Shoulder pain: examining the painful shoulder
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- Letitia McBride
- 6 years ago
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1 There is so much we don't know in medicine that could make a difference, and often we focus on the big things, and the little things get forgotten. To highlight some smaller but important issues, we've put together a series of pearls that the Red Whale found at the bottom of the ocean of knowledge! Shoulder pain: examining the painful shoulder Shoulder pain is a common problem we see in general practice. This useful article, part of the rational clinical examination series in JAMA, looks at the evidence surrounding the assessment of shoulder pain (JAMA 2013;310:837). Shoulder pain is common, affecting 7-26% of adults at any one time. (The wide range is down to age: it is far more common in the elderly.) Rotator cuff disorder (RCD) is the most common cause of shoulder pain. The majority will improve with non-operative treatment such as physiotherapy, so a confident assessment by us may prevent needless outpatient referrals. Anatomy of the shoulder There are four rotator cuff muscles: Supraspinatus - initiates abduction (which is then taken up by the deltoid). Infraspinatus external rotation (with teres minor). Teres minor. Subscapularis - internal rotation. Clinical evaluation With anyone presenting with shoulder pain consider referred pain from neck and lung. Adhesive capsulitis ('frozen shoulder') will have both reduced active and passive glenohumeral joint movements. The authors suggest that there are two major signs that aid elucidation of the problem: pain and weakness. Tests used in assessing shoulder pain test one or other (or both) of these. Pain provocation tests Painful arc test This is the one we all know. Standing with their arm by their side the patient, keeping their arm straight, abducts it to the vertical. In a positive test they experience a zone of pain between 60 and 120 suggesting a RCD or subacromial impingement. This test has a positive likelihood ratio of 3.7 (CI ), meaning that patients with a positive test are 3.7 times more likely to have RCD than the population. This makes it the most diagnostically useful test we have for this condition. Strength tests Internal rotation lag test (subscapularis) In this test you rotate the shoulder and position the patient's hand behind their back (as in an arm lock). The elbow should be at 90. The hand is drawn away from the back and the patient asked to hold it there. If they are unable to do this and the hand flops against their back, it signifies a weakness of subscapularis. External rotation lag test (supraspinatus and infraspinatus) The arm is held by the patient's side and the elbow flexed to 90 - I call this the 'dalek' position. The arm is then externally rotated passively (keeping the elbow tight to the chest wall). When fully rotated the patient is asked to hold it there. Being unable to do this indicates derangement of supra- or infraspinatus. Drop arm test (supraspinatus) A commonly used test; the patient slowly lowers their arm from 90 abduction. If they are unable to do this and drop it instead this is a positive test. Composite test In this test the patient adopts the 'dalek' position again and this time resisted external rotation is tested by asking them to push against your hand. Pain and or weakness is a positive result indicating infraspinatus derangement. How effective are these tests? Well, it is not entirely clear! As detailed above, the painful arc test seems the most useful. Using population studies alone suggests a painful arc in an elderly patient gives you a 40% chance they have a RCD, but this drops to just 10% in those >30y.
2 There is a lack of primary care data, with many of the studies coming from hospital outpatients. After looking at a lot of statistics the authors summarise it all by suggesting the more positive tests you have the more likely you are to have a rotator cuff disorder! Examination of the painful shoulder Movement tests are helpful at assessing patients with painful shoulders. Patients with normal pain provocation/strength tests should be considered to have something else. The authors suggest generalists should attempt the 5 tests detailed above when assessing shoulder pain. Adhesive capsulitis will have reduced both active and passive glenohumeral joint movements. We make every effort to ensure the information in these pages is accurate and correct at the date of publication, but it is of necessity of a brief and general nature, and this should not replace your own good clinical judgement, or be regarded as a substitute for taking professional advice in appropriate circumstances. In particular check drug doses, side effects and interactions with the British National Formulary. Save insofar as any such liability cannot be excluded at law, we do not accept any liability for loss of any type caused by reliance on the information in these pages. GP Update Limited January 2016
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