Shoulder Assessment

• Where to start when someone complains of shoulder pain:

  • its very common
  • affecting as many as 25% of the general population at any given moment
  • up to 2/3 if adults experience it at some point during their lifetime
• Common Outcome Measures:

  • shoulder pain and disability index (SPADI)
  • disabilities of the arm, shoulder and hand (DASH)
  • constant-murley shoulder outcome score (CMS)
  • Oxford Shoulder Score (OSS)
  • Simple Shoulder Test (SST)
  • other:
  • visual analogue scale (VAS)
  • neck disability index (NDI)
• Red Flags:

  • nontraumatic acute pain
  • trauma + acute pain + weakness = possible cuff tear, common in middle aged population
  • unreduced dislocation must been seen on the same day - axillary nerve damage, vascular compromise
  • malignancy - weight loss, unwell, night pain, sweats, obvious mass/swelling
  • systemic inflammatory disease - multi-joint involvement, enthesis pain
  • systemic or local infection - malaise, fever
  • avascular necrosis of head of humerus
  • visceral masquerades - internal organs refer pain to shoulders
  • referred pain
• Red Flags - Areas of visceral masquerades referred pain:

  • can have serious implications
  • good subjective assessment is important
  • consider the effects of food intake versus mechanical triggers of pain
  • shortness of breath
  • chest tightness

  
• Red Flags - Areas of visceral masquerades referred pain pt1:

  • gallbladder can cause referred pain to the right shoulder - gallbladder stores bile which can be triggered by eating fatty foods, so cause of pain may be due to dietary intake and not mechanical in nature
  • gallbladder can also cause referred pain to the right shoulder - so pain could be due to alcohol consumption or be dietary related

  
• Red Flags - Areas of visceral masquerades referred pain pt2:

  • lungs and diaphragm can cause referred pain to the left shoulder - indicative of cardiovascular issue, more specifically if pts report pain to left shoulder, left chest and left arm along with shortness of breath it could indicate cardiac pathology, so pts need to be sent for further testing asap as it could be the start of warning signs for a heart attack

  
• Examples of questions for screening:

  • for cardiovascular system, you could ask for:
  • heart trouble
  • pain or pressure on the chest, jaw or left upper limb
  • palpitations, so an abnormality of the heartbeat
  • history of smoking
  • high blood pressure
  • shortness of breath - including nocturnal
  • swelling of extremities
  • family history of cardiovascular disorder
  • elevated cholesterol level
  • for the pulmonary systems you could ask for:
  • history of smoking
  • shortness of breath
  • wheezing
  • prolonged coughing
  • sputum - amount/colour
  • history of asthma, emphysema, pneumonia tuberculosis
• Red flag indicators:

  • constant night pain
  • dizziness
  • loss of consciousness
  • traumatic brain injury
  • neurological deficits
  • history of trauma
  • saddle anaesthesia
  • numbness - cauda equina syndrome
  • history of cancer
  • recent infection
  • other possibilities:
  • Abdominal problems, such as gallstones or pancreatitis
  • Pelvic problems, such as a ruptured ovarian cyst
  • Heart or blood vessel problems in which pain is more often felt in the left arm and shoulder, such as heart attack or inflammation around the heart (pericarditis)
• Avascular Necrosis of the humeral head xray:

  • deterioration and thickening of the bone occurs due to the head of the humerus collapsing and eroding
  • this is not a case for physiotherapy - needs to be referred on and may even require a surgical intervention

  
• Avascular Necrosis of the humeral head:

  • ACN is the result of ischemic injury to the epiphyseal bone leading to humeral head collapse and arthritis
  • common causes: trauma, chronic corticosteroid use, or system disease processes, such as sick cell disease, systemic lupus erythematosus, or alcohol abuse
  • nonoperative treatments: risk factor management, anti-inflammatory medication, activity modification, physiotherapy - help with restoration of movement & pain management
  • surgical treatments: arthroscopic debridement, core decompression, vascularised bone grafts and shoulder arthroplasty
• Sources of radicular or somatic pain to shoulder:

  • there can be neuromuscular structures that also refer pain to the shoulder:
  • cervical radicular/somatic pain around C3 - C6
  • thoracic pain around T2 dorsal ramus
  • refers around the acromioclavicular joint area
  • 1st and 2nd ribs segments
• Less common sources of shoulder pain:

  • suprascapular nerve entrapment
  • occurs around the scapula notch
  • there will be obvious muscle wasting around the supraspinatus and the infraspinatus muscle, with this there will be associated weakness and also a shoulder dysfunction with movement
  • long thoracic nerve palsy
  • when taken into flexion or abduction, the scapula will wing
  • caused by an insufficiency with the serratus anterior, caused by that nerve being compromised - could be due to an infection or virus
  • cases like these may require referral
• Management:

  • consider the context
  • advice and education
  • symptom control
  • build capacity
  • return to function