| Why: | Correct diagnosis will enable you to initiate appropriate treatment and to advise the patient on the likely prognosis. Although there are many causes of shoulder pain, identifying key clinical features will help distinguish between patients with two of the commonest causes of shoulder pain; rotator cuff tendinopathy and adhesive capsulitis (frozen shoulder). |
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| How: | History |
| Where do you feel the pain?
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| What makes it worse?
Pain worse on shoulder movement, especially reaching out, up or behind, points to the shoulder as the origin of the pain.
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| Examination |
| Compare active and passive range of movement
Active abduction and active internal rotation are commonly reduced and painful in both adhesive capsulitis and rotator cuff tendinopathy. Passive movements are reduced in adhesive capsulitis but usually near normal in rotator cuff tendinopathy. In adhesive capsulitis active and passive range are nearly equal. The finding of reduced external rotation is very helpful in identifying adhesive capsulitis. External rotation is well preserved in all shoulder problems except adhesive capsulitis and gleno-humeral arthritis (which is much less common). Test external rotation by rotating the patient's hand outwards with the elbow flexed at 90° and kept tucked in close to the waist. In adhesive capsulitis external rotation is significantly reduced compared to the normal side.
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| What next and when: | Having identified adhesive capsulitis you should:
Carry out a proper history and examination, with testing for diabetes and possibly a chest X-ray. Although most cases of adhesive capsulitis are idiopathic, there may be underlying pathology such as diabetes, or carcinoma of the lung. Explain to the patient the typical natural history of the condition, which usually lasts about 18 months, but in the end resolves completely:
3–6/12 ‘freezing’ — painful and very stiff 6/12 ‘frozen’ — immobile but much less painful 6/12 ‘thawing’ — gradual recovery of range
Interventions are not very helpful in the early stages. Steroid injections may give short term relief but do not alter the overall course. In the early stages physiotherapy is geared towards pain relief and very gentle exercises to maintain a little mobility. Overdoing the exercises will result in pain but will not help the movement. Physiotherapy exercises are more important in the third stage when muscle strength and joint mobility can be restored. Prescribe adequate analgesia. In the early stages adhesive capsulitis pain can be severe and may require opiate analgesics and night sedation. About 20% of patients will later develop adhesive capsulitis in the other shoulder.
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| Having identified rotator cuff tendinopathy
Analgesics and/or short-term anti-inflammatories may help Subacromial steroid injections may help Physiotherapy — strengthening the rotator cuff reduces pain and improves function Surgical referral may be appropriate in refractory cases, especially if there is subacromial impingement
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| Patient information: | Excellent leaflets on this and other conditions from Arthritis Research Campaign http://www.arc.org.uk/arthinfo/patpubs/6039/6039.asp |
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| Web links/references: | There is a shortage of good studies on the effectiveness of interventions in shoulder pain. Useful reviews are to be found at: BMJ Clinical Evidence http://clinicalevidence.bmj.com/ceweb/conditions/msd/msd.jsp |
| Shoulder pain interventions from the Cochrane Library http://www.jr2.ox.ac.uk/bandolier/booth/Arthritis/shoulder.html |
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| Who are you: | Dr B Silverman, Associate Specialist in Rheumatology, Addenbrooke's Hospital Cambridge |
| Dr J R Jenner, Consultant Rheumatologist, Addenbrooke's Hospital |
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| Date: | October 2007 |