Herbert J. Stevenson, MD

Most shoulder pain responds best to NSAIDs or subacromial corticosteroid injections followed by a home exercise program or formal physical therapy exercises. Accumulating evidence is making it clearer what works and what doesn’t for specific diagnoses.

Time to healing varies greatly among persons with shoulder pain, and specific prognostic indicators may help you and your patients know what to expect.

Quick diagnostic review

Consider the patient’s age, history of trauma, details of injury, and previous shoulder problems. Observe the patient’s general movements, assess range of motion, and use provocative testing to form a differential diagnosis ( Figure 1 ).

If the diagnosis is unclear, arrange for imaging studies ( Table 1 ). A more thorough review for diagnosing shoulder pain may be found in the article “Approach to the patient with shoulder pain” (J Fam Pract 2002; 7:605–611). The conditions causing shoulder pain (in order of frequency, as seen by primary care physicians) are subacromial impingement syndrome (SIS), adhesive capsulitis, acute bursitis, calcific tendinitis, glenohumeral arthrosis, biceps tendinitis, and labral tear.^1,2

TABLE 1
Value of imaging tests for shoulder injuries

FIGURE 1
Evaluating shoulder pain for possible rotator cuff tear

Subacromial impingement syndrome

This condition was first described by Neer, who estimated it leads to 95% of rotator cuff tears.³

Impingement occurs from repetitive overhead activities, acute trauma, or instability of the glenohumeral joint (subtle or overt). Current theory holds that degeneration of the rotator cuff tendons or inflammation of the subacromial bursa—caused by irritation against the coracoacromial arch—can progress to degeneration and a complete rotator cuff tear. So-called rotator cuff tendinitis is better described as a tendinopathy with mucoid degeneration of the tendon. SIS stage I involves edema and hemorrhage, as would be seen with rotator cuff tendinopathy or bursitis.

Progressive feedback loop of subacromial impingement syndrome. Acute bursitis involves the subacromial bursa and typically is secondary to subacromial impingement. As underlying tendinopathy, instability, or heterotrophic bone irritates the bursa, it will become inflamed and irritated. Inflammation exacerbates the impingement and that in turn causes worsening of the bursitis.

Stage II and III impingement syndrome. SIS stage II is a progression to fibrosis and partial tear of the rotator cuff. Stage III is a full-thickness tear of the rotator cuff. These stages of SIS are seen predominantly in patients over the age of 40 years, and they become more common with increasing age. The tear—partial or complete— usually occurs in the supraspinatus tendon. Tears of other rotator cuff muscles are less common.

Magnetic resonance imaging (MRI), with or without arthrography, is used in clinical practice and in research to diagnose rotator cuff tears. Growing evidence indicates that ultrasound is a less expensive and equally effective way to diagnose stage II or III impingement. In the United States, however, the option of ultrasound is limited by scarce availability and inadequate operator skill.

The subacromial injection test is useful in clinical practice. Local anesthetic is injected into the subacromial space. Persisting loss of strength despite pain relief is a positive sign of impairment of the rotator cuff.

MRI or ultrasound must be done in conjunction with history taking and physical examination. As the age of a person increases, the amount of asymptomatic rotator cuff tendon injury will also increase. The incidence of rotator cuff tears has been found to be between 50% to 60% in cadavers of deceased elderly. Thirty percent were found to be stage III impingement; 20% to 30% were partial stage II impingement.⁴

Adhesive capsulitis

Also known as frozen shoulder, adhesive capsulitis may begin with any inflammatory condition, but it is most commonly idiopathic. It characteristically progresses through 3 stages.

The hallmark of adhesive capsulitis is a progressive lack of range of motion with both passive and active movement.

The first stage involves progressive pain and decreased range of motion as the capsule scars.

The second stage involves maturation of capsule scaring, resulting in decreased pain and increased restriction of movement.

The third stage is resolution of the condition, leading to a gradual increase in range of motion.

Full range of motion may or may not return, and the time to resolution is typically 1 to 2 years. Adhesive capsulitis is most common in older persons, especially women in the fourth and fifth decades.⁵

Comparing nonoperative treatments

Nonoperative treatment modalities include protection, relative rest, and ice (PRI); anti-inflammatory medications; physical therapy (supervised or home exercise program); acupuncture; and steroid injection.

Operative treatments, depending on the particular disorder, include rotator cuff repair, subacromial decompression, capsular tightening, or manipulation under anesthesia.

The efficacy of nonoperative treatments for shoulder pain is not well known. Studies of treatment modalities have been numerous but generally of poor quality due to a lack of uniformity in how shoulder disorders are defined and in the variability of outcome measures used. Several recent systematic reviews have tried to identify which interventions are efficacious ( Table 2 ).^6-11

Overall, NSAIDs and subacromial steroid injections are effective in the short-term treatment of shoulder pain.^26-28 However, only nonselective NSAIDs have been studied. Evidence is insufficient to recommend use of cyclooxygenase-2 (COX-2) medications for shoulder pain.

Steroid injections may not confer extra benefit when added to NSAIDs, but they appear superior to NSAIDs in improving shoulder abduction. This is particularly true for the painful stiff shoulder, as seen with impingement or rotator cuff disease.^26,28

Two recent randomized control trials showed corticosteroid injections to be superior to physical therapy for treatment of shoulder complaints.^12,13

Shoulder instability may be treated nonoperatively at first with PRI, NSAIDs, and strengthening and proprioceptive exercises for the rotator cuff. If 3 to 6 months of nonoperative treatment fails, the patient should be referred for surgical evaluation, especially in cases of full-thickness rotator cuff tears.¹⁴

TABLE 2
Nonoperative treatment options for shoulder pain

Treatment of specific shoulder disorders

Subacromial impingement syndrome stage I

A recommendation (SOR: B) can be made for the use of NSAIDs in the treatment of stage I impingement ( Table 3 ). This is based on level 2 evidence that NSAIDs are beneficial for rotator cuff tendinopathy and bicipital tendinitis, compared with placebo in a 1 to 2 week follow-up.^15,17 No specific NSAID has proved better than another.^18,19

Steroid injection ( Figure 2 ) is beneficial for the acute treatment of SIS I reflected by improvement in pain (SOR: A).^20-23 This is particularly evident during the first 1 to 2 weeks following injections.³⁸ At 4 to 6 weeks, there appears to be no difference in the efficacy of steroid injection compared with NSAIDs,^24,25 but they are both better than placebo.⁴³

Physical therapy, specifically rotator cuff strengthening and range of motion, is as beneficial as surgery for SIS I at 6 month and 2¹/2-year follow-up, and both were better than placebo (SOR: B).^26,27

TABLE 3
Treatments for SIS I impingement (rotator cuff tendinitis/tendinosis)

FIGURE 2
Steroid injection in the subacromial space

SIS stages II and III

There is very good evidence (SOR: B) regarding the efficacy of nonoperative treatment of SIS II and III, based on level 2 cohort studies that suggest nonoperative care leads to improvements in patient satisfaction, pain, and daily activities.^28,29 Similar outcomes are reported for patients undergoing physical therapy alone.^30,31 Weiss reported that corticosteroid injections for stage III/full-thickness rotator cuff tears resulted in an 86% improvement as measured by return to previous activities and less or no pain with motion ( Table 4 ).³²

The most constant outcome measure was report of a reduction in pain. Younger patients or those with higher functional demands will likely consider surgical repair if nonoperative measures fail, particularly for full-thickness tears.

TABLE 4
Nonoperative treatments for SIS III (full-thickness rotator cuff tears)

Adhesive capsulitis

There is no consistent evidence that treatment of any one form reduces the pain or improves range of motion in frozen shoulders. Various treatments that have been tried include, though are not limited to, steroid injection, NSAIDs, and physical therapy.^33-37 Studies on treatment efficacy are complicated by inherent discrepancy between patient and observer opinions of limitations in this condition, with objective range of motion findings often not being consistent with patient reported limitations.³⁸

Indicators of quicker or slower recovery

Studies of prognosis following treatment have been difficult to assess due the heterogeneity of the underlying conditions and variability of treatments. A follow-up questionnaire in one instance found no difference between treatment groups. Complaints of pain or impaired mobility 2 to 3 years after treatment were similar among patients treated with steroid injection and physical therapy and with physical therapy alone.³⁰ Overall, 76% of respondents were symptom free at 2 to 3 years.

Two prospective studies confirm that speed of recovery is slow, with complete recovery 23% at 1 month, 21% to 51% at 6 months, 59% at 1 year, and 69% at 18 months.^39,40

Prognostic indicators of quicker recovery were preceding overuse or slight trauma and early presentation to the physician.⁵⁸ Protracted recovery occurred more often with high pain levels during the day or associated neck pain.⁵⁸ These results suggest that patients with subacromial impingement stage I respond better to nonoperative treatment than those patients with underlying degenerative changes or referred pain from the neck.

Finally, specialty surgical referral may be necessary in cases of failed nonoperative therapy or persistent diagnostic and therapeutic challenges.

Corresponding author
Thomas H. Trojian, MD, 99 Woodland Street, Hartford, CT 06105. E-mail: ttrojian@stfrancsicare.org.

Most shoulder pain responds best to NSAIDs or subacromial corticosteroid injections followed by a home exercise program or formal physical therapy exercises. Accumulating evidence is making it clearer what works and what doesn’t for specific diagnoses.

Time to healing varies greatly among persons with shoulder pain, and specific prognostic indicators may help you and your patients know what to expect.

Quick diagnostic review

Consider the patient’s age, history of trauma, details of injury, and previous shoulder problems. Observe the patient’s general movements, assess range of motion, and use provocative testing to form a differential diagnosis ( Figure 1 ).

If the diagnosis is unclear, arrange for imaging studies ( Table 1 ). A more thorough review for diagnosing shoulder pain may be found in the article “Approach to the patient with shoulder pain” (J Fam Pract 2002; 7:605–611). The conditions causing shoulder pain (in order of frequency, as seen by primary care physicians) are subacromial impingement syndrome (SIS), adhesive capsulitis, acute bursitis, calcific tendinitis, glenohumeral arthrosis, biceps tendinitis, and labral tear.^1,2

TABLE 1
Value of imaging tests for shoulder injuries

FIGURE 1
Evaluating shoulder pain for possible rotator cuff tear

Subacromial impingement syndrome

This condition was first described by Neer, who estimated it leads to 95% of rotator cuff tears.³

Impingement occurs from repetitive overhead activities, acute trauma, or instability of the glenohumeral joint (subtle or overt). Current theory holds that degeneration of the rotator cuff tendons or inflammation of the subacromial bursa—caused by irritation against the coracoacromial arch—can progress to degeneration and a complete rotator cuff tear. So-called rotator cuff tendinitis is better described as a tendinopathy with mucoid degeneration of the tendon. SIS stage I involves edema and hemorrhage, as would be seen with rotator cuff tendinopathy or bursitis.

Progressive feedback loop of subacromial impingement syndrome. Acute bursitis involves the subacromial bursa and typically is secondary to subacromial impingement. As underlying tendinopathy, instability, or heterotrophic bone irritates the bursa, it will become inflamed and irritated. Inflammation exacerbates the impingement and that in turn causes worsening of the bursitis.

Stage II and III impingement syndrome. SIS stage II is a progression to fibrosis and partial tear of the rotator cuff. Stage III is a full-thickness tear of the rotator cuff. These stages of SIS are seen predominantly in patients over the age of 40 years, and they become more common with increasing age. The tear—partial or complete— usually occurs in the supraspinatus tendon. Tears of other rotator cuff muscles are less common.

Magnetic resonance imaging (MRI), with or without arthrography, is used in clinical practice and in research to diagnose rotator cuff tears. Growing evidence indicates that ultrasound is a less expensive and equally effective way to diagnose stage II or III impingement. In the United States, however, the option of ultrasound is limited by scarce availability and inadequate operator skill.

The subacromial injection test is useful in clinical practice. Local anesthetic is injected into the subacromial space. Persisting loss of strength despite pain relief is a positive sign of impairment of the rotator cuff.

MRI or ultrasound must be done in conjunction with history taking and physical examination. As the age of a person increases, the amount of asymptomatic rotator cuff tendon injury will also increase. The incidence of rotator cuff tears has been found to be between 50% to 60% in cadavers of deceased elderly. Thirty percent were found to be stage III impingement; 20% to 30% were partial stage II impingement.⁴

Adhesive capsulitis

Also known as frozen shoulder, adhesive capsulitis may begin with any inflammatory condition, but it is most commonly idiopathic. It characteristically progresses through 3 stages.

The hallmark of adhesive capsulitis is a progressive lack of range of motion with both passive and active movement.

The first stage involves progressive pain and decreased range of motion as the capsule scars.

The second stage involves maturation of capsule scaring, resulting in decreased pain and increased restriction of movement.

The third stage is resolution of the condition, leading to a gradual increase in range of motion.

Full range of motion may or may not return, and the time to resolution is typically 1 to 2 years. Adhesive capsulitis is most common in older persons, especially women in the fourth and fifth decades.⁵

Comparing nonoperative treatments

Nonoperative treatment modalities include protection, relative rest, and ice (PRI); anti-inflammatory medications; physical therapy (supervised or home exercise program); acupuncture; and steroid injection.

Operative treatments, depending on the particular disorder, include rotator cuff repair, subacromial decompression, capsular tightening, or manipulation under anesthesia.

The efficacy of nonoperative treatments for shoulder pain is not well known. Studies of treatment modalities have been numerous but generally of poor quality due to a lack of uniformity in how shoulder disorders are defined and in the variability of outcome measures used. Several recent systematic reviews have tried to identify which interventions are efficacious ( Table 2 ).^6-11

Overall, NSAIDs and subacromial steroid injections are effective in the short-term treatment of shoulder pain.^26-28 However, only nonselective NSAIDs have been studied. Evidence is insufficient to recommend use of cyclooxygenase-2 (COX-2) medications for shoulder pain.

Steroid injections may not confer extra benefit when added to NSAIDs, but they appear superior to NSAIDs in improving shoulder abduction. This is particularly true for the painful stiff shoulder, as seen with impingement or rotator cuff disease.^26,28

Two recent randomized control trials showed corticosteroid injections to be superior to physical therapy for treatment of shoulder complaints.^12,13

Shoulder instability may be treated nonoperatively at first with PRI, NSAIDs, and strengthening and proprioceptive exercises for the rotator cuff. If 3 to 6 months of nonoperative treatment fails, the patient should be referred for surgical evaluation, especially in cases of full-thickness rotator cuff tears.¹⁴

TABLE 2
Nonoperative treatment options for shoulder pain

Treatment of specific shoulder disorders

Subacromial impingement syndrome stage I

A recommendation (SOR: B) can be made for the use of NSAIDs in the treatment of stage I impingement ( Table 3 ). This is based on level 2 evidence that NSAIDs are beneficial for rotator cuff tendinopathy and bicipital tendinitis, compared with placebo in a 1 to 2 week follow-up.^15,17 No specific NSAID has proved better than another.^18,19

Steroid injection ( Figure 2 ) is beneficial for the acute treatment of SIS I reflected by improvement in pain (SOR: A).^20-23 This is particularly evident during the first 1 to 2 weeks following injections.³⁸ At 4 to 6 weeks, there appears to be no difference in the efficacy of steroid injection compared with NSAIDs,^24,25 but they are both better than placebo.⁴³

Physical therapy, specifically rotator cuff strengthening and range of motion, is as beneficial as surgery for SIS I at 6 month and 2¹/2-year follow-up, and both were better than placebo (SOR: B).^26,27

TABLE 3
Treatments for SIS I impingement (rotator cuff tendinitis/tendinosis)

FIGURE 2
Steroid injection in the subacromial space

SIS stages II and III

There is very good evidence (SOR: B) regarding the efficacy of nonoperative treatment of SIS II and III, based on level 2 cohort studies that suggest nonoperative care leads to improvements in patient satisfaction, pain, and daily activities.^28,29 Similar outcomes are reported for patients undergoing physical therapy alone.^30,31 Weiss reported that corticosteroid injections for stage III/full-thickness rotator cuff tears resulted in an 86% improvement as measured by return to previous activities and less or no pain with motion ( Table 4 ).³²

The most constant outcome measure was report of a reduction in pain. Younger patients or those with higher functional demands will likely consider surgical repair if nonoperative measures fail, particularly for full-thickness tears.

TABLE 4
Nonoperative treatments for SIS III (full-thickness rotator cuff tears)

Adhesive capsulitis

There is no consistent evidence that treatment of any one form reduces the pain or improves range of motion in frozen shoulders. Various treatments that have been tried include, though are not limited to, steroid injection, NSAIDs, and physical therapy.^33-37 Studies on treatment efficacy are complicated by inherent discrepancy between patient and observer opinions of limitations in this condition, with objective range of motion findings often not being consistent with patient reported limitations.³⁸

Indicators of quicker or slower recovery

Studies of prognosis following treatment have been difficult to assess due the heterogeneity of the underlying conditions and variability of treatments. A follow-up questionnaire in one instance found no difference between treatment groups. Complaints of pain or impaired mobility 2 to 3 years after treatment were similar among patients treated with steroid injection and physical therapy and with physical therapy alone.³⁰ Overall, 76% of respondents were symptom free at 2 to 3 years.

Two prospective studies confirm that speed of recovery is slow, with complete recovery 23% at 1 month, 21% to 51% at 6 months, 59% at 1 year, and 69% at 18 months.^39,40

Prognostic indicators of quicker recovery were preceding overuse or slight trauma and early presentation to the physician.⁵⁸ Protracted recovery occurred more often with high pain levels during the day or associated neck pain.⁵⁸ These results suggest that patients with subacromial impingement stage I respond better to nonoperative treatment than those patients with underlying degenerative changes or referred pain from the neck.

Finally, specialty surgical referral may be necessary in cases of failed nonoperative therapy or persistent diagnostic and therapeutic challenges.

Corresponding author
Thomas H. Trojian, MD, 99 Woodland Street, Hartford, CT 06105. E-mail: ttrojian@stfrancsicare.org.

Most shoulder pain responds best to NSAIDs or subacromial corticosteroid injections followed by a home exercise program or formal physical therapy exercises. Accumulating evidence is making it clearer what works and what doesn’t for specific diagnoses.

Time to healing varies greatly among persons with shoulder pain, and specific prognostic indicators may help you and your patients know what to expect.

Quick diagnostic review

Consider the patient’s age, history of trauma, details of injury, and previous shoulder problems. Observe the patient’s general movements, assess range of motion, and use provocative testing to form a differential diagnosis ( Figure 1 ).

If the diagnosis is unclear, arrange for imaging studies ( Table 1 ). A more thorough review for diagnosing shoulder pain may be found in the article “Approach to the patient with shoulder pain” (J Fam Pract 2002; 7:605–611). The conditions causing shoulder pain (in order of frequency, as seen by primary care physicians) are subacromial impingement syndrome (SIS), adhesive capsulitis, acute bursitis, calcific tendinitis, glenohumeral arthrosis, biceps tendinitis, and labral tear.^1,2

TABLE 1
Value of imaging tests for shoulder injuries

FIGURE 1
Evaluating shoulder pain for possible rotator cuff tear

Subacromial impingement syndrome

This condition was first described by Neer, who estimated it leads to 95% of rotator cuff tears.³

Impingement occurs from repetitive overhead activities, acute trauma, or instability of the glenohumeral joint (subtle or overt). Current theory holds that degeneration of the rotator cuff tendons or inflammation of the subacromial bursa—caused by irritation against the coracoacromial arch—can progress to degeneration and a complete rotator cuff tear. So-called rotator cuff tendinitis is better described as a tendinopathy with mucoid degeneration of the tendon. SIS stage I involves edema and hemorrhage, as would be seen with rotator cuff tendinopathy or bursitis.

Progressive feedback loop of subacromial impingement syndrome. Acute bursitis involves the subacromial bursa and typically is secondary to subacromial impingement. As underlying tendinopathy, instability, or heterotrophic bone irritates the bursa, it will become inflamed and irritated. Inflammation exacerbates the impingement and that in turn causes worsening of the bursitis.

Stage II and III impingement syndrome. SIS stage II is a progression to fibrosis and partial tear of the rotator cuff. Stage III is a full-thickness tear of the rotator cuff. These stages of SIS are seen predominantly in patients over the age of 40 years, and they become more common with increasing age. The tear—partial or complete— usually occurs in the supraspinatus tendon. Tears of other rotator cuff muscles are less common.

Magnetic resonance imaging (MRI), with or without arthrography, is used in clinical practice and in research to diagnose rotator cuff tears. Growing evidence indicates that ultrasound is a less expensive and equally effective way to diagnose stage II or III impingement. In the United States, however, the option of ultrasound is limited by scarce availability and inadequate operator skill.

The subacromial injection test is useful in clinical practice. Local anesthetic is injected into the subacromial space. Persisting loss of strength despite pain relief is a positive sign of impairment of the rotator cuff.

MRI or ultrasound must be done in conjunction with history taking and physical examination. As the age of a person increases, the amount of asymptomatic rotator cuff tendon injury will also increase. The incidence of rotator cuff tears has been found to be between 50% to 60% in cadavers of deceased elderly. Thirty percent were found to be stage III impingement; 20% to 30% were partial stage II impingement.⁴

Adhesive capsulitis

Also known as frozen shoulder, adhesive capsulitis may begin with any inflammatory condition, but it is most commonly idiopathic. It characteristically progresses through 3 stages.

The hallmark of adhesive capsulitis is a progressive lack of range of motion with both passive and active movement.

The first stage involves progressive pain and decreased range of motion as the capsule scars.

The second stage involves maturation of capsule scaring, resulting in decreased pain and increased restriction of movement.

The third stage is resolution of the condition, leading to a gradual increase in range of motion.

Full range of motion may or may not return, and the time to resolution is typically 1 to 2 years. Adhesive capsulitis is most common in older persons, especially women in the fourth and fifth decades.⁵

Comparing nonoperative treatments

Nonoperative treatment modalities include protection, relative rest, and ice (PRI); anti-inflammatory medications; physical therapy (supervised or home exercise program); acupuncture; and steroid injection.

Operative treatments, depending on the particular disorder, include rotator cuff repair, subacromial decompression, capsular tightening, or manipulation under anesthesia.

The efficacy of nonoperative treatments for shoulder pain is not well known. Studies of treatment modalities have been numerous but generally of poor quality due to a lack of uniformity in how shoulder disorders are defined and in the variability of outcome measures used. Several recent systematic reviews have tried to identify which interventions are efficacious ( Table 2 ).^6-11

Overall, NSAIDs and subacromial steroid injections are effective in the short-term treatment of shoulder pain.^26-28 However, only nonselective NSAIDs have been studied. Evidence is insufficient to recommend use of cyclooxygenase-2 (COX-2) medications for shoulder pain.

Steroid injections may not confer extra benefit when added to NSAIDs, but they appear superior to NSAIDs in improving shoulder abduction. This is particularly true for the painful stiff shoulder, as seen with impingement or rotator cuff disease.^26,28

Two recent randomized control trials showed corticosteroid injections to be superior to physical therapy for treatment of shoulder complaints.^12,13

Shoulder instability may be treated nonoperatively at first with PRI, NSAIDs, and strengthening and proprioceptive exercises for the rotator cuff. If 3 to 6 months of nonoperative treatment fails, the patient should be referred for surgical evaluation, especially in cases of full-thickness rotator cuff tears.¹⁴

TABLE 2
Nonoperative treatment options for shoulder pain

Treatment of specific shoulder disorders

Subacromial impingement syndrome stage I

A recommendation (SOR: B) can be made for the use of NSAIDs in the treatment of stage I impingement ( Table 3 ). This is based on level 2 evidence that NSAIDs are beneficial for rotator cuff tendinopathy and bicipital tendinitis, compared with placebo in a 1 to 2 week follow-up.^15,17 No specific NSAID has proved better than another.^18,19

Steroid injection ( Figure 2 ) is beneficial for the acute treatment of SIS I reflected by improvement in pain (SOR: A).^20-23 This is particularly evident during the first 1 to 2 weeks following injections.³⁸ At 4 to 6 weeks, there appears to be no difference in the efficacy of steroid injection compared with NSAIDs,^24,25 but they are both better than placebo.⁴³

Physical therapy, specifically rotator cuff strengthening and range of motion, is as beneficial as surgery for SIS I at 6 month and 2¹/2-year follow-up, and both were better than placebo (SOR: B).^26,27

TABLE 3
Treatments for SIS I impingement (rotator cuff tendinitis/tendinosis)

FIGURE 2
Steroid injection in the subacromial space

SIS stages II and III

There is very good evidence (SOR: B) regarding the efficacy of nonoperative treatment of SIS II and III, based on level 2 cohort studies that suggest nonoperative care leads to improvements in patient satisfaction, pain, and daily activities.^28,29 Similar outcomes are reported for patients undergoing physical therapy alone.^30,31 Weiss reported that corticosteroid injections for stage III/full-thickness rotator cuff tears resulted in an 86% improvement as measured by return to previous activities and less or no pain with motion ( Table 4 ).³²

The most constant outcome measure was report of a reduction in pain. Younger patients or those with higher functional demands will likely consider surgical repair if nonoperative measures fail, particularly for full-thickness tears.

TABLE 4
Nonoperative treatments for SIS III (full-thickness rotator cuff tears)

Adhesive capsulitis

There is no consistent evidence that treatment of any one form reduces the pain or improves range of motion in frozen shoulders. Various treatments that have been tried include, though are not limited to, steroid injection, NSAIDs, and physical therapy.^33-37 Studies on treatment efficacy are complicated by inherent discrepancy between patient and observer opinions of limitations in this condition, with objective range of motion findings often not being consistent with patient reported limitations.³⁸

Indicators of quicker or slower recovery

Studies of prognosis following treatment have been difficult to assess due the heterogeneity of the underlying conditions and variability of treatments. A follow-up questionnaire in one instance found no difference between treatment groups. Complaints of pain or impaired mobility 2 to 3 years after treatment were similar among patients treated with steroid injection and physical therapy and with physical therapy alone.³⁰ Overall, 76% of respondents were symptom free at 2 to 3 years.

Two prospective studies confirm that speed of recovery is slow, with complete recovery 23% at 1 month, 21% to 51% at 6 months, 59% at 1 year, and 69% at 18 months.^39,40

Prognostic indicators of quicker recovery were preceding overuse or slight trauma and early presentation to the physician.⁵⁸ Protracted recovery occurred more often with high pain levels during the day or associated neck pain.⁵⁸ These results suggest that patients with subacromial impingement stage I respond better to nonoperative treatment than those patients with underlying degenerative changes or referred pain from the neck.

Finally, specialty surgical referral may be necessary in cases of failed nonoperative therapy or persistent diagnostic and therapeutic challenges.

Corresponding author
Thomas H. Trojian, MD, 99 Woodland Street, Hartford, CT 06105. E-mail: ttrojian@stfrancsicare.org.

Shoulder pain is a common problem that can pose difficult diagnostic and therapeutic challenges for the family physician. It is the third most common musculoskeletal complaint in the general population, and accounts for 5% of all general practitioner musculoskeletal consults.^1,2 The incidence of shoulder pain is 6.6 to 25 cases per 1000 patients, with a peak incidence in the fourth through sixth decades.^3-6 Shoulder pain is second only to knee pain for referrals to orthopedic surgery or primary care sports medicine clinics.^7,8 Furthermore, 8% to 13% of athletic injuries involve the shoulder and account for up to 3.9% of new emergency department visits.^9,10

Differential diagnosis

The challenge for the physician evaluating shoulder pain is the myriad of etiologies and the potential for multiple disorders. Compounding the challenge is a lack of uniformity in the literature regarding diagnostic classification.¹¹ As Table 1 shows, the age of the patient will help focus the differential diagnosis. Patients younger than 30 years old tend to have biomechanical or mild inflammatory etiologies for their pain such as atraumatic instability, tendinosis, and arthropathies. Less than 1% of shoulder injuries in persons younger than 30 years are complete rotator cuff tears, which occur in 35% of patients older than 45 years with shoulder pain.^12,13

The rotator cuff is the most commonly affected structure in the shoulder, and subacromial impingement syndrome is the leading cause of rotator cuff injury.^4,12,14-16 Neer¹⁴ described 3 stages of shoulder impingement that he estimated lead to 95% of rotator cuff tears. Impingement can be caused by repetitive overhead activities, acute trauma, or subtle instability (atraumatic instability). The current theory is that inflammation of the rotator cuff tendons and/or bursa, caused by irritation against the coracoacromial arch, can progress to a complete rotator cuff tear over time.

Referred sources of shoulder pain should be included in the differential diagnosis of shoulder pain. Potential sources include cervical spondylolysis, cervical arthritis, cervical disc disease, myocardial ischemia, reflex sympathetic dystrophy, diaphragmatic irritation, thoracic outlet syndrome, and gallbladder disease.

TABLE 1
Differential diagnosis of shoulder pain

Using the history and physical examination

As noted above, the likelihood of specific conditions such as a complete rotator cuff tear varies with the setting, age of the patient, and specialty of the physi-cian.^4,13,17,18 It is important to keep this pretest probability in mind while interpreting the history and physical examination. For example, a positive empty can test in a 50-year-old patient almost certainly represents a rotator cuff tear, whereas many younger patients with this finding will not have a tear. Moreover, certain components of the history and physical examination are more indicative of disorders while others are better at ruling them out. This concept is represented by the positive and negative likelihood ratios listed in Table 2.

The clinical evaluation begins with identification of the chief complaint and a thorough history. Common complaints include pain, weakness, stiffness, instability, locking, catching, and deformity.²⁶ Determining the duration of symptoms and mechanism of injury will narrow the differential diagnosis. If trauma occurred, the mechanism can determine radiological needs. Aggravating and alleviating factors should be reviewed, including work, recreation, sports, or hobbies. Night pain when lying on the affected side and a history of trauma in a patient older than 65 years both suggest a rotator cuff tear, but no individual symptom is definitive for the diagnosis (Table 2).¹⁹ Pain with overhead work may indicate impingement syndrome, especially if the patient is symptomatic through the arc of 60 to 120 degrees.

The physical examination should include observation, palpation, range of motion (ROM), and provocative testing. Observation requires adequate exposure of the shoulders bilaterally to identify any gross deformities or abnormalities, including muscle atrophy, acromioclavicular joint disparity, or evidence of trauma. Muscle atrophy of either the supraspinatus or infraspinatus muscles is moderately predictive of rotator cuff tears in the elderly population, with a positive predictive value of 81%. However, this sign is not useful if absent, with a negative predictive value of only 43%.¹⁹ No studies have assessed the role of palpation in the evaluation of shoulder pain. Nevertheless, the role of palpation in discerning acromioclavicular joint pathology from shoulder and neck makes it a useful part of the examination.

The shoulder’s ROM should be evaluated both actively and passively. The shoulder is a mobile joint with a complexity of movements. These include flexion to 180 degrees, extension to 40 degrees, abduction to 120 degrees with palms down and 180 degrees with palms up, internal rotation to 55 degrees, and external rotation to 45 degrees with arms at the side. Although determining abduction ROM is consistent among examiners,²⁷ interrater reliability is poor for assessment of external rotation ROM. Lack of full ROM that is equally limited with both passive and active examination is found in arthropathies and adhesive capsulitis.

Pain between 60 and 120 degrees of abduction “the painful arc”) is associated with subacromial impingement, whereas pain after 120 degrees is an indication of acromioclavicular joint origin. However, Calis and coworkers¹⁷ found that the presence of subacromial impingement has a positive likelihood ratio of only 1.7.

After assessing the ROM, the next steps are to evaluate the rotator cuff and biceps tendon, perform impingement testing, check for instability, and finally assess the acromioclavicular joint. The tests are listed in Table 2 in our preferred order of examination and represent the tests best supported by the evidence; the results are based on a literature search of Medline, PubMed, DARE, and Sports Discuss. The technique of each examination maneuver has been published elsewhere and is not described in detail here. Figure 1 through 4 illustrate several common examination maneuvers described below. A Web site that demonstrates the physical examination more thoroughly can be found at http://www.nismat.org/orthocor/exam/shoulder.html#Evaluation.

TABLE 2
Use of history and physical examination to diagnose shoulder pain

Figure 1
The empty can test

Rotator cuff tests

The drop arm test assesses the integrity of the rotator cuff, predominantly the supraspinatus muscle. The empty can test (Figure 1) isolates the supraspinatus against resistance. The lift off test (Figure 2) assesses the subscapularis integrity.

Figure 2
The lift off test

Impingement syndrome

Hawkin’s sign (Figure 3) is a test for evidence of impingement by re-creation of its symptoms.

Figures 3A & 3B
Hawkin’s sign

Glenohumeral joint stability

The augmented anterior apprehension test evaluates anterior shoulder instability. The relocation test, which helps confirm anterior instability, is carried out immediately after a positive anterior apprehension test.

Labral tears

The crank test is used to identify chronic labral injury, whereas the active compression test²⁵ (Figure 4) indicates labral injury if pain is deep in the shoulder.

Figure 4
The active compression test

Acromioclavicular joint

The active compression test²⁵ (Figure 4) indicates acromioclavicular joint inflammation, arthritis, or injury if pain is localized to the top of the shoulder.

Diagnostic tests

Imaging studies used in the evaluation of shoulder pain include plain radiographs, arthrography, computed tomography (CT), ultrasound (US), and magnetic resonance imaging (MRI). Often no imaging is required, or plain radiographs are the sole imaging study needed. Soft tissue injuries are best identified by MRI or US, whereas bony pathology is seen best with plain radiographs or CT. Indications for imaging include severe injury, uncontrolled pain, failure of conservative therapy, return to play considerations, and examiner discretion. Table 3 outlines the accuracy of imaging modalities organized by diagnosis.

TABLE 3
Imaging tests to diagnose shoulder pain

Plain radiographs

Plain radiographs are the first step in diagnostic imaging. They can reveal fractures, dislocation, subluxation, bony lesions, outlet obstruction, acromioclavicular joint pathology, and arthritic changes. No definitive clinical studies on the needs of radiographs have been done. Plain radiographs should be taken when ROM is lost, especially when there is abduction of less than 90 degrees, severe pain, and after trauma. Our preferred x-rays include a glenohumeral anteroposterior (AP) view, a supraspinatus outlet view, and an axillary view. Anteroposterior views with internal and external rotation are added in cases of trauma to help rule out fracture. Positive acromioclavicular joint tests (crossover or palpation) should be followed by acromioclavicular joint radiographs because a shoulder series does not give a clear view of this joint. Additional views of the neck as well as a chest x-ray or abdominal imaging should be considered if a referred source of shoulder pain remains a possibility.

Arthrography

Arthrography was the diagnostic test of choice before MRI. It is specific for rotator cuff tears but lacks sensitivity¹⁵ because it cannot detect partial-thickness or associated soft tissue injuries of the shoulder. Arthrography still has a role in evaluating adhesive capsulitis by demonstrating decreased intracapsular volume.²⁶ The test can be therapeutic if the capsule is dilated during the procedure. Additionally, patients with claustrophobia may be good candidates for arthrography if a full-thickness tear is suspected and MRI is not possible.

Computed tomography

Computed tomography may be used to evaluate bony lesions, including glenoid rim fractures, humoral fractures, and acromioclavicular joint disease. Computed tomography arthrograms may have a role in assessing labral tears and full-thickness rotator cuff tears.³⁵ The use of CT arthrography has fallen into disfavor compared with MRI because of the risks associated with contrast exposure and poor sensitivity for partial-thickness rotator cuff tears or associated soft tissue injury.

Ultrasound

Ultrasound has been used in the evaluation of rotator cuff tears with varying degrees of sensitivity and specificity.^12,29,34 This inconsistency may be related to variation in operator skill. Advantages of US include relatively low cost, speed, and noninvasiveness.

Magnetic resonance imaging

Magnetic resonance imaging has become the gold standard for diagnostic imaging of the shoulder related to soft tissue injury. The advantages include its noninvasive nature, lack of contrast exposure, nonionizing radiation, high degree of resolution, and the ability to evaluate multiple potential pathologic processes.³⁶ Magnetic resonance imaging is the preferred test for evaluating impingement syndrome and rotator cuff pathology. A normal MRI greatly reduces the chances of a rotator cuff tear, with a negative likelihood ratio of 0.08.^16,29,30 Magnetic resonance imaging is also useful in the evaluation of avascular necrosis, biceps tendon disorders, inflammatory processes, and tumors.¹³ The diagnosis of labral lesions can be challenging given the relatively low sensitivity and negative predictive value noted in several trials.^16,28,31 Finally, it is important to note that up to one third of all asymptomatic patients and more than half of those older than 60 years demonstrate asymptomatic rotator cuff tears on MRI.³⁷

Approach to the patient

A general approach to the patient with shoulder pain is summarized in Figure 5. Pre- and posttest probabilities are included to give an understanding of how tests may help diagnose or rule out a complete rotator cuff tear. A recent prospective study combining multiple examination maneuvers demonstrated that a combination of 3 physical examination findings (supraspinatus weakness, weakness in external rotation, and impingement) along with the patient’s age can often diagnose or rule out a rotator cuff tear.³⁸ This group of tests did not distinguish full versus partial thickness tears. This approach is summarized in Figure 6.

Figure 5
Basic approach to assess for complete rotator cuff tear

Figure 6
Alternative approach to a suspected rotator cuff tear

Shoulder pain is a common problem that can pose difficult diagnostic and therapeutic challenges for the family physician. It is the third most common musculoskeletal complaint in the general population, and accounts for 5% of all general practitioner musculoskeletal consults.^1,2 The incidence of shoulder pain is 6.6 to 25 cases per 1000 patients, with a peak incidence in the fourth through sixth decades.^3-6 Shoulder pain is second only to knee pain for referrals to orthopedic surgery or primary care sports medicine clinics.^7,8 Furthermore, 8% to 13% of athletic injuries involve the shoulder and account for up to 3.9% of new emergency department visits.^9,10

Differential diagnosis

The challenge for the physician evaluating shoulder pain is the myriad of etiologies and the potential for multiple disorders. Compounding the challenge is a lack of uniformity in the literature regarding diagnostic classification.¹¹ As Table 1 shows, the age of the patient will help focus the differential diagnosis. Patients younger than 30 years old tend to have biomechanical or mild inflammatory etiologies for their pain such as atraumatic instability, tendinosis, and arthropathies. Less than 1% of shoulder injuries in persons younger than 30 years are complete rotator cuff tears, which occur in 35% of patients older than 45 years with shoulder pain.^12,13

The rotator cuff is the most commonly affected structure in the shoulder, and subacromial impingement syndrome is the leading cause of rotator cuff injury.^4,12,14-16 Neer¹⁴ described 3 stages of shoulder impingement that he estimated lead to 95% of rotator cuff tears. Impingement can be caused by repetitive overhead activities, acute trauma, or subtle instability (atraumatic instability). The current theory is that inflammation of the rotator cuff tendons and/or bursa, caused by irritation against the coracoacromial arch, can progress to a complete rotator cuff tear over time.

Referred sources of shoulder pain should be included in the differential diagnosis of shoulder pain. Potential sources include cervical spondylolysis, cervical arthritis, cervical disc disease, myocardial ischemia, reflex sympathetic dystrophy, diaphragmatic irritation, thoracic outlet syndrome, and gallbladder disease.

TABLE 1
Differential diagnosis of shoulder pain

Using the history and physical examination

As noted above, the likelihood of specific conditions such as a complete rotator cuff tear varies with the setting, age of the patient, and specialty of the physi-cian.^4,13,17,18 It is important to keep this pretest probability in mind while interpreting the history and physical examination. For example, a positive empty can test in a 50-year-old patient almost certainly represents a rotator cuff tear, whereas many younger patients with this finding will not have a tear. Moreover, certain components of the history and physical examination are more indicative of disorders while others are better at ruling them out. This concept is represented by the positive and negative likelihood ratios listed in Table 2.

The clinical evaluation begins with identification of the chief complaint and a thorough history. Common complaints include pain, weakness, stiffness, instability, locking, catching, and deformity.²⁶ Determining the duration of symptoms and mechanism of injury will narrow the differential diagnosis. If trauma occurred, the mechanism can determine radiological needs. Aggravating and alleviating factors should be reviewed, including work, recreation, sports, or hobbies. Night pain when lying on the affected side and a history of trauma in a patient older than 65 years both suggest a rotator cuff tear, but no individual symptom is definitive for the diagnosis (Table 2).¹⁹ Pain with overhead work may indicate impingement syndrome, especially if the patient is symptomatic through the arc of 60 to 120 degrees.

The physical examination should include observation, palpation, range of motion (ROM), and provocative testing. Observation requires adequate exposure of the shoulders bilaterally to identify any gross deformities or abnormalities, including muscle atrophy, acromioclavicular joint disparity, or evidence of trauma. Muscle atrophy of either the supraspinatus or infraspinatus muscles is moderately predictive of rotator cuff tears in the elderly population, with a positive predictive value of 81%. However, this sign is not useful if absent, with a negative predictive value of only 43%.¹⁹ No studies have assessed the role of palpation in the evaluation of shoulder pain. Nevertheless, the role of palpation in discerning acromioclavicular joint pathology from shoulder and neck makes it a useful part of the examination.

The shoulder’s ROM should be evaluated both actively and passively. The shoulder is a mobile joint with a complexity of movements. These include flexion to 180 degrees, extension to 40 degrees, abduction to 120 degrees with palms down and 180 degrees with palms up, internal rotation to 55 degrees, and external rotation to 45 degrees with arms at the side. Although determining abduction ROM is consistent among examiners,²⁷ interrater reliability is poor for assessment of external rotation ROM. Lack of full ROM that is equally limited with both passive and active examination is found in arthropathies and adhesive capsulitis.

Pain between 60 and 120 degrees of abduction “the painful arc”) is associated with subacromial impingement, whereas pain after 120 degrees is an indication of acromioclavicular joint origin. However, Calis and coworkers¹⁷ found that the presence of subacromial impingement has a positive likelihood ratio of only 1.7.

After assessing the ROM, the next steps are to evaluate the rotator cuff and biceps tendon, perform impingement testing, check for instability, and finally assess the acromioclavicular joint. The tests are listed in Table 2 in our preferred order of examination and represent the tests best supported by the evidence; the results are based on a literature search of Medline, PubMed, DARE, and Sports Discuss. The technique of each examination maneuver has been published elsewhere and is not described in detail here. Figure 1 through 4 illustrate several common examination maneuvers described below. A Web site that demonstrates the physical examination more thoroughly can be found at http://www.nismat.org/orthocor/exam/shoulder.html#Evaluation.

TABLE 2
Use of history and physical examination to diagnose shoulder pain

Figure 1
The empty can test

Rotator cuff tests

The drop arm test assesses the integrity of the rotator cuff, predominantly the supraspinatus muscle. The empty can test (Figure 1) isolates the supraspinatus against resistance. The lift off test (Figure 2) assesses the subscapularis integrity.

Figure 2
The lift off test

Impingement syndrome

Hawkin’s sign (Figure 3) is a test for evidence of impingement by re-creation of its symptoms.

Figures 3A & 3B
Hawkin’s sign

Glenohumeral joint stability

The augmented anterior apprehension test evaluates anterior shoulder instability. The relocation test, which helps confirm anterior instability, is carried out immediately after a positive anterior apprehension test.

Labral tears

The crank test is used to identify chronic labral injury, whereas the active compression test²⁵ (Figure 4) indicates labral injury if pain is deep in the shoulder.

Figure 4
The active compression test

Acromioclavicular joint

The active compression test²⁵ (Figure 4) indicates acromioclavicular joint inflammation, arthritis, or injury if pain is localized to the top of the shoulder.

Diagnostic tests

Imaging studies used in the evaluation of shoulder pain include plain radiographs, arthrography, computed tomography (CT), ultrasound (US), and magnetic resonance imaging (MRI). Often no imaging is required, or plain radiographs are the sole imaging study needed. Soft tissue injuries are best identified by MRI or US, whereas bony pathology is seen best with plain radiographs or CT. Indications for imaging include severe injury, uncontrolled pain, failure of conservative therapy, return to play considerations, and examiner discretion. Table 3 outlines the accuracy of imaging modalities organized by diagnosis.

TABLE 3
Imaging tests to diagnose shoulder pain

Plain radiographs

Plain radiographs are the first step in diagnostic imaging. They can reveal fractures, dislocation, subluxation, bony lesions, outlet obstruction, acromioclavicular joint pathology, and arthritic changes. No definitive clinical studies on the needs of radiographs have been done. Plain radiographs should be taken when ROM is lost, especially when there is abduction of less than 90 degrees, severe pain, and after trauma. Our preferred x-rays include a glenohumeral anteroposterior (AP) view, a supraspinatus outlet view, and an axillary view. Anteroposterior views with internal and external rotation are added in cases of trauma to help rule out fracture. Positive acromioclavicular joint tests (crossover or palpation) should be followed by acromioclavicular joint radiographs because a shoulder series does not give a clear view of this joint. Additional views of the neck as well as a chest x-ray or abdominal imaging should be considered if a referred source of shoulder pain remains a possibility.

Arthrography

Arthrography was the diagnostic test of choice before MRI. It is specific for rotator cuff tears but lacks sensitivity¹⁵ because it cannot detect partial-thickness or associated soft tissue injuries of the shoulder. Arthrography still has a role in evaluating adhesive capsulitis by demonstrating decreased intracapsular volume.²⁶ The test can be therapeutic if the capsule is dilated during the procedure. Additionally, patients with claustrophobia may be good candidates for arthrography if a full-thickness tear is suspected and MRI is not possible.

Computed tomography

Computed tomography may be used to evaluate bony lesions, including glenoid rim fractures, humoral fractures, and acromioclavicular joint disease. Computed tomography arthrograms may have a role in assessing labral tears and full-thickness rotator cuff tears.³⁵ The use of CT arthrography has fallen into disfavor compared with MRI because of the risks associated with contrast exposure and poor sensitivity for partial-thickness rotator cuff tears or associated soft tissue injury.

Ultrasound

Ultrasound has been used in the evaluation of rotator cuff tears with varying degrees of sensitivity and specificity.^12,29,34 This inconsistency may be related to variation in operator skill. Advantages of US include relatively low cost, speed, and noninvasiveness.

Magnetic resonance imaging

Magnetic resonance imaging has become the gold standard for diagnostic imaging of the shoulder related to soft tissue injury. The advantages include its noninvasive nature, lack of contrast exposure, nonionizing radiation, high degree of resolution, and the ability to evaluate multiple potential pathologic processes.³⁶ Magnetic resonance imaging is the preferred test for evaluating impingement syndrome and rotator cuff pathology. A normal MRI greatly reduces the chances of a rotator cuff tear, with a negative likelihood ratio of 0.08.^16,29,30 Magnetic resonance imaging is also useful in the evaluation of avascular necrosis, biceps tendon disorders, inflammatory processes, and tumors.¹³ The diagnosis of labral lesions can be challenging given the relatively low sensitivity and negative predictive value noted in several trials.^16,28,31 Finally, it is important to note that up to one third of all asymptomatic patients and more than half of those older than 60 years demonstrate asymptomatic rotator cuff tears on MRI.³⁷

Approach to the patient

A general approach to the patient with shoulder pain is summarized in Figure 5. Pre- and posttest probabilities are included to give an understanding of how tests may help diagnose or rule out a complete rotator cuff tear. A recent prospective study combining multiple examination maneuvers demonstrated that a combination of 3 physical examination findings (supraspinatus weakness, weakness in external rotation, and impingement) along with the patient’s age can often diagnose or rule out a rotator cuff tear.³⁸ This group of tests did not distinguish full versus partial thickness tears. This approach is summarized in Figure 6.

Figure 5
Basic approach to assess for complete rotator cuff tear

Figure 6
Alternative approach to a suspected rotator cuff tear

Shoulder pain is a common problem that can pose difficult diagnostic and therapeutic challenges for the family physician. It is the third most common musculoskeletal complaint in the general population, and accounts for 5% of all general practitioner musculoskeletal consults.^1,2 The incidence of shoulder pain is 6.6 to 25 cases per 1000 patients, with a peak incidence in the fourth through sixth decades.^3-6 Shoulder pain is second only to knee pain for referrals to orthopedic surgery or primary care sports medicine clinics.^7,8 Furthermore, 8% to 13% of athletic injuries involve the shoulder and account for up to 3.9% of new emergency department visits.^9,10

Differential diagnosis

The challenge for the physician evaluating shoulder pain is the myriad of etiologies and the potential for multiple disorders. Compounding the challenge is a lack of uniformity in the literature regarding diagnostic classification.¹¹ As Table 1 shows, the age of the patient will help focus the differential diagnosis. Patients younger than 30 years old tend to have biomechanical or mild inflammatory etiologies for their pain such as atraumatic instability, tendinosis, and arthropathies. Less than 1% of shoulder injuries in persons younger than 30 years are complete rotator cuff tears, which occur in 35% of patients older than 45 years with shoulder pain.^12,13

The rotator cuff is the most commonly affected structure in the shoulder, and subacromial impingement syndrome is the leading cause of rotator cuff injury.^4,12,14-16 Neer¹⁴ described 3 stages of shoulder impingement that he estimated lead to 95% of rotator cuff tears. Impingement can be caused by repetitive overhead activities, acute trauma, or subtle instability (atraumatic instability). The current theory is that inflammation of the rotator cuff tendons and/or bursa, caused by irritation against the coracoacromial arch, can progress to a complete rotator cuff tear over time.

Referred sources of shoulder pain should be included in the differential diagnosis of shoulder pain. Potential sources include cervical spondylolysis, cervical arthritis, cervical disc disease, myocardial ischemia, reflex sympathetic dystrophy, diaphragmatic irritation, thoracic outlet syndrome, and gallbladder disease.

TABLE 1
Differential diagnosis of shoulder pain

Using the history and physical examination

As noted above, the likelihood of specific conditions such as a complete rotator cuff tear varies with the setting, age of the patient, and specialty of the physi-cian.^4,13,17,18 It is important to keep this pretest probability in mind while interpreting the history and physical examination. For example, a positive empty can test in a 50-year-old patient almost certainly represents a rotator cuff tear, whereas many younger patients with this finding will not have a tear. Moreover, certain components of the history and physical examination are more indicative of disorders while others are better at ruling them out. This concept is represented by the positive and negative likelihood ratios listed in Table 2.

The clinical evaluation begins with identification of the chief complaint and a thorough history. Common complaints include pain, weakness, stiffness, instability, locking, catching, and deformity.²⁶ Determining the duration of symptoms and mechanism of injury will narrow the differential diagnosis. If trauma occurred, the mechanism can determine radiological needs. Aggravating and alleviating factors should be reviewed, including work, recreation, sports, or hobbies. Night pain when lying on the affected side and a history of trauma in a patient older than 65 years both suggest a rotator cuff tear, but no individual symptom is definitive for the diagnosis (Table 2).¹⁹ Pain with overhead work may indicate impingement syndrome, especially if the patient is symptomatic through the arc of 60 to 120 degrees.

The physical examination should include observation, palpation, range of motion (ROM), and provocative testing. Observation requires adequate exposure of the shoulders bilaterally to identify any gross deformities or abnormalities, including muscle atrophy, acromioclavicular joint disparity, or evidence of trauma. Muscle atrophy of either the supraspinatus or infraspinatus muscles is moderately predictive of rotator cuff tears in the elderly population, with a positive predictive value of 81%. However, this sign is not useful if absent, with a negative predictive value of only 43%.¹⁹ No studies have assessed the role of palpation in the evaluation of shoulder pain. Nevertheless, the role of palpation in discerning acromioclavicular joint pathology from shoulder and neck makes it a useful part of the examination.

The shoulder’s ROM should be evaluated both actively and passively. The shoulder is a mobile joint with a complexity of movements. These include flexion to 180 degrees, extension to 40 degrees, abduction to 120 degrees with palms down and 180 degrees with palms up, internal rotation to 55 degrees, and external rotation to 45 degrees with arms at the side. Although determining abduction ROM is consistent among examiners,²⁷ interrater reliability is poor for assessment of external rotation ROM. Lack of full ROM that is equally limited with both passive and active examination is found in arthropathies and adhesive capsulitis.

Pain between 60 and 120 degrees of abduction “the painful arc”) is associated with subacromial impingement, whereas pain after 120 degrees is an indication of acromioclavicular joint origin. However, Calis and coworkers¹⁷ found that the presence of subacromial impingement has a positive likelihood ratio of only 1.7.

After assessing the ROM, the next steps are to evaluate the rotator cuff and biceps tendon, perform impingement testing, check for instability, and finally assess the acromioclavicular joint. The tests are listed in Table 2 in our preferred order of examination and represent the tests best supported by the evidence; the results are based on a literature search of Medline, PubMed, DARE, and Sports Discuss. The technique of each examination maneuver has been published elsewhere and is not described in detail here. Figure 1 through 4 illustrate several common examination maneuvers described below. A Web site that demonstrates the physical examination more thoroughly can be found at http://www.nismat.org/orthocor/exam/shoulder.html#Evaluation.

TABLE 2
Use of history and physical examination to diagnose shoulder pain

Figure 1
The empty can test

Rotator cuff tests

The drop arm test assesses the integrity of the rotator cuff, predominantly the supraspinatus muscle. The empty can test (Figure 1) isolates the supraspinatus against resistance. The lift off test (Figure 2) assesses the subscapularis integrity.

Figure 2
The lift off test

Impingement syndrome

Hawkin’s sign (Figure 3) is a test for evidence of impingement by re-creation of its symptoms.

Figures 3A & 3B
Hawkin’s sign

Glenohumeral joint stability

The augmented anterior apprehension test evaluates anterior shoulder instability. The relocation test, which helps confirm anterior instability, is carried out immediately after a positive anterior apprehension test.

Labral tears

The crank test is used to identify chronic labral injury, whereas the active compression test²⁵ (Figure 4) indicates labral injury if pain is deep in the shoulder.

Figure 4
The active compression test

Acromioclavicular joint

The active compression test²⁵ (Figure 4) indicates acromioclavicular joint inflammation, arthritis, or injury if pain is localized to the top of the shoulder.

Diagnostic tests

Imaging studies used in the evaluation of shoulder pain include plain radiographs, arthrography, computed tomography (CT), ultrasound (US), and magnetic resonance imaging (MRI). Often no imaging is required, or plain radiographs are the sole imaging study needed. Soft tissue injuries are best identified by MRI or US, whereas bony pathology is seen best with plain radiographs or CT. Indications for imaging include severe injury, uncontrolled pain, failure of conservative therapy, return to play considerations, and examiner discretion. Table 3 outlines the accuracy of imaging modalities organized by diagnosis.

TABLE 3
Imaging tests to diagnose shoulder pain

Plain radiographs

Plain radiographs are the first step in diagnostic imaging. They can reveal fractures, dislocation, subluxation, bony lesions, outlet obstruction, acromioclavicular joint pathology, and arthritic changes. No definitive clinical studies on the needs of radiographs have been done. Plain radiographs should be taken when ROM is lost, especially when there is abduction of less than 90 degrees, severe pain, and after trauma. Our preferred x-rays include a glenohumeral anteroposterior (AP) view, a supraspinatus outlet view, and an axillary view. Anteroposterior views with internal and external rotation are added in cases of trauma to help rule out fracture. Positive acromioclavicular joint tests (crossover or palpation) should be followed by acromioclavicular joint radiographs because a shoulder series does not give a clear view of this joint. Additional views of the neck as well as a chest x-ray or abdominal imaging should be considered if a referred source of shoulder pain remains a possibility.

Arthrography

Arthrography was the diagnostic test of choice before MRI. It is specific for rotator cuff tears but lacks sensitivity¹⁵ because it cannot detect partial-thickness or associated soft tissue injuries of the shoulder. Arthrography still has a role in evaluating adhesive capsulitis by demonstrating decreased intracapsular volume.²⁶ The test can be therapeutic if the capsule is dilated during the procedure. Additionally, patients with claustrophobia may be good candidates for arthrography if a full-thickness tear is suspected and MRI is not possible.

Computed tomography

Computed tomography may be used to evaluate bony lesions, including glenoid rim fractures, humoral fractures, and acromioclavicular joint disease. Computed tomography arthrograms may have a role in assessing labral tears and full-thickness rotator cuff tears.³⁵ The use of CT arthrography has fallen into disfavor compared with MRI because of the risks associated with contrast exposure and poor sensitivity for partial-thickness rotator cuff tears or associated soft tissue injury.

Ultrasound

Ultrasound has been used in the evaluation of rotator cuff tears with varying degrees of sensitivity and specificity.^12,29,34 This inconsistency may be related to variation in operator skill. Advantages of US include relatively low cost, speed, and noninvasiveness.

Magnetic resonance imaging

Magnetic resonance imaging has become the gold standard for diagnostic imaging of the shoulder related to soft tissue injury. The advantages include its noninvasive nature, lack of contrast exposure, nonionizing radiation, high degree of resolution, and the ability to evaluate multiple potential pathologic processes.³⁶ Magnetic resonance imaging is the preferred test for evaluating impingement syndrome and rotator cuff pathology. A normal MRI greatly reduces the chances of a rotator cuff tear, with a negative likelihood ratio of 0.08.^16,29,30 Magnetic resonance imaging is also useful in the evaluation of avascular necrosis, biceps tendon disorders, inflammatory processes, and tumors.¹³ The diagnosis of labral lesions can be challenging given the relatively low sensitivity and negative predictive value noted in several trials.^16,28,31 Finally, it is important to note that up to one third of all asymptomatic patients and more than half of those older than 60 years demonstrate asymptomatic rotator cuff tears on MRI.³⁷

Approach to the patient

A general approach to the patient with shoulder pain is summarized in Figure 5. Pre- and posttest probabilities are included to give an understanding of how tests may help diagnose or rule out a complete rotator cuff tear. A recent prospective study combining multiple examination maneuvers demonstrated that a combination of 3 physical examination findings (supraspinatus weakness, weakness in external rotation, and impingement) along with the patient’s age can often diagnose or rule out a rotator cuff tear.³⁸ This group of tests did not distinguish full versus partial thickness tears. This approach is summarized in Figure 6.

Figure 5
Basic approach to assess for complete rotator cuff tear

Figure 6
Alternative approach to a suspected rotator cuff tear