This is for the lecture at the Madagascar National University School of Medicine

1. Differential diagnosis
& non-surgical management
of
non-traumatic shoulder pain

2. Contents
1. To know difference of pathophysiology among myofascial pain syndrome, frozen
shoulder and impingement syndrome
2. To understand the physical exams
3. To know the differential diagnosis points
4. Proper choice of treatment for shoulder pain
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3. Abbreviation
• ROM: range of motion
• LOM: limitation of motion (limitation of ROM)
• GH: gleno-humeral
• MPS: myofascial pain syndrome
• TrP: trigger point
• TPI: trigger point injection
• P/Ex: physical examination
• US: Ultrasound
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4. Common Shoulder Pain
• Myofascial Pain Syndrome (MPS)
• Adhesive Capsulitis (Frozen Shoulder)
• Impingement Syndrome (Rotator Cuff Issues)
• Miscellaneous
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5. • Myofascial Pain Syndrome around the neck &
shoulder
• Adhesive capsulitis of Shoulder
• Shoulder impingement syndrome
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6. Myofascial Pain Syndrome
• “heavy weight on shoulder”
• “headache on the back of the head”
• “I feel my eyes exploded”
• “Something stings my upper back”
• Often associated with
• Tension headache
• Migraine
• Cervical radiculopathy
• General pain
• Autonomic symptoms
• Trigger point and referred pain
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7. Taut band, trigger points
2020-02-20 강윤규, 그림으로 보는 TPI 통증치료, 한미의학
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8. Taut band, trigger points
2020-02-20 강윤규, 그림으로 보는 TPI 통증치료, 한미의학
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9. P/Ex
• Pain character and location
• Range of motion (ROM)
• Neck ROM
• Shoulder ROM
• Palpation for trigger point and find referred pain
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10. Range of motion
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Trapezius m. Levator scapulae m.

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14. Most common TrP’s
• Upper trapezius
• Levator scapulae
• Infraspinatus
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15. Treatment
• Physical modality – heat, electrical therapy
• Manipulations
• Trigger Point Injection
• ESWT – extracorporeal shock wave therapy
• Stretching & exercise
• NSAIDs, Pain killers
• We can use multiple modalities
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16. TPI & muscle twitching
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17. Why MPS occurs?
• Intrinsic (intramuscular) origin?
• Musculoskeletal imbalance? Deformity?
• Radicular pain?
• Tendinopathy?
• Try to find the prevalent another cause.
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18. • Myofascial Pain Syndrome around the neck & shoulder
• Adhesive capsulitis of Shoulder
• Shoulder impingement syndrome
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19. Adhesive Capsulitis
• “frozen shoulder” or “shoulder of fifties in Korean language”
• Painful, restricted shoulder range of motion
• Normal radiographic findings
• “I cannot raise up my arms”
• “I cannot have a shampoo”
• “I cannot put arms on my jacket”
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20. Etiology
• Idiopathic!
• Associated with
• Diabetes
• Inflammatory arthritis
• Trauma
• Prolonged immobilization
• Thyroid diseases
• Cerebrovascular accident (stroke)
• Coronary artery disease
• Autoimmune diseases
• Sometimes secondary?
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21. Pathology
• Perivascular inflammation
• Fibroblastic proliferation
• Increased collagen and nodular band formation
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22. Stage
Stage
Symptom
Duration Signs and Symptoms
1
1-3
months
Painful shoulder movement
Minimal shoulder ROM restriction
2
3-9
months
Painful shoulder movement
Progressive restricted glenohumeral joint motion
3
9-15
months
Reduced pain with shoulder movement
Severely restricted glenohumeral joint motion
4
15-24
months
Minimal pain
Progressive normalization of G-H joint motion
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23. Gleno-humeral joint?
• Shoulder joint
• Gleno-humeral joint
• Acromio-clavicular joint
• Sterno-clavicular joint
• Scapulo-thoracic joint
• Shoulder movement
• Scapular movement
• Arm(humerus) movement – flexion/extension/abduction/adduction
• Arm(humerus) movement – rotation
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25. Range of Motion
• Flexion/Extension
• Abduction/Adduction
• Internal rotation/External rotation
• Gleno-Humeral abduction
• Shoulder abduction = G-H abduction + scapular protraction
• Scapular movement can compensate G-H LOM
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26. Shoulder ROM
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27. Shoulder abduction
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28. P/Ex
• Limited ROM
• Flexion
• Abduction
• External rotation
• G-H abduction
• Spared ROM of internal rotation/extension
 ‘Capsular pattern’ of LOM (limitation of motion)
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29. Treatment
• Conservative treatment
• Physical modalities – heat, electrical therapy
• Oral NSAIDs
• Gentle ROM exercise
• Injection
• Intra-articular steroid injection
• Hydraulic water expansion of shoulder joint
• Surgery
• Arthroscopic release of capsule
• Manipulation under general anesthesia
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30. Intra-articular steroid injection
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31. Anterior approach
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32. Fluoroscopy guided
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33. Ultrasound guided
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34. US guided
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35. • Myofascial Pain Syndrome around the neck & shoulder
• Adhesive capsulitis of Shoulder
• Shoulder impingement syndrome
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36. Rotator cuff syndrome
• Synonyms;
• Rotator cuff tear/injury
• Rotator cuff tendinitis
• Rotator cuff syndrome
• Shoulder impingement
• Subacromial impingement
• Impingement syndrome
• Calcific tendinitis
• Subacromial bursitis/subacromial-subdeltoid bursitis
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37. Symptoms
• “I cannot raise my arms”
• “I cannot turn my arms to the back”
• “I got abrupt shoulder pain when I reach out my arms”
• “pain and tenderness on anterior shoulder”
• “I cannot lay myself down sideways”
• “At night, frequently I wake up due to abrupt shoulder pain”
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38. Etiology & Pathophysiology
• Hooked acromion?
• Trauma
• Microtrauma
• Overuse
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39. Stage
• Stage 1
• Inflammation & edema in the rotator cuff
• Subacromial impingement
• Subacromial bursitis
• Stage 2
• Rotator cuff injuries, fibrosis, tendinitis
• Stage 3
• Partial or complete tear of rotator cuff tendon
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41. Subacromial impingement
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42. P/Ex
• ROM
• Limitation in shoulder adduction, internal rotation
• ‘Non-capsular pattern’ of LOM
• Neer-Walsh sign
• Empty can test
• Hawkins-Kennedy test
• Painful arc
• Anterior apprehension test
• Drop arm test
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43. Range of Motion
• Commonly LOM in internal rotation
• Often pain in external rotation
• Often positive finding on anterior apprehension test
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44. Neer-Walsh sign
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45. Hawkins-Kennedy test
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46. Empty-can test
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47. Drop arm test
• For shoulder abduction
• Deltoid – mid to end range of motion of abduction
• Supraspinatus – initiation of shoulder abduction
• In case of supraspinatus dysfunction/rupture
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48. Drop arm test
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49. Painful arc
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50. Diagnosis
• X-ray
• Ultrasound
• MRI
• P/Ex
• Subacromial bursa lidocaine injection
• Confirm the pain generating site
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51. Treatment
• NSAIDs
• Physical modalities – heat and electrical therapy
• Manual therapy
• Exercise
• Steroid injection
• Intra-articular
• Subacromial bursa
• Suprascapular nerve block
• Surgery
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52. Subacromial bursa injection
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53. US-guided bursa injection
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54. Pendulum exercise
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Then, scapula stabilization exercise!

55. Differential Diagnosis
MPS of neck &
shoulder
Adhesive capsulitis of
shoulder
Impingement
syndrome of shoulder
Pain on resting
Relief with exercise Continuous pain Night-time pain
Slow time course
Often abrupt onset Slow time-course Often abrupt onset
Trigger points on upper
trapezius, etc
Originated from
shoulder joint capsule
Impingement pain, local
inflammation
Shortness on involved
muscle with TrPs Capsular pattern LOM
Non-capsular
impingement LOM
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56. Differential Diagnosis
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Impingement Adhesive capsulitis

57. Co-existance
• Showing impingement with capsular pattern LOM
• 1st cause: impingement syndrome
 Immobilization of glenohumeral joint
 Loss of glenohumeral ROM
2ndary frozen shoulder
Often combined with MPS, headache, neck pains
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58. Co-existance
• Choice for the target for the first treatment?
• Treat the cause of the pathology
• Treat the most complaining symptoms of functional activity limitation
• Treat the easily treatable symptom
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59. Take Home!
• Range of Motion
• Capsular vs non-capsular pattern of Limitation of Motion
• P/Ex for impingement syndrome
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60. THANK YOU!
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