The document provides guidance on evaluating painful shoulders. It reviews taking a thorough history, performing a physical exam including special tests, and diagnosing and managing common causes of shoulder pain. Key causes discussed include rotator cuff pathology, adhesive capsulitis, shoulder instability, AC joint separation, arthritis, and labral tears. For each, it outlines presenting symptoms, physical exam findings, diagnosis methods, and treatment approaches. The document emphasizes that most shoulder pain can be treated conservatively with rest, physical therapy, and injections before specialist referral is needed.

1. Evaluation of the Painful Shoulder
J. Lindsay Quade, MD
Clinical Instructor
Internal Medicine/Pediatrics, Sports Medicine
University of Michigan Health System

2. Objectives
• To improve physician comfort with obtaining relevant history in the evaluation
of the painful shoulder
• To improve physician comfort with physical examination of the shoulder,
including special testing
• To improve physician comfort with diagnosis and management of common
causes of shoulder pain

3. The Shoulder
• Shoulder pain is common in the primary care setting, responsible for 16% of all
musculoskeletal complaints.
• Taking a good history, paying special attention to the age of the patient and
location of the pain, can help tailor the physical exam and narrow the diagnosis.
• Knowledge of common shoulder disorders is important as they can often be
treated with conservative measures and without referral to a subspecialist.

4. Shoulder Anatomy

5. Shoulder Anatomy

6. Shoulder Anatomy

7. Shoulder Anatomy

8. MSK Shoulder Pain Differential
• Articular Causes
• Glenohumeral (GH) and acromoclavicular
(AC) arthritis
• Ligamentous and labral lesions
• GH and AC joint instability
• Osseus: fracture, osteonecrosis, neoplasm,
infection
• Periarticular Causes
• Chronic impingement and rotator cuff
tendinitis
• Bicep tendinitis
• Rotator cuff and long biceps tendon tears
• Subacromial bursitis
• Adhesive capsulitis

9. Taking Your History
• Age
• Hand dominance
• Occupation
• Sports/physical activities
• Trauma
• Onset
• Location
• Character
• Duration
• Radiation
• Aggravating/relieving
factors
• Night pain
• Effect on shoulder
function
• Stiffness/restriction of
movement
• Grinding or clicking
• Weakness
• Numbness/tingling
• Pain

10. The Physical Exam
• Inspection
• Asymmetry
• Bony deformity or abnormal contour
• Muscle atrophy or bulge
• Scapular winging

11. The Physical Exam
• Range of Motion
• Active
• Passive
• Apley’s “scratch” test
• Scapular movement
•Strength Testing

12. The Rotator Cuff Muscles
• Supraspinatus
• Abduction
• Infraspinatus
• External rotation
• Subscapularis
• Internal rotation
• Teres minor
• External rotation

13. The Physical Exam
• Palpation
• AC, SC, and GH joints
• Biceps tendon
• Coracoid process
• Acromion
• Scapula

14. Special Tests
• Rotator Cuff
• “Drop-arm”
• “Empty can,” push-off, and
resistance testing
• Impingement
• Neer’s
• Hawkins

15. Special Tests
• Biceps
• Speed’s
• Yergason’s
• AC Joint
• Cross-arm

16. Special Tests
• Shoulder Instability
• Sulcus sign
• Apprehension, relocation,
release
• Load and shift

17. Special Tests
• Labrum
• O’Brien’s
• Crank test
• SLAPprehension

18. Specific Examples
• Rotator Cuff Pathology
• “Frozen Shoulder”
• Shoulder Instability
• AC Joint Separation
• Arthritis
• Labral Tear
• “SICK Scapula”
Main points:
Presenting symptoms
PE findings
Diagnosis
Conservative treatment or refer?

19. Rotator Cuff Pathology
• Presentation & symptoms:
• PAIN
• +/- weakness
• Age?  trauma vs chronic
• Physical exam findings:
• Pain with ROM & resistance testing (+empty can, +push-off)
• + drop arm if full-thickness tear
• + Neer’s and Hawkins if impingement

20. Rotator Cuff Pathology
• Diagnosis:
• Xray – often negative
• Ultrasound
• Consider MRI if planning for surgery
• Management:
• Tendinopathy or impingement – conservative treatment, PT, subacromial GC injection
• Partial-thickness tear – PT (up to 12 weeks), possibly subacromial GC injection
• Full-thickness tear – Ortho referral

21. “Frozen Shoulder” (Adhesive Capsulitis)
• Presentation & symptoms:
• Pain, often >3 months
• Progressive loss of ROM
• Age >40yo
• Risk factors: immobility, DM, hypothyroidism
• Physical exam findings:
• Limited active ROM, external rotation often 50% normal
• Endpoint with passive ROM

22. “Frozen Shoulder” (Adhesive Capsulitis)
• Diagnosis:
• CLINICAL!
• Xray if need to rule-out fracture or OA
• US later if concerned for RC pathology
• Management:
• Set expectations
• Pain control, gentle ROM exercises/PT
• If severe, intra-articular GC injection under fluoroscopy

23. Shoulder (GH) Instability
• Presentation & symptoms:
• Pain
• Instability
• Age < 40yo
• Transient neurologic symptoms
• History of dislocation or subluxation
•Physical exam findings:
• + sulcus
• + apprehension & relocation
• + load & shift testing

24. Shoulder (GH) Instability
• Diagnosis:
• Clinical
• Xrays often normal
• MR arthrogram if no improvement
• Management:
• Activity modification
• PT focused on aggressive strengthening
• Refer to Ortho if no improvement with PT or if recurrent dislocation

25. Acute Shoulder Dislocation
• Physical Exam:
• External rotation & abduction, palpable humeral head
• Check innervation of skin over lateral deltoid! (Axillary nerve)
• Diagnosis:
• Clinical
• Xray
• Management:
• Relocate & immobilize
• ROM exercises within 7-10 days  aggressive rehab program

26. AC Joint Separation
• Presentation & symptoms:
• Direct blow to shoulder or FOOSH
• Male contact sport athlete, ~20yo
• Pain/swelling
• Physical exam findings:
• Pain and swelling over AC joint
• “Stepped” deformity if more severe
• + cross-arm test
• + painful arc

27. AC Joint Separation
• Diagnosis:
• Clinical +
• Xray
• Management:
• Types I-III: Non-operative (rest, ice, analgesics, sling for immobilization, PT)
• Types IV+: Ortho referral for surgery

28. Shoulder Arthritis
• Presentation & symptoms:
• Age >50
• Progressive pain with activity
• Decreased ROM
• Impingement symptoms
• History of rotator cuff injury, previous trauma, or shoulder surgery
• Physical exam findings:
• AC joint: tenderness over AC joint, pain at extreme internal rotation, + cross-arm test
• GH joint: decreased ROM, pain and crepitus at extremes of motion

29. Shoulder Arthritis
• Diagnosis:
• Clinical +
• Xray
• Management:
• AC joint:
• Activity modification, NSAIDs, GC injection
• GH joint:
• Goal = maintain function with adequate pain control
• PT, glucosamine & chondroitin, intra-articular GC injection
• Referral to Ortho if conservative treatment fails

30. Labral Tear
• Presentation & Symptoms:
• Pain +/- instability
• Clicking/popping
• Overhead athlete, history of dislocation, history of trauma
• Physical Exam:
• Pain with passive external rotation
• Pain with palpation of bicipital groove
• + Apprehension/relocation, O’Brien’s, SLAPprehension, crank tests
• Can also have + biceps testing

31. Labral Tear
• Diagnosis:
• Xrays usually normal but may show Hills-Sach lesion
• MRI or MR arthrogram
• Management:
• Conservative: rest, NSAIDs  PT
• Operative: Ortho referral
• If conservative measures fail, larger tears, concomitant RC tear

32. “SICK Scapula”
• Presentation & Symptoms:
• Pain
• Repetitive overhead activity
• Drooping shoulder on dominant side
• Physical Exam:
• Scapular malposition
• Inferior medial border prominence
• Coracoid pain and malposition
• Kinesis abnormalities of scapula

33. “SICK Scapula”
• Diagnosis:
• Clinical
• Management:
• Physical Therapy & kinetic-chain
based rehabilitation
• Pain free ROM  Strengthening
Proprioception exercises

34. Take-Home Points
• Shoulder pain is common
• Taking a good history can help narrow both your differential and your physical exam
• Having a good grasp of shoulder anatomy is necessary for interpreting physical exam
findings
• Develop your own shoulder exam approach and follow it consistently
• Aim to know at least one special test for each category of shoulder pain

35. Take-Home Points
• Rotator cuff pathology can often be diagnosed with US
• Frozen shoulder is a clinical diagnosis
• To be diagnosed with arthritis, there should be pain on exam and an abnormal xray
• If you are concerned about a labral tear, consider referral +/- an MR arthrogram
• Most chronic shoulder pain can be treated conservatively
• If patient is not improving clinically, refer to Sports Medicine

36. YouTube!
“Complete Musculoskeletal Exam of the Shoulder”
by University of Michigan Family Medicine

37. Questions?

38. References
• Beuerlein MJS, McKee MD, Fam, AG. (2010). The shoulder. In Lawry GV (2nd.), Fam’s musculoskeletal examination and joint injection
techniques, (pp. 7-19). Philadelphia: Mosby.
• Burbank KM, Stevenson JH, Czarnecki GR, Dorfman J. Chronic shoulder pain: part I. Evaluation and diagnosis. Am Fam Physician. 2008 Feb
15; 77 (4): 453-60.
• Burbank KM, Stevenson JH, Czarnecki GR, Dorfman J. Chronic shoulder pain: part II. Treatment. Am Fam Physician. 2008 Feb 15; 77 (4):
493-7.
• Dodson CC, Altchek DW. SLAP lesions: an update on recognition and treatment. J Orthop Sports Phys Ther. 2009 Feb; 39 (2): 71-80.
• Edmonds EW, Denerink DD. Common conditions in the overhead athlete. Am Fam Physician. 2014 Apr 1; 89 (7): 537-41.
• Ewald, A. Adhesive capsulitis: a review. Am Fam Physician. 2011 Feb 15; 83 (4): 417-22.
• O’Connor, F, et al. (2013). ACSM’s Sports Medicine: A comprehensive review. Musculoskeletal injuries in the tennis player, (pp. 717).
Philadelphia: Lippincott.
• Woodward TW, Best TM. The painful shoulder: part I. Clinical evaluation. Am Fam Physician. 2000 May 15; 61 (10): 3079-88.
• Woodward TW, Best TM. The painful shoulder: part II. Acute and chr onic disorders. Am Fam Physician. 2000 Jun 1; 61 (11): 3291-300.

39. Photo References
1. Slide 4: http://www.chiro.org/LINKS/Shoulder.shtml
2. Slide 5: http://www.physiodc.com/shoulder-pain-with-yoga-adjust-your-downward-dog/
3. Slide 6: http://www.njorthoclinic.com/need-biceps-tenodesis-labrum-tear/
4. Slide 7: https://acewebcontent.azureedge.net/blogs/blog-examprep-091313-2.jpg
5. Slide 10: http://www.pic2fly.com/Biceps+Popeye+Deformity.html ; http://www.wheelessonline.com/userfiles/2010-07-
19%2015_44_46.jpg
6. Slide 11: https://www.studyblue.com/notes/note/n/scapula--deltoid-regions/deck/3234274 (large picture);
http://www.masmusculo.com.es/workout/el-apleys-scratch-test/ ; https://acewebcontent.azureedge.net/blogs/blog-examprep-
091313.jpg (scapula pic)
7. Slide 12: http://jimmysmithtraining.com/six-pack-diet/good-hurt-bad-hurt (left);
http://createperformance.blogspot.com/2012/09/thanks-to-g.html
8. Slide 13: http://www.physiodc.com/shoulder-pain-with-yoga-adjust-your-downward-dog/
9. Slide 14: http://meded.ucsd.edu/clinicalmed/joints2.htm (top picture); http://chrisjohnsonpt.com/are-you-taking-your-shirt-off-
properly-2/

40. Photo References
10. Slide 15: http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=52373 (left picture);
http://openi.nlm.nih.gov/detailedresult.php?img=2684214_12178_2008_9024_Fig4_HTML&req=4
11. Slide 16: http://www.arthritisresearch.us/rheumatoid-arthritis/the-shoulder.html (cartoon);
https://www.youtube.com/watch?v=0_Y8twcQ9Ho
12. Slide 17: http://ameblo.jp/g-money0229/entry-11512342937.html (cartoon); https://www.youtube.com/watch?v=3G6mb1QQ90I
13. Slide 20: http://radiopaedia.org/images/1983198
14. Slide 21: http://www.myerssportsmedicine.com/frozen-shoulder/
15. Slide 23: http://shawchiroandsport.com/shoulder-joint-increased-mobility-means-increased-risk-injury/hypermobile-shoulders
16. Slide 25: http://www.physiownc.com/shoulder-pain/
17. Slide 26: https://www.studyblue.com/notes/note/n/unit-17-exam-2/deck/6899151
18. Slide 27: http://quoteimg.com/ac-joint-separation-classification/

41. Photo References
19. Slide 28: http://grutter.us/ShoulderArm/AC%20arthritis.html
20. Slide 29: http://www.orthoinfo.org/topic.cfm?topic=A00222
21. Slide 30: http://josephhechtmd.com/slap-legion-surgery/
22. Slide 31: http://www.appliedradiology.com/articles/mr-arthrography
23. Slide 32: http://www.sportsandortho.com/UserFiles/sick2.png
24. Slide 33: https://acewebcontent.azureedge.net/blogs/blog-examprep-091313-2.jpg
25. Slide 37: http://galleryhip.com/michigan-football-logo-go-blue.html
All photos obtained through Yahoo! or Google image search