Shoulder Pain

Shoulder Pain

Differentials

• Osteoarthritis of the glenohumeral or acromioclavicular joints

• Acromioclavicular joint dislocation

• Shoulder instability or dislocation

• Rotator cuff tear or tendinopathy

• Subacromial bursitis

• Biceps tendinopathy

• Labral tear (SLAP or non-SLAP)

• Adhesive capsulitis (frozen shoulder)

• Thoracic outlet syndrome

• Polymyalgia rheumatica (PMR)

• Cervical radiculopathy

• Referred pain from myocardial ischaemia, Pancoast tumour, or diaphragmatic irritation (e.g. perforated ulcer, splenic rupture, biliary disease)

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History

• Neck symptoms such as neck pain or stiffness and hand numbness suggesting cervical radiculopathy or thoracic outlet syndrome

• Morning stiffness and bilateral shoulder pain indicating possible PMR or other inflammatory conditions

• Activity-related pain worsened by overhead movements suggesting impingement or rotator cuff issues

• History of trauma or feeling of instability raising suspicion of labral tear or recurrent shoulder dislocation

• Systemic symptoms or bilateral involvement prompting consideration of inflammatory or referred causes

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Examination

• Palpation over the subacromial region indicating bursitis, over the bicipital groove indicating biceps tendinopathy, or at the acromioclavicular joint identifying AC joint pathology

• Range of motion restricted both actively and passively suggesting frozen shoulder, while primarily active limitation points to rotator cuff pathology

• Special tests such as Neer’s and Hawkins-Kennedy for impingement, Yergason’s and Speed’s for biceps tendinopathy, cross-arm adduction for AC joint pathology, and Spurling’s if cervical involvement is suspected

• Assessment of scapular positioning for dyskinesis or muscular atrophy contributing to impingement or thoracic outlet syndrome

• Contralateral shoulder examination to compare baseline range and identify asymmetries

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Investigations

• ESR and CRP to detect inflammatory processes such as PMR or septic arthritis

• X-ray of the shoulder and possibly the cervical spine to identify degenerative changes or alignment issues

• Ultrasound to evaluate rotator cuff, biceps tendon, and subacromial bursa

• MRI to visualise labral tears, significant rotator cuff tears, or intra-articular lesions if symptoms persist despite initial management

• ECG or chest imaging if cardiac or Pancoast tumour referral is suspected

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Management

• Non-pharmacological approaches including physiotherapy for strengthening and postural correction, hydrodilatation for adhesive capsulitis, and avoidance of repetitive overhead activities

• Pharmacological treatments such as NSAIDs for pain and inflammation and local steroid injections into the subacromial space, AC joint, or glenohumeral joint for persistent bursitis, arthritis, or frozen shoulder

• Ultrasound-guided injections improving accuracy for deeper structures like rotator cuff tendons or biceps tendon sheath

• Advice on ergonomics and home exercise programmes aimed at restoring range of motion and scapular stabilisation

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Red Flags

• Night pain and systemic symptoms (fever, weight loss) suggesting malignancy or infection

• Traumatic onset with a clearly unstable shoulder indicating possible fracture, acute dislocation, or significant rotator cuff tear

• Neurological signs such as numbness, weakness, or paraesthesia raising concern for cervical radiculopathy or brachial plexopathy

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Other Interventions

• Shockwave therapy for resistant tendinopathies

• Surgical referral for recurrent shoulder dislocations, rotator cuff tears not responsive to conservative treatment, significant labral injuries, or severe acromioclavicular joint arthritis

• Close follow-up with rehabilitation to ensure proper healing and maintain shoulder function