GP CLINICAL: Clinical Review - Shoulder disorders - part 1.

The essentials

- Pain can occur in the shoulder or be referred from or to it.

- The classical chronology of frozen shoulder involves three phases.

- Patients find it hard to cope with the limitations of a frozen shoulder.

- Rotator cuff disease is a spectrum of problems.

- Tears in the rotator cuff have a destabilising effect on the humeral head.

1. The origins of shoulder pain

The most common presenting complaint in shoulder patients is pain.

It can originate from a variety of sources, including true shoulder pain, acromioclavicular pain and referred pain.

True shoulder pain is felt around the shoulder, usually radiating down the arm to the level of the deltoid insertion. It can also radiate along the radial border of the forearm.

Radiation to the hand is unusual, but when this occurs it is to the thenar eminence. Pain reaching as far as the fingers is more likely to be nerve root pain, commonly from the 6th, 7th and 8th cervical nerves.

Thoracic outlet pain radiates to the chest, axilla and the ulna side of the forearm. The pain of cervical spondylosis has a variable radiation depending on the level involved, but often goes up to the occiput and down to the supraclavicular fossae and upper arms.

Pain may also be referred to the shoulder. Pain from the diaphragm and gall bladder can be referred to the shoulder, and cardiac pain can be felt in either shoulder.

Relevance of the history

History may point to a diagnosis. A sudden violent force suggests dislocation or fracture. Moderate injury may cause a rotator cuff tear or subluxation.

If the pain is of slow onset, impingement, frozen shoulder or arthritis are likely. Shoulder disorders cause night pain because patients may be unable to lie on the affected side.

Certain activities can provoke shoulder pain. Window cleaners suffer rotator cuff pain, tennis players often have rotator cuff impingement.

Some systemic conditions predispose to shoulder pathology, for example diabetics are at increased risk of frozen shoulder and Ehlers-Danlos syndrome predisposes to subluxation.

Begin an examination with the normal side, then compare …