Clinical Pattern Recognition - Shoulder Pain

From anatomy to discovering the patient!

• Primary shoulder dislocation peaks in the second and sixth decade

• 98% of cases, shoulder displaces anteriorly

• 70% of people who have dislocated can expect to dislocate again within 2 years of the initial injury

• Sub-acromial pain syndrome accounts for 44% to 60% of all conditions that cause shoulder pain and is the most frequent cause of visits to a physician’s office

• See more prevalence information in the Clinical Pattern Recognition: Orthopaedics app here

Meet the 5 common shoulder pain patients from the Shoulder Pain and Mobility Deficit Clinical Practice Guidelines and more!

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Clinical Pattern Recognition

Click on the pain pattern to learn about the patients and develop your clinical patterns!

1. Adhesive Capsulitis or Frozen Shoulder - Shoulder pain and mobility deficits (1-minute video)

2. Labral tears, SLAP lesions, Bankart lesions, Anterior or Multidirectional Instability - Shoulder pain with movement coordination impairments (1-minute video)

3. Sub-Acromial Pain Syndrome (previously Shoulder Impingement) - Shoulder pain and muscle power deficits (1-minute video)

4. Acromioclavicular Joint Sprain - Shoulder pain and movement coordination impairments (1-minute video)

5. Thoracic Outlet Syndrome (TOS) - Shoulder pain with radiating pain (1-minute video)

Sources: 

Hayes K, Callanan M, Walton J, Paxinos A, Murrell GAC. Shoulder Instability: Management and Rehabilitation. J Orthop Sport Phys Ther. October 2002.

van der Windt DA, Koes BW, de Jong BA, Bouter LM. Shoulder disorders in general practice: incidence, patient characteristics, and management. Ann Rheum Dis. 1995; 54: 959– 964.

Vecchio PC, Kavanagh RT, Hazleman BL, King RH. Community survey of shoulder disorders in the elderly to assess the natural history and effects of treatment. Ann Rheum Dis. 1995; 54: 152– 154. 

Adhesive Capsulitis (Frozen Shoulder)

Shoulder Pain with Mobility Deficits

• The exact cause of adhesive capsulitis is not completely understood; however, it has been divided into primary and secondary categories; primary being idiopathic and secondary being related to systemic, extrinsic or intrinsic pathology. If your patient has a history of diabetes mellitus, thyroid dysfunction, or a history of contralateral frozen shoulder along with symptoms similar to 1 of the 4 clinical stages they may be suffering from adhesive capsulitis!

• If you do not know the common clinical findings no problem! Click here

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Sub-Acromial Pain Syndrome (Shoulder Impingement)

Shoulder Pain with Muscle Power Deficits

• The Sub-acromial pain syndrome is perhaps the most common cause of shoulder pain in patients and a frequent cause of primary care physician visits. Patients will often present with sharp shoulder pain exacerbated in mid ranges of shoulder movement and repetitive activities. Take a look at some ways to assess and treat this common pathology!

• If you do not know the common clinical findings no problem! Click here

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Labral Tear, SLAP Lesions, Bankart Lesions, Anterior or Multidirectional Instability

Shoulder Pain with Movement Coordination Impairments

• Many labral tears are caused from shoulder dislocations. Anterior dislocations are most common and are often caused from a forceful collision, fall on an outstretched arm, or a sudden wrenching movement. The patient may present with apprehension at end ranges of motion.

• If you do not know the common clinical findings no problem! Click here

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Thoracic Outlet Syndrome

Shoulder Pain with Radiating Pain

• Thoracic Outlet Syndrome can be tricky to treat because it can have both arterial and venous contributions as well as having multiple entrapment sites. Often times patients will complain of numbness or tingling in their hands as well as saying that their arms feel weak or even cold. Typically overhead movements of the upper extremities make the pain worse.

• If you do not know the common clinical findings no problem! Click here

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Anatomy

Image via Complete Anatomy 2018 by 3D4 Medical

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Special Test

If you suspect that your patient has thoracic outlet syndrome this test is a good place to start. If this test is positive then you can continue further testing to figure out which entrapment site is the issue. (Click image to watch 1-2 minute video)

Treatment

Once the entrapment site is found, manual therapy is a good choice to work on mobility in the area. The first rib is a common entrapment site. Take a look at how it can be mobilized! (Click image to watch 1-2 minute video)

Therapeutic Exercise

Once you have worked on the entrapment site it is important to get the nerves and vessels moving again. This can be done through nerve sliders. After the patient has mastered sliders, is not irritable, and only has pain at or near end range make sure to progress them to tensioners! (Click image to watch 1-2 minute video)