Shoulder pain can originate from many causes. Therefore, during the evaluation of shoulder pain, one should carefully note any history of trauma, infection, iniflammatory disease, occupational hazards, or previous cervical disease. It is important to know whether shoulder pain is continuous or is on specific movements only.
Apart from originating from shoulder itself, shoulder pain frequently is referred from the cervical spine and intrathoracic lesions i.e. Pancoast tumor, gallbladder, hepatic, or diaphragmatic disease.
Manual inspection of the periarticular structures will often provide important diagnostic information. The examiner should apply direct manual pressure over the subacromial bursa, which lies lateral to an immediately beneath the acromion. Subacromial bursitis is a frequent cause of shoulder pain.
Anterior to the subacromial bursa, the bicipital tendon traverses the bicipital groove. This tendon is best identified by palpating it in its groove as the patient rotates the humerus internally and externally. Direct pressure over the tendon may reveal pain indicative of bicipital tendonitis.
Palpation of the acromioclavicular joint may disclose local pain, bony hypertrophy, or synovial swelling. Whereas osteoarthritis and RA commonly affect the acromioclavicular joint, osteoarthritis seldom involves the glenohumeral joint, unless there is a traumatic or occupational cause.
The glenohumeral joint is best palpated anteriorly by placing the thumb over the humeral head (just medial and inferior to the coracoid process) and having the patient rotate the humerus internally and externally. Pain localized to this region is indicative of glenohumeral pathology. Synovial effusion or tissue is seldom palpable, but if present may suggest infection, RA, or an acute tear of the rotator cuff.
Rotator cuff tendonitis or tear is a very common cause of shoulder pain. The rotator cuff is formed by the tendons of the supraspinatus, infraspinatus, teres minor and subcapularis muscles.
Rotator cuff tendonitis is suggested by pain on active abduction but not passive abduction, pain over the lateral deltoid muscle, night pain and impingement sign.
Impingement sign is raising the patient’s arm into forced flexion while stabilizing the scapula and preventing it from rotating. A positive sign is present if pain develops before 180 degree of forward flexion.
A complete tear of the rotator cuff is less common. Its diagnosis is suggested by the drop arm test, in which the patient is asked to maintain the arm outstretched as it is passively abducted. If the patient is unable to hold the arm up once 90 degree of abduction is reached, the test is positive.
Tendinitis or tear of the rotator cuff can be confirmed by MRI (tendintis and tear) or arthrography (tear only).
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