1. The document discusses shoulder pain and provides a differential diagnosis. It covers anatomy of the shoulder joint, muscles, nerves and bursae. 2. Common causes of shoulder pain discussed include degenerative arthritis, rotator cuff tears, shoulder instability, adhesive capsulitis, bursitis and tendonitis. 3. The differential diagnosis section covers the history, examinations, tests and investigations for various shoulder conditions. It describes conditions like rotator cuff tears, shoulder dislocations, impingement syndrome and frozen shoulder.

1. SHOULDER PAIN :
DIFFERENTIAL DIAGNOSIS
1
Presentor : Rohit
Moderator : Dr Sandeep Khuba

2. Anatomy of Shoulder joint
3 bones:
1. Clavicle
2. Scapula
3. Humerus
2

3. Scapula
• Glenoid
• Acromion
• Coracoid
• Subscapular fossa
• Scapular spine
• Supraspinatus fossa
• Infraspinatus fossa
3

4. Humerus
• Head
• Greater tubercle
• Lesser tubercle
• Intertubercular
(bicipital) groove
• Deltoid tuberosity
4

5. 5
3 joints:
1. Acromioclavicular
2. Glenohumeral
3. Sternoclavicular
two articulation/gliding planes
1. Scapulothoracic articulation
2. subacromial surfaces

6. Glenohumeral joint
• Main joint of the shoulder : Ball and socket joint
(synovial)
– humerus fits loosely in joint >
Very mobile (Price: instability)
– 45% of all dislocations
(m/c in body : lack of bony stability)
– Passive stability/ Static joint stability
• Glenoid labrum (50%)
• Joint capsule
• Ligaments
• Bony restraints
• Surrounding musculatature
– dynamic stability
• rotator cuff muscles
• the scapular rotators
6

7. Muscles of shoulder:
Stabiliser muscles
mainly responsible for
stabilization and
rotation of the scapula
• Trapezius
• serratus anterior,
• levator scapulae,
• rhomboid muscles
7

8. Muscles of shoulder:
Extrinsic muscles
• biceps,
• triceps, and
• deltoid muscles
• several actions of
the glenohumeral
joint.
8

9. Intrinsic muscles : Rotator cuff muscles
SITS : (Supraspinatus, Infraspinatus, Teres Minor, Subscapularis, )
Function: IR & ER of the glenohumeral joint, along with humeral abduction.
9

10. • The rotator cuff muscles
depress the humeral head
against the glenoid.
• With a poorly functioning
(torn) rotator cuff, the
humeral head can migrate
upward within the joint
because of an opposed
action of the deltoid
muscle.
10

11. 11

12. Bursae
small sacs of fluid that cushions and protects
the tendons of the rotator cuff
• Subacromial
• Subdeltoid
• Subscapular
• Sub coracoid
12

13. 13

14. Nerve supply
14
Root value C5,C6 for both nerves

15. • Axillary Nerve - supplies the Deltoid muscle. Most
commonly stretched with shoulder dislocations.
• Long Thoracic Nerve - supplies Serratus Anterior muscle
and can cause Winging of the Scapula
• SuprascapularNerve supplies supraspinatus and infras
pinatus muscles and can be entrapped or diseased
• Musculocutaneous Nerve - supplies the Biceps muscle
and is injured rarely.
15

16. Differential diagnosis of Shoulder pain
16

17. HISTORY
• Age
– Young adults – Glenohumeral instability
– Older adults – Rotator cuff tears, Adhesive capsulitis
• Onset
– Sudden – Trauma / dislocation
– Gradual – Arthritis
• Site of pain
– Anterior – AC pathology, Muscular causes
– Diffuse – OA, Adhesive capsulitis, Rotator cuff injury
• Radiation
– Shoulder → Upper arm : Rotator cuff injury
– Neck →shoulder : Cervicogenic causes, facet arthropathy
17

18. HISTORY
• Characteristics
– Reduced ROM : 60°-120° abduction - Subacromial (Shoulder) impingement
syndrome
>120° abduction - AC pathology
Loss - OA, adhesive capsulitis
• Aggravating factors
– Repetitive stress / Work related / Sports related / Overhead lifting
• Relieving factors
– Immobility / Rest
• Systemic symptoms - Consider sources of referred pain
– Cardiovascular symptoms - Myocardial ischemia
– Neck pain - Cervical spondylosis, discogenic pain
– Abdominal pain - Diaphragmatic irritation
– CRPS
18

19. Bony or Joint Space Disorders
19

20. 1.Degenerative arthritis of the
shoulder
• M/c – OA
• RA – morning stiffness improving with
activity.
• Post traumatic
• Collagen vascular
disease : SLE, scleroderma, RA
• Intense inflammation, swelling ,
erythema : gout, septic arthritis
• Joint effusion : OA, RA, Septic arthritis
20

21. OA of Shoulder Joint
• Constant, Aching PAIN +stiffness.
• Activity makes the pain worse.
• rest and heat provide some relief
• Pain is present at rest and may interfere
with sleep.
• grating or popping sensation, swelling
of joint
• crepitus may be present on physical
examination.
21

22. Investigations X ray
22

23. 2.Acromioclavicular Joint Pain
Typically, Pain when reaching across the chest
23

24. 1.Downward traction of arm increases
pain : chin adduction test
2.Cross arm test- raise arm and actively
adduct - increased pain
Signs:
24

25. AC Shear Test
- Interlock fingers with hand on
distal clavicle and spine of
scapula
- Pain in A-C joint when hands
squeezed together = (+) test
25
History / Maneuver Sens
(%)
Spec
(%)
AC
Active
compression
100 97

26. Injection – diagnostic as well as
therapeutic
1” medial to tip of acromion
process
MRI
Investigations:
26

27. 3.Shoulder instability
• Young (<35/40)
• May be hypermobile & asymptomatic, Often sport related
• AGE best prognostic factor:
– <20 yrs 90% recurrence
– 20-40 yrs 60% recurrence
– >40 yrs 10% recurrence
• Dislocations or subluxations- recurrent (GHJ/ACJ/SCJ)
• Pathology: lax capsule, labral tear, #glenoid
• Most common is anterior instability (97%)
• Can lead to cuff degeneration & impingement
27

28. Shoulder instability
• Anterior Glenohumeral
Instability: Most common
– Apprehension test
• sense of instability and
apprehension with arm placed
at 90 deg abduction and 90 deg
ER.
– Relocation test
• Examiner applies posterior force on
proximal humerus while externally
rotating patient’s arm
• Positive test = patient expresses relief
28
Test
Instability
Sens
(%)
Spec
(%)
Relocation 57 100
Apprehension 68 100

29. Sulcus sign : Inferior laxity
(+) test - sulcus at infra-acromial area
– compare to unaffected side
Load & shift sign :
Anterior and
posterior laxity
(+) if greater than
50% displacement
29

30. Dislocations
• Anterior dislocation –
squaring
• Posterior dislocation –
postero-inferior to the
acromion
– Scapular "winging" -
serratus anterior
dysfunction
30

31. Periarticular disorders:
Muscles
31

32. Myofascial Pain Syndrome
33

33. Disorders of the Intrinsic muscles:
Rotator cuff dysfunction
37
•Helps to lift and rotate arm and to stabilize the ball of shoulder with the joint

34. Three stages of rotator cuff disease [Neer]
Stage I <25yrs edema and hemorrhage of the
tendon and bursa
Stage II 25-40 yrs tendinitis and fibrosis of the
rotator cuff
Stage III >40 yrs tearing of the rotator cuff
(partial or full thickness)
38
2 main causes of rotator cuff dysfunction:
1. age related degeneration(chronic) - more common, > 40 yr age
2. Sports injury or trauma (acute)- less common, mostly in young
pts.

35. Rotator cuff Tears can be:
Partial thickness Full thickness Full thickness
with humoral
detachment
often appear as
fraying of an
intact tendon.
"through-and-through".
These tears can be small pin point, larger
button hole, or involve the majority of
he tendon where the tendon still remains
substantially attached to the humeral head and
thus maintains function
and may result in
significantly
impaired
shoulder motion
and function
39

36. Inability to elevate the arm above the level of
the shoulder without the help of the opposite
arm is the hallmark of rotator cuff
disturbance.
Patients often have lesser ROM Actively than Passively due to weakness
40

37. • commonly, the onset is gradual and may be caused by repetitive
overhead activity or by wear and degeneration of the tendon.
– Workers who do overhead activities such as painting, stocking shelves
or construction
– Athletes such as swimmers, pitchers and tennis players
• Pt may feel pain in the front of your shoulder that radiates down the
side of the arm.
• Other symptoms may include stiffness and loss of motion.
• may have difficulty using arm to reach overhead to comb hair or
difficulty placing behind your back to fasten a button.
• When the tear occurs with an injury, there may be sudden acute
pain, a snapping sensation and an immediate weakness of the arm.
41

38. It should be remembered that with
rotator cuff tears,
passive range of motion is normal, but
active range of motion is limited
VS
frozen shoulder
both passive and active ranges
of motion are limited
42

39. Examination
Supraspinatus:
Function: abduction of shoulder for 1st 10-15 degrees of
the arc
Jobe test/empty can test
Both arms are abducted to 90 degrees in the scapular plane and then are fully
pronated to point the thumbs toward the ground :
to abduct arms against the examiner's resistance 43

40. • Infraspinatus: external rotation (90%
force)
• Teres minor: external rotation (10%
force)
Test for both:
Arm at 0 deg abduction, elbow at 90 deg,
Externally rotate-pain
Isolated test for teres minor:
Hornblower test: 90 abd, 90
flexion, full ext rot, hold
position 44

41. Subscapularis: internal rotation
Gerber Lift Off test Belly press test
45

42. Drop arm test: Purpose: tears in the rotator cuff, primarily
supraspinatus muscle
46
• A patient with a complete rotator cuff tear will be unable to hold the arm in the
abducted position, and it will fall to the patient's side
•May be able to lower arm slowly to 90° (this is mostly deltoid function)
•If the athlete is able to hold the arm at 90º, pressure on the wrist will cause the arm to
fall.

43. Shrug Sign : massive rotator cuff tears
The patient will often shrug or hitch the shoulder forward
to use the intact muscles of the rotator cuff and the
deltoid to keep the arm in the abducted position.
47

44. Rotator Cuff Tear
History / Maneuver Sens
(%)
Spec
(%)
History of trauma 36 73
Night pain 88 20
Painful arc 33 81
Empty can test 84
89
50
58
Drop arm 21 100

45. X-RAY
A complete tear of the
supraspinatus resulting in a shift
upwards of the head of the
humerus d/t action of deltoid.
USG
showing rotator cuff tear
Investigations
49

46. Normal Rotator cuff full thickness tear
MRI and ultrasound are comparable in efficacy
MRI
50

47. 51
Treatment Options
• pain relief and improve the function of shoulder.
– Anti-inflammatory medication/Steroid injection
– Strengthening exercise and physical therapy
• It may take several weeks or months to restore
the strength and mobility to ones shoulder.
• Rest and limited overhead activity / Use of a sling
• Surgery for tears

48. Periarticular disorders:
Capsulitis/Tendonitis/Bursitis
52

49. 1.Adhesive Capsulitis/ Frozen shoulder
53
The causes of frozen shoulder are not
fully understood.
The process involves thickening and
contracture of the capsule surrounding
the shoulder joint.
Frozen shoulder occurs much more commonly in individuals with diabetes, affecting 10-
20% of these individuals.
Other Risk factors : hypothyroidism, hyperthyroidism, lung disease, RA, Parkinson's disease,
stroke and cardiac disease or surgery.
Frozen shoulder can develop after a shoulder is injured or immobilized for a period of time.

50. Frozen shoulder
• Age : 30-55
• STIFF & PAINFUL JOINT
• Worse at night & in cold weather
• Severely restricted ROM
both passive and active ranges
of motion are limited
Risk factors:
• diabetes, stroke, lung
disease, rheumatoid arthritis,
heart disease
54

51. Stage 1 "freezing" or
painful stage
6-9 months slow onset of pain. As
the pain worsens, the
shoulder loses motion
Stage 2 The "frozen" or
adhesive stage
4-9 months slow improvement in
pain but the stiffness
remains
Stage 3 "thawing" or
recovery
5-26 months when shoulder motion
slowly returns toward
normal
Frozen shoulder :
Stages
55

52. 56
Treatment
• Prevention : Attempts to prevent frozen shoulder include early motion of
the shoulder after it has been injured.
• The first goal is pain control >>>> restore motion, physical therapy.
• nerve blocks :Suprascapular nerve block
• Surgical : manipulation under anesthesia and shoulder arthroscopy
– After surgery, physical therapy is important to maintain the motion
that was achieved with surgery.

53. 2.Supraspinatus tendonitis
Acute
• younger pts with inciting event include
– carrying heavy loads in front and away from the body,
– throwing injuries, or
– vigorous use of exercise equipment.
Chronic
• older pts,insiduous
57

54. • Pain felt primarily in deltoid
region
• Constant, severe, sleep
disturbances+
• Awaken on night when turned
onto the affected shoulder
• To relieve pain, patients splint
shoulder : “shrugging
appearance”
• Point tenderness over greater
tuberosity
58

55. • Gradual loss of ROM
shoulder
• hair combing, or reaching
overhead quite difficult
• Painful arc of abduction
• catch or sudden onset of
pain in the midrange of
the arc caused by
impingement of the
humeral head onto the
supraspinatus tendon.
59

56. Positive Dawbarn sign
• pain to palpation over the greater tuberosity of the humerus
when the arm is hanging down that disappears when the
arm is fully abducted.
.
• With continued disuse, muscle wasting may occur and a
frozen shoulder may develop
• May be a/w bursitis
60

57. 3.Biceps Tendinitis
• Primarily
degenerative disease
due to wear and tear
under the
coracoacromial arch
• Pain in anterior
shoulder
• worse with overhead
activities 61

58. Tests
Speed test
Elbow extended, supinated forearm
Pt tries to flex shoulder against resis:
Positive test = tender in bicipital
groove
Yergason test
Forearm flexed 90
Supinate against resistance >>
Tenderness along the bicipital
groove
62

59. 4.Subdeltoid bursitis
• Pain with any movement of the
shoulder, specially abduction
• Pain in subdeltoid area going upto
upper humerus
• 1st awakening- abduct shoulder-
sudden pain increased
O/E
• Tender acromion
• Swelling of bursa
• Passive elevation & medial rotation
reproduces pain
63

60. Injection – diagnostic as
well as therapeutic
Just under the acromion
MRI
64

61. Shoulder impingement syndrome
a/k/a painful arc syndrome
65

62. -subacromial spurs (bony
projections from the
acromion),
-osteoarthritic spurs
-variations in the shape of
the acromion.
-Thickening or
calcification of the
coracoacromial ligament.
66

63. Symptoms
• Pain, Weakness
• Loss of movement at affected
shoulder
• Worsened by overhead
abduction (60-120 deg)
• May occur at night if patient
turns over that shoulder
• Grinding/ popping sensation
+-
67

64. Neer Sign- pronation +
forced flexion leading to pain
Hawkin sign- more sensitive, performed
by elevating the patient's arm forward to 90
degrees while forcibly internally rotating the
shoulder .
Impingement test- injecting lignocaine into the sub-acromial
bursa-relief of pain
68
Test
Impingement
Sens
(%)
Spec
(%)
Hawkin’s 89 60

65. Suprascapular nerve entrapment
69

66. • Deep poorly circumscribed pain
• Posterior and lateral aspect of the
shoulder
• Muscle atrophy may be +
• (supra & infraspinatus)
O/E
• Deep pressure over suprascapular
notch-painful
• Cross body adduction test+
because of the stretching of the
nerve
70

67. Referred Pain to the shoulder
Referred from viscera
– Liver & Gall bladder
– Lung
– Heart (angina)
– Diaphragmatic irritation
Cervical Radicular Pain *C5
Cervical facet pain
Sympatheticlally mediated pain : CRPS
71

68. Red flags
• Unexplained deformity or swelling
• Significant weakness not due to pain
• Suspected malignancy
• Fever/malaise
• Significant/unexplained sensory or motor deficit
• Pulmonary or vascular compromise
72

69. Urgent referral
• Displaced or unstable fractures.
• Failed attempted reduction of dislocated
shoulder.
• Massive cuff tear.
• Severe dislocation of ACJ or SCJ.
• Undiagnosed severe pain.
73

70. DIAGNOSIS POSITIVE FINDINGS IMAGING
AC JOINT ARTHRITIS Pain at AC joint
+ve cross-body adduction test
h/o trauma/weight lifting
X-ray :OA at AC joint
AC separation
ADHESIVE CAPSULITIS Age >40yrs
Restricted active and passive motion
h/o DM/thyroid d/s
X-ray:Normal
GLENOHUMERAL
INSTABILITY
Age<40yrs,h/o subluxation/dislocation
+ve apprehension test
X-ray:Normal
GLENOHUMERAL OA Age >50yrs
Progressive pain
Crepitus with ROM
Xray :narrowing of joint
space, spurring,
osteophytes
SHOULDER
IMPINGEMENT
SYNDROME
Age >40 yrs
Pain with overhead activity/PAINFUL
ARC, Night pain/weakness
+ve hawkin’s test
X ray:Acromial spur,
humeral head sclerosis
or cyst, loss of acro-
humeral interval
FULL-THICKNESS
ROTATOR CUFF TEARS
bit older than impingement pts,
Pain rolling on shoulder in bed/night
pain ,Weakness ,Lateral arm pain,
Passive motion typically greater than
active motion
MRI to document extent
of tear

71. Remember:
• Polyarthralgia- examine all other joints,
work up for connective tissue disorders.
• Systemic features like fever/malaise- alert .
Rule out septic joint.
• Perform Neurovascular examination of UL
75

72. Thank you
76