
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Range of motion
a. Active-thrower may have natural asymmetry
b. Passive
4. Manual Muscle Testing
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Abduction
0-180°; deltoid, supraspinatus
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Adduction
0-45°; pectoralis major, latissimus dorsi
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Forward flexion
0-180°; anterior deltoid
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Extension
0-60°; posterior deltoid
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External Rotation
0-90°; infraspinatus, teres minor
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Internal Rotation
0-70°; subscapularis
5. Special Tests
Impingement Signs/Test
a. Neer's impingement sign - positive if maximum passive forward
flexion/internal rotation causes pain in last 10-15° of motion arc
- thought to be due to supraspinatus tendon being impinged against
anterior inferior acromion
b. Hawkin's impingement sign
- humerus forward flexed to 90° (with elbow flexed to 90°) then
actively internally rotate shoulder. Positive test is pain.
c. Impingement injection test
- response to subacromial injection of lidocaine 2%
- regarded as positive if >50% reduction or abolition of
impingement signs
d. Biceps Evaluation
¾
Yergason’s Test
- active resisted supination with the elbow flexed to 90° and
forearm fully pronated
- positive if elicits pain at bicipital groove
¾
Speed’s Test * more sensitive than Yergason’s
- humerus forward flexed to ~ 60°, resisted elevation of arm with
Shoulder Pain: Evaluation and Management
Gaetano P. Monteleone, Jr., M.D.
Dept. of Family Medicine
West Virginia University School of Medicine
monteleoneg@rcbhsc.wvu.edu
www.thesportsmedicinecenter.com
the elbow fully
extended and forearm fully supinated
- positive if elicits pain at bicipital groove
- considered more accurate test for biceps tendinitis
•
Instability Tests
- examine both sides, asymptomatic side first
- examine in both the upright and supine positions
- document amount of glenohumeral translation
- attempt to reproduce symptoms of subluxation/apprehension
a. Apprehension test
- performed both upright and supine
- arm abducted to 90°, externally rotated, anterior translation stress
applied to humeral head
- positive if produces “apprehension”
b. Relocation Test
- generally attributed to Jobe
- perform apprehension test to elicit anterior apprehension
- at point of apprehension, apply posteriorly directed force to prevent
anterior translation of humeral head. Positive test produces abolition of
apprehension and pain with posteriorly-directed force
c. Load/Shift test
- perform upright with arm at side and supine with arm at 20°-30°
abduction and 90° abduction
- humeral head is “loaded” to ensure centering on the glenoid fossa
- anterior/posterior translational directional stress forces applied in
attempt to “shift” humeral head
- grade as trace, 1+, 2+, 3+ (Fig. I) according to degree of
translation
d. Andrew's modified-Lachman test of the shoulder
- with patient in supine position, examiner places one hand behind
proximal humerus while gently grasping the elbow at the bicondylar axis
at the elbow. Patient's humerus is abducted approximately 120°. With the
elbow held steady the examiner gently translocates the humeral head
anteriorly, evaluating for amount of excursion and quality of end point.
-shoulder with anterior instability may show increase in laxity and
difference in end point quality compared to unaffected side
- patient must be completely relaxed
e. Labral "clunk" test
- same position as the test in 'd'. The examining hand behind the humeral
Shoulder Pain: Evaluation and Management
Gaetano P. Monteleone, Jr., M.D.
Dept. of Family Medicine
West Virginia University School of Medicine
monteleoneg@rcbhsc.wvu.edu
www.thesportsmedicinecenter.com
head palpates for a "clunk"
as the other hand moves the humerus in a rotary motion, in effect trying to
trap the labral tear between the humeral head and glenoid. This is
analogous to the McMurray's test for meniscal tears of the knee.
f. Sulcus sign
- patient seated with arms at side
- downward traction force applied to adducted arm (arm at side)
- space or distance between lateral acromion and humeral head noted
- graded 1+ (< 1 cm), 2+ (1-2 cm), 3+ (> 2 cm)
- indicative of inferior instability
- pathognomonic of multidirectional instability
6. Generalized ligamentous laxity- if laxity is evident at the GH joint, assess for laxity in
other common areas:
a. Thumb hyperabduction - “thumb-to-wrist” test
b. Index MCP hyperextension
c. Elbow recurvatum
d. Knee recurvatum
7. Neurovascular Assessment a. C5-T1 neuro exam: sensory, motor, reflex
b. Adson’s maneuver- arm abducted to 60°, in slight extension, external rotation;
full extension at elbow. Examiner palpates radial pulse. Pt then rotates head to
side of arm being examined. Positive test is dramatic diminution or ablation of
pulse.
c. Wright's maneuver- similar to above, except 90° flexion at elbow. Positive
test is change in pulse as above.
d. Roos maneuver- Pt abducts shoulders to 90°, elbows flexed to 90°, externally
rotates to 90°. The pt then opens and closes his/her hands repetitively for up to 3
minutes. A positive test reproduces the pt's pain, paresthesias.
N.B. Thoracic outlet syndrome will produce positive tests in b-d.
E.
Diagnostic testing
1. Plain radiography
The indicated studies will depend on the clinical situation. In the acute dislocation, the
radiographs should provide information regarding the direction of dislocation, presence of
associated bony lesions (Bankart, Hill-Sachs, reverse Hill-Sachs), and presence of acute fracture
of the proximal humerus.
“Trauma series”
• true AP view (in the plane of the scapula)
Shoulder Pain: Evaluation and Management
Gaetano P. Monteleone, Jr., M.D.
Dept. of Family Medicine
West Virginia University School of Medicine
monteleoneg@rcbhsc.wvu.edu
www.thesportsmedicinecenter.com
• scapular lateral “Y” view
• axillary lateral view (West Point view)
These three views are all at 90° to one another thus maximizing the information. In addition, the
positioning of the patient for the above views requires minimal glenohumeral motion and,
therefore, minimizes pain for the acutely injured patient.
“Instability series”
• AP views with the humerus in internal and external rotation (IR and ER)
• West Point (axillary lateral) view
• Stryker notch view
"Impingement series"
• AP with IR and in ER views
• West Point view
• Supraspinatus outlet view (Alexander)
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•
•
•
•
•
•
a. AnteroPosterior (AP) views
(see figure at right)
•
important to differentiate between AP of shoulder and
AP of GH joint (also known as the AP of the scapula)
scapular AP view is the true AP view of GH joint
AP with IR of humerus will reveal Hill-Sachs lesion in 92% of cases. Humerus looks like
a "light bulb"
AP with ER of humerus will visualize
humeral neck in profile tuberosities
b. Scapular Lateral or “Y” view
may be helpful in acute dislocation since
minimal motion required
helpful in determining anterior/posterior
relationship of humerus to glenoid
not define fractures of glenoid
Shoulder Pain: Evaluation and Management
Gaetano P. Monteleone, Jr., M.D.
Dept. of Family Medicine
West Virginia University School of Medicine
monteleoneg@rcbhsc.wvu.edu
www.thesportsmedicinecenter.com
•
•
c. West Point axillary lateral view
provides excellent visualization of glenoid and
humeral head (Bankart and Hill-Sachs lesions,
respectively.
delineates the spatial relationship of the two
structures thus best for determining direction of
dislocation (see figure at right).
•
d. Stryker Notch view
most sensitive technique for detection of Hill-Sachs defect
•
e. Supraspinatus outlet (Alexander) view
helpful for visualizing subacromial spurs which may contribute to RC pathology and
shoulder impingement
2. Arthrography
Double contrast arthrography has been demonstrated to be useful in detecting
rotator cuff tears, biceps tendon abnormalities, adhesive capsulitis, and glenoid labral
lesions. Its use has generally been supplanted by MRI. Some medical centers use an
MRI-arthrogram to assess labral integrity.
3. CT Arthrography
Double contrast CT-arthrography remains helpful for the detection of
capsulolabral lesions associated with anterior instability, however its use has been
supplanted by the MRI. Still its sensitivity and specificity in detecting and characterizing
glenohumeral pathology have been reported as high as 100% in studies correlating
surgical findings. It also enables detection of large capsular spaces in instability.
Drawbacks include invasiveness, administration of contrast, and possible complications
(anaphylaxis, infx).
4. Magnetic Resonance Imaging
The use of MRI in the evaluation of shoulder pathology has become increasingly
more common and widespread. Many recent studies have demonstrated the high
sensitivity and specificity of MRI in the assessment of labral lesions (sensitivity 90100%, specificity 70-100%). The use of MRI in impingement diagnoses is helpful when
assessing the integrity of the RC tendons and the subacromial space. However, high
interobserver and intraobserver variability has been reported as compared to other
modalities. In addition, MRI continues to entail high cost. MRI may be enhanced with
Shoulder Pain: Evaluation and Management
Gaetano P. Monteleone, Jr., M.D.
Dept. of Family Medicine
West Virginia University School of Medicine
monteleoneg@rcbhsc.wvu.edu
www.thesportsmedicinecenter.com
intra-articular injection of contrast, known
as MR-arthrogram. This helps to visualize the glenoid labrum, a structure at risk in pts
with instability.
D.
Specific Injuries
1. Rotator Cuff Tendinitis/Impingement
The RC tendons may become inflamed with overuse in the weekend warrior. The tendons
can become so inflamed they may be encroached upon when glenohumeral joint moved
(ie: abducted, forward flexion, etc.). This encroachment may be due to:
•
•
•
Bone- acromion (shape of acromion, existence of spurs, etc.)
Instability (secondary impingement due to increased joint motion, especially pediatric pts)
Rotator cuff tendinitis, bursitis (swollen, thickened tendons decrease usable space in the supraspinatus
outlet)
The following is a schema regarding the histopathology of tendinitis and impingement as related
to age proposed by Neer:
Neer Classification
Histopathology
Age (Years)
Stage I
Tendon with edema, hemorrhage and inflammation.
< 25
Stage II
Tendon fibrosis, scar and fiber dissociation; thickened bursa.
25-40
Stage III
Bony alteration of the acromion and tuberosity, tendon rupture.
> 40
•
•
•
•
•
a. History
Pain with overhead activity
Lack of trauma
Age over 35
More insidious onset
Sometimes weakness (secondary to pain), not true neuromyopathic weakness
•
•
•
•
b. Physical Exam
+ pain to palpation in a variety of areas
+ pain with manual muscle testing of RC, biceps
+ impingement signs (Neer's, Hawkin's signs), impingement injection test
Full ROM (lack of full ROM requires ruling out adhesive capsulitis vs RC tear)
- instability testing (unless impingement secondary to instability in young)
Shoulder Pain: Evaluation and Management
Gaetano P. Monteleone, Jr., M.D.
Dept. of Family Medicine
West Virginia University School of Medicine
monteleoneg@rcbhsc.wvu.edu
www.thesportsmedicinecenter.com
c. Radiology
Recall that the impingement series includes the AP with IR and ER, West Point views.
Some authors include the supraspinatus outlet view (Alexander view) to assess the shape
of the acromion and for subacromial spurs. Bigliani evaluated acromial shape and
reported that the acromion can be flat (Type 1), curved (Type 2) and beaked/with a spur
(Type 3). See figure below. He noted that there was a higher incidence of rotator cuff
tears in type 3 acromion.
d. Treatment
• Rehab = RC and scapular stabilizer strengthening
• Cryotherapy
• NSAID's
• ? Steroid injection: if no concern for RC tear or labral tear.
• Consider REFERRAL for surgery for recalcitrant pain or large subacromial spur/type
3 acromion.
e. Monitoring
Recheck patient for improvements in pain, activities of daily living, work-related
function. If anti-inflammatory regimen, rehab, etc. does not significantly improve
symptoms, reconsider the diagnosis. AC joint abnormalities can present similarly
to impingement. Consider tumors, as well. Consider REFERRAL for recalcitrant
sxs. Removal of the bursa, shaving the inferior acromion, creating a larger
supraspinatus outlet may decrease symptoms.
At the end of the handout are examples of rotator cuff strengthening exercises and range of
motion exercises to utilize with most patients. These come courtesy of Tools RG Exercise
Xpress software from the Saunders Co. Small weights may be a substitute for the theraband
material.
2. Rotator Cuff Tear
Full thickness disruption of the tendon. Most common is the supraspinatus tendon at
insertion into the greater tuberosity. Occurs mostly in patients greater than 40 yrs.
Hx- mechanism = Indirect force on an abducted arm. Symptoms include acute pain and
weakness after a traumatic event. Remember, if the patient has had chronic irritation of
the tendons (overuse, spur), the trauma need not be high velocity.
PE- may have painful arc from 70-120° abduction. Patients with a large tear may not be
able to abduct past 90°. The examiner will still be able to passively abduct
fully (NOTE: therefore PROM > AROM!). There may be a positive drop arm test
with large tears. If initially undiagnosed, there may be atrophy of supraspinatus and
infraspinatus.
Shoulder Pain: Evaluation and Management
Gaetano P. Monteleone, Jr., M.D.
Dept. of Family Medicine
West Virginia University School of Medicine
monteleoneg@rcbhsc.wvu.edu
www.thesportsmedicinecenter.com
Dx- Mainly H&P. Xrays may demonstrate a
type 3 acromion (figure below, C). Rarely necessary to make the diagnosis, an MRI will
demonstrate these tears readily. Differential diagnosis includes nerve entrapment,
adhesive capsulitis, RC impingement.
Rx- aggressive P.T. similar to that of RC tendinitis. NSAID's may benefit acutely. Avoid
steroids, since altered healing potential is possible. If rehab fails to increase ROM,
decrease pain consider surgical repair. Consider surgical options more quickly in young
athletes.
from Bigliani LU, et al. Orthop Trans. 10:228, 1986.
3. Adhesive Capsulitis- also known as "frozen shoulder" or calcific tendinitis. The RC
tendons no longer function to mobilize the shoulder.
Hx- Progressive loss of ROM with accompanying pain. There may or may not be
antecedent trauma. Pts with impingement or RC tear can progress to this.
PE- the normal Glenohumeral:Scapulothoracic (GH:ST) ratio is changed. The normal
GH:ST is 2:1. As the shoulder abducts from 0-180°, the humeral head contributes 2° for
every 1° of scapular motion. With adhesive capsulitis, there is decreased glenohumeral
motion, so that the GH:ST may be 1:1, or even 1:2. The pt will try to raise his/her arm by
side-bending their thoracic spine. There is lack of active abduction, and passive
abduction. The lack of BOTH active and passive abduction distinguishes adhesive
capsulitis from RC tear. Remember, with RC tear, the examiner will still be able to
passively abduct the pts shoulder.
Dx- H&P. Xrays may demonstrate degenerative changes and calcifications. In addition,
xrays will demonstrate other causes of decreased ROM (fractures, loose bodies, etc.).
Rx- aggressive PT to improve ROM and strength is mainstay of rx. Mobilization is key!
Steroid injections have been recommended if PT fails. REFERRAL to orthopedics of
cases that do not respond to PT. May require manipulation under anesthesia.
•
In addition, PREVENTION of this can occur if aggressive mobilization as
treatment of RC tears and impingement. The natural inclination of pts with
pain is to limit motion. Proper education and abundant use of home
exercise programs with ROM and theraband exercises may help to
prevent. Further, adequate follow-up is required to encourage maintenance
Shoulder Pain: Evaluation and Management
Gaetano P. Monteleone, Jr., M.D.
Dept. of Family Medicine
West Virginia University School of Medicine
monteleoneg@rcbhsc.wvu.edu
www.thesportsmedicinecenter.com
of exercise programs.
4. Biceps tendon rupture
I am including this injury in this lecture since biceps rupture may be the result of chronic
inflammation as well as a traumatic rupture. Two main types: proximal (more common) and
distal ruptures. Rarely, short head of the biceps may rupture. One series demonstrated 96%
proximal (long head) ruptures, 1% proximal (short head) ruptures, 3% distal ruptures.
a. Proximal biceps ruptures: involve the long head of the biceps that inserts into the inferior
portion of the glenoid rim. Remember, the short head of the biceps inserts into the coracoid
process. Generally involves resistance to active flexion of the elbow. The tear often occurs at the
biceps groove, but can occur at the site of insertion-with or without avulsion fracture of the
glenoid rim.
Hx- pain in the biceps. May have a history of biceps tendinitis associated with
impingement. Pain with flexion activities of the elbow and supination at the forearm.
PE- classic finding of retracted and “balled up” muscle belly giving the Popeye
appearance to the muscle (compare to unaffected side). May also see ecchymosis at the
site. There is generally some weakness to flexion at the elbow, though not nearly as
severe as with distal ruptures. Recall that with proximal ruptures, the patient still has
functional short head of the muscle.
Dx- usually based on H&P. Xray usually negative; occasionally + for avulsion fracture.
If uncertain, MRI will demonstrate this abnormality nicely.
Rx- supportive care is necessary (PRICES). PT may be helpful. Generally, not a longstanding problem unless this occurs in a bodybuilder, where the look of the muscle
matters. There will always be the Popeye look to the muscle.
b. Distal biceps ruptures: involve the distal tendon rupture from its insertion into the radial
tuberosity. Typically occurs in men during fourth through sixth decades of life (with a large
range from 20-70 yrs). Pre-existing degenerative changes of the tendon appears to be a risk
factor for rupture.
Hx- acute onset of pain, ecchymosis, edema during resisted flexion. In fact most distal
ruptures occur during eccentric contraction of this tendon- meaning exercise involving
elongation of the tendon, such as the “down phase” of doing a curl.
PE- ecchymosis, edema, pain to palpation at the antecubital fossa. Significant weakness
to elbow flexion and forearm supination.
Dx- mostly on H&P. Xray typically normal but may demonstrate avulsion fracture at the
radial tuberosity.
Rx- While results are conflicting, but most authors suggest early surgical treatment.
Nonsurgical treatment has been recommended by some- there appears to be significant
loss of extension and flexion with resultant weakness.
Shoulder Pain: Evaluation and Management
Gaetano P. Monteleone, Jr., M.D.
Dept. of Family Medicine
West Virginia University School of Medicine
monteleoneg@rcbhsc.wvu.edu
www.thesportsmedicinecenter.com
5. Osteolysis of the Clavicle
Degenerative condition of the distal end of the clavicle. Common with repetitive arm
motion with the humerus adducted. The condition is characterized by resorption of the distal end
of the clavicle. Appears to be more common in males. Pathophysiology uncertain. May relate to
avascular necrosis, micro fractures, synovitis.
Hx- pain at the AC joint; usually a history of trauma at the site (eg: AC sprain, etc.).
PE- pain + deformity at the AC joint. Pain with crossed-chest adduction test.
Dx- H&P; Xrays may demonstrate diagnostic sclerosis and cystic degeneration at the
distal clavicle. Occasionally you will see widening of the AC joint space. Xrays may be
normal if early in the disease process. If questions, consider injection of a local
anesthetic into the AC joint. This will produce significant reduction in symptoms.
Rx- mostly nonsurgical. PRICES, steroid injections and PT. If continued symptoms,
consider surgery. Surgical procedure involves resection of the distal 2.5 cm of the
clavicle.
Shoulder Pain: Evaluation and Management
Gaetano P. Monteleone, Jr., M.D.
Dept. of Family Medicine
West Virginia University School of Medicine
monteleoneg@rcbhsc.wvu.edu
www.thesportsmedicinecenter.com
REFERENCES
Altchek, DA (Ed) Operative Techniques in Sports Medicine. Shoulder Instability.Vol 1(4), 1993.
Arciero RA, Wheeler JH, Ryan JB, et al. Arthroscopic Bankart repair vs nonoperative treatment for acute, initial
anterior shoulder dislocations. Am J Sport Med. 22(5):589-94, 1994.
Bahr R, Craig EV. The clinical presentation of shoulder instability including on the field management. Clin in Sport
Med. 14(4): 761-76, 1995.
Burkhead WZ, Rockwood CA. Treatment of instability of the shoulder with an exercise program. JBJS. 74-A(6):
890-96, 1992.
Carter AM, Erickson SM. Proximal biceps tendon rupture. PSM. 27(6):, 1999.
Fongemie AE, Buss DD, Rolnick SJ. Management of shoulder impingement syndrome and rotator cuff tears. Am
Fam Phys. 57(4):667-74, 1998.
Glockner SM. Shoulder pain:a diagnostic dilemma. Am Fam Phys. 51(7):1677-87, 1995.
Glousman RE. Instability versus impingement syndrome in the throwing athlete. Orthop Clin of North Am. 24(1):8999, 1993.
Gusmer PB, Potter HG. Imaging of shoulder instability. Clin in Sports Med. 14(4):777-95, 1995.
Hovelius L, Augustini GB, Orebro FH, et al. Primary anterior dislocations of the shoulder in young patients. JBJS.
78A(11):1677-84, 1996.
Matsen FA, Thomas SC, Rockwood CA: Glenohumeral instability. In Rockwood and Matsen (Eds) The Shoulder.
W.B. Saunders, Philadelphia, 1990, pp. 526-622.
Mellion MB, Walsh WM, Shelton GL. The team physician's handbook. 2nd edition.Mosby, Phila, PA, 1996.
Pagnani MJ, Warren RF: The pathophysiology of anterior instability. Sport Med Arthro Rev. 1(3):177-89, 1993.
Rodgers JA, Crosby LA. Rotator cuff disorders. Am Fam Phys. 54(1):127-34, 1996.
Siegel LB, Cohen NJ, Gall EP. Adhesive capsulitis- a sticky issue. AFP. 59(7):1843-50, 1999.
Speer KP, Hannafin JA, Altchek DW, et al. An evaluation of the shoulder relocation test. Am J Sport Med. 22(2):
177-83, 1994.