Shoulder Pain Differential Diagnosis PDF

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Summary

Differential diagnosis summary that will come in handy for clinical exam ISCE in fourth year....

Description

SHOULDER PAIN DIFFERENTIAL DIAGNOSIS

ROTTATOR CUFF DISORDERS

Condition

Symptoms

Impingement syndrome – supraspinatus tendon impinged between acromion and humeral head

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Rotator cuff tear

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Calcific tendonitis

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GLENOHUMERAL DISORDERS

Adhesive capsulitis (Frozen shoulder)

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Osteoarthritis

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Signs

Investigations

Painful arc 60-120 abduction Muscle wasting Restriction of active movement, full passive but painful

USS shoulder X-ray (AP, axillary, transscapular) – dislocation/arthritis /calcific deposits • C-spine X-ray if referred neck pain suspected • MRI – instability • Bloods – FBC, ESR/CRP – if red flags present

Pain, weakness and restricted movement Hx of heavy lifting, repetitive movement – especially above shoulder level

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Young people – trauma Atraumatic in elderly – caused by bony spurs or intrinsic degeneration Often asymptomatic but may cause pain radiate along the arm

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Severely restricted abduction – supraspinatus If arm is passively abducted beyond 90degree, able to abduct further with deltoid

Pain, restricted movement from deposits of hydroxyapatite in tendon Worse with elevating arm More common in women

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Pain on abduction

Females, 40-65y Pain and stiffness espy on external rotation – putting on jacket More common in people with diabetes/prolonged immobilisation

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Generalised shoulder pain – restricted passive and active Most severe with external rotation

Most common >60y May affect other joints Painful, tender, stiff Worse throughout the day and after exercise

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Crepitus upon movement Restricted ROM Effusions

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Red flags: • Hx of malignancy • Weight loss • Deformity • Mass/swelling • Ascites/abdo pain • Overlying skin erythema – tumour or infection • Fever – malignancy/ Infection • Change in shoulder contour – dislocation • Hx of trauma/convulsion – dislocation • Sensory/motor deficit – neurological lesion

Management Conservative • Patient education and reassurance, reduce/avoid overhead activities • Shoulder exercise - Physiotherapy with goal of optimising function • Ice pack to shoulder 20min several times/day – wrap in towel Medical • Painkillers – paracetamol, NSAIDs • Steroids injections – intraarticular Surgical • Subacromial decompression – arthroscopy under GA Conservative • Patient education, reduce/avoid overhead activities • Physiotherapy, exercise, ice pack Medical • Painkillers – paracetamol, NSAIDs • Steroids injections – intraarticular Surgical • Rotator cuff tendon repair – arthroscopy under GA Conservative • Patient education, reduce precipitating factors • Physiotherapy, ice pack, exercise Medical • Painkillers – paracetamol, NSAIDs, steroids injection • Aspiration/lavage Surgical • Open/arthroscopic shoulder surgery – excise deposit Conservative • Patient education (info leaflet), encourage early activity • Physiotherapy – joint mobilisation + stretching exercises Medical • Painkillers – paracetamol, NSAIDs, TENS • Intraarticular steroids injection Surgical • Rarely done – manipulation under anaesthesia/arthroscopic arthrolysis Conservative • Education, advice and access to information • Lifestyle changes – weight loss, local muscle strengthening exercise, ice pack • Physio and OT input – promote function, reduce adverse effects on ADL Medical • Painkillers – PCM, NSAIDs (PPI cover), COX-2i, opioids, intraarticular steroids Surgical • Joint replacement

AC DISORDER

Condition

Symptoms • •

Caused by trauma or OA Pain and tenderness localised to AC joint

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Restricted passive, horizontal movement of arm when elbow is extended

Shoulder dislocation (most are anterior)

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Traumatic – fall with outstretched hand Joint hypermobility – increased risk Younger people – contact sports like rugby Unable to move arm painful After fall to an outstretched hand or direct blow Middle age/elderly Osteoporotic Pain, loss of shoulder/arm function, swelling, bruising Associated with trauma or overuse Aching pain in shoulder Pain is worse with overhead activity/lifting

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External rotation position (anterior) Anterior bulge, palpable humeral head anteriorly Resisted abduction and internal rotation Neurovascular damage may occur Tenderness and bruising over arm Neurovascular damage may occur – axillary nerve (regimental badge area), distal pulses

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TRAUMA

• • Fractured humerus

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BICEPS

Biceps tendonitis

EXTRINSIC CAUSES

Signs

Acromioclavicular joint disruption

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Tenderness over bicipital groove Ruptured long head of bicep tendon – muscle belly bulges (Popeye’s sign)

Investigations USS shoulder (IOC) X-ray (AP, axillary, transscapular) – dislocation/arthritis • MRI – instability • Bloods – FBC, ESR/CRP – if red flags present • •

Red flags: • Hx of malignancy • Weight loss • Deformity • Mass/swelling • Ascites/abdo pain • Overlying skin erythema – tumour or infection • Fever – malignancy/ Infection • Change in shoulder contour – dislocation • Hx of trauma/convulsion – dislocation • Sensory/motor deficit – neurological lesion

Management Conservative • Patient education, rest, ice pack • Physio to strengthen muscles and ligament + sling for 1-3 weeks Medical • Painkillers – PCM, NSAIDs Surgical • Grade IV, V, VI – orthopaedic referral Conservative + Medical • Immobilise with sling before reduction (without fracture -> closed reduction) • Adequate analgesia and relaxation for closed reduction • Neurovascular assessment • After reduction – immobilised fir 3-4 weeks + analgesia + physiotherapy Surgical • If suspected a tear in capsule or fracture Conservative + Medical • Minimise movement, immobilise ASAP + potent analgesia • Sling/shoulder immobiliser 3 weeks • Physio referral Surgical • If displaced – open reduction and fixation/ intramedullary device

Conservative • Patient education, ice pack, physio • Rest from lifting and overhead use, gentle stretching exercises • • Medical • • Painkillers – PCM, NSAIDs (first few weeks), steroids injection (3-6w after) Surgical • Rarely indicated – only if rupture of tendons (refer to orthopaedics) • Acromipplasty with anterior acromionectomy/ arthroscopic decompression Referred neck Conservative • Pain and tenderness of • Restriction of shoulder pain/Torticollis lower neck and movement • Patient education and reassurance (radiculopathy with no neuro signs) suprascapular area • Movement of neck and • Manage comorbidities – chronic pain conditions, anxiety, mood disorders • Referred to shoulder and shoulder may • Strengthening exercises of neck and shoulder upper arm reproduced pain • Encourage activity and return to normal lifestyle, use a firm pillow • U/L paraesthesia Medical • Analgesia – PCM, NSAIDs, consider amitriptyline, pregabalin Surgical • If vertebral #, disc protrusions/lesions, cord injury/compression Myocardial ischaemia, referred diaphragmatic pain (gall bladder disease, subphrenic abscess, ruptured ectopic pregnancy) Polymyalgia rheumatica/Giant cell arteritis Apical lung cancer, metastases •

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