Shoulder pain is the third most common musculoskeletal complaint in the general population with 1% of adults consulting a general practitioner annually.¹ Such shoulder pain can present in the traumatic or atraumatic variety. Traumatic shoulder pain can result from fractures, dislocations, separations, ligamentous tears, labral tears, and/or rotator cuff tears (RCTs). Atraumatic shoulder disorders include impingement, calcific tendonitis, osteoarthritis, frozen shoulder, septic arthritis, and metastatic disease. In addition, pain can be referred to the shoulder via cervical radiculopathy, visceral pain, etc. This chapter introduces the clinical presentation, physical exam, diagnostic evaluation, and treatment of patients who present with shoulder pain. Detailed descriptions of the most common topics are found in subsequent chapters, but here we discuss the approach to evaluating and diagnosing various shoulder problems.

As with any problem in medicine, a detailed history of the pain can make diagnosing the shoulder issue significantly more efficient. Common chief complaints include pain, weakness, stiffness, locking, catching, deformity, and lack of function. First, determine if this pain is the result of trauma. A focal pain pattern would point to musculoskeletal issues while a diffuse pain pattern is more indicative of such things as cervical radiculopathy, rheumatologic disorders, and referred pain from visceral etiologies such as cardiogenic, pleuritic, etc. You should then inquire about onset (sudden or gradual), duration, location, radiation, exacerbating/alleviating factors, pain with sleep (shoulder pain is often worse at night), pain with activity or at rest, associated neurologic complaints, comorbidities, handedness, and whether the symptoms are constant or intermittent.^2,3

There are several common pain patterns to keep in mind when a patient presents with any shoulder pain. First, anterior pain along the joint line can suggest labral problems, shoulder arthritis, and tendinitis of the long head of the biceps. Next, lateral pain over the deltoid (commonly in the distribution of a policemen’s patch) is often a result of impingement syndrome/rotator cuff tendinitis or an RCT. Rotator cuff tendinopathy involving the external rotators (teres minor and infraspinatus) can cause focal posterior shoulder pain or sometimes referred pain over the scapula. If the patient indicates focal pain on the top of the shoulder, it is likely that the acromioclavicular joint (AC) is involved. Finally, poorly localized pain should lead the practitioner to look at other possible etiologies further down the differential diagnosis. When this poorly localized pain is present with an otherwise normal shoulder examination, some type of referred pain to the area could be present. Table 35-1 summarizes these common pain patterns (see Table 35-1).

A catching sensation is often a vague complaint explained by the patient as “popping and clicking” around the shoulder and could point to a labral tear, loose body, or osteoarthritis. Popping and clicking can also be an inconsequential, coincidental finding particularly if it is not associated with any distinct pain.

In addition to diagnostic patterns by location there is also a different differential diagnosis based upon the age of the patient. In general, in anyone <40 years of age, glenohumeral (GH) instability due to labral injuries (dislocations and superior labrum anterior-posterior [SLAP] tears), chondral injuries, AC separations, stress fractures and fractures secondary to high-energy trauma are more common. Conversely, in the mature shoulder (age >40), calcific tendinitis, fractures, AC and GH osteoarthritis, frozen shoulder, rotator cuff tendinitis, impingement, and RCT are more common.^4,5

Before you begin the physical examination, make sure the patient is disrobed and the shoulders and scapula are easily visible.

Resisted Motion: Arm abduction (C5), elbow flexion (C5)/extension (C7), wrist extension (C6)/flexion (C7), finger flexion (C8), finger abduction and adduction (T1) (see Fig. 35-1).

Reflex: Biceps (C5), brachioradialis (C6), triceps (C7) (see Fig. 35-2).

Sensation: AC joint (C4), deltoid (C5), tip of thumb (C6), tip of middle finger (C7), tip of little finger (C8), medial elbow (T1), medial upper arm (T2) (see Fig. 35-3).

Pulses: Axillary, brachial, radial, ulnar.

Abduction: movement of the straight arm away from the torso (see Fig. 35-4).