Identification and Evaluation of Hearing Loss

It is important for clinicians to take a detailed history and focused review of systems to determine the onset and character of shoulder pain and rule out other causes or referred shoulder or radicular symptoms. Patient history can be vague and may not reveal a specific event or time when symptoms began. Patients may have suffered a subtle injury that may not have been regarded as a true injury in their minds. Shoulder pain has been noted to occur more commonly in women as well as middle-age and elderly individuals. A number of risk factors and occupations increase the incidence of shoulder pain, including:

• Age: Rotator cuff disorders are more common after age 40. The disease progresses from tendinitis to partial rotator cuff tears and then to full thickness rotator cuff tears as patients age.
• Family history: Genetic disorders such as Ehlers Danlos syndrome and Marfan syndrome are known to cause shoulder instability.
• Female sex
• Medical comorbidities: Hypercholesterolemia, diabetes mellitus, thyroid disease
• Occupation: Certain occupations require more repetitive motions or load-bearing activities that put stress on the shoulder joint.
• Previous trauma
• Previous shoulder surgery
• Smoking (tobacco use)
• Steroid use

Patient History

• ONSET—when, precipitating event
• LOCATION—focal, diffuse, radiating, etc.
• DURATION—how long, any previous episodes
• CHARACTER—quality (dull, sharp, stabbing, throbbing)
• AGGRAVATING FACTORS—movement, motion, position, sleep
• RELIEVING FACTORS—heat/cold, medication, stretching, etc.
• TIMING—constant, intermittent, time of day (night pain is common)
• SEVERITY—rated 3-–8 on a 10-point scale; severe pain might indicate acute subacromial bursitis or infection.

Physical Examination

A thorough physical exam of the shoulder should focus on pain, mobility, muscle power and movement coordination. Both shoulders are examined to assess symmetry. The exam should include the following elements:

General
BMI, height, weight, poise of the shoulder

Inspection
Atrophy in the supraspinatus, infraspinatus fossae
Swelling
Erythema

Palpation
Palpation of the acromioclavicular joint, coracoid and subacromial space is performed to elicit tenderness.

Range of Motion
Forward elevation, abduction, external rotation with arm at side, external and internal rotation of the arm abducted to 90 degrees

Strength Testing
Internal and external rotation with arm at side, abduction in the plane of the scapula

Special Tests
Lag signs, drop arm signs, Neer and Hawkins-Kennedy impingement tests, compression of acromioclavicular joint with arm horizontal adduction, scapular assist test, scapular retraction test, nerve tension test

Table 1: Shoulder Conditions to Consider

Condition	History	Physical	Exclude if:
Adhesive capsulitis	Age 40–50 years Gradual onset with progressively worse pain and stiffness Pain at rest	Passive glenohumeral ROM limited External rotation worse Passive ROM reproduces pain	Significant arthritis on X-ray Passive ROM normal
Rotator cuff disease	Developing or worsening pain with repetitive overhead activity	Midrange pain with active elevation Midrange resistive tests reproduce pain Rotator cuff muscle weakness Painful arc of abduction/internal rotation	No pain with resistive tests Cuff muscle strength normal Significant loss of passive ROM
Glenohumeral joint arthritis	Age >65–70 Gradual onset, pain and stiffness	Reduced active and passive ROM Radiographic changes Swelling and tenderness

Laboratory Testing

Laboratory testing is typically not required for shoulder pain but may be considered if there is concern for infection, microcrystalline arthropathy (i.e., gout) or autoimmune disease. Labs to consider in these instances would be:

• Complete blood cell count, serum uric acid, erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor and cyclic citrullinated peptide antibody testing, and antinuclear antibody
• Possible joint aspiration with examination of aspirate fluid, which is typically performed by a specialist, if there is concern for microcrystalline arthropathy or infection

Plain X-ray imaging/radiographs should always be included if performing laboratory testing to evaluate for erosion.

Imaging

While radiographs are often used in the initial assessment of a patient with atraumatic shoulder pain, the utility of advanced diagnostic imaging is typically not helpful, as it is unlikely to alter initial management.⁴ Advanced imaging can assist in confirming a diagnosis of shoulder pain but is usually reserved until a patient has failed a course of conservative therapy that typically includes physical therapy.⁵ It is key to recognize when advanced imaging is appropriate as unnecessary imaging studies can potentially waste financial resources, increase the failure rate of conservative physiotherapy and increase potential for premature surgery and subspecialty referral.

Common imaging modalities used in the diagnosis of shoulder pain include plain radiographs, MRI, CT, MRI or CT arthrogram, and ultrasound. The two most commonly used imaging tests used to diagnose shoulder pain are MRI and ultrasound.

Radiographs
Radiographs (X-rays) are the most cost-effective imaging modality for diagnosis of bony degenerative changes related to the glenohumeral and acromioclavicular joint arthritis. Routine radiographic views for shoulder pain should include a true antero-posterior view in the scapular plane (Grashley view) with the arm in maximal internal rotation, with the arm in external rotation and axillary view, and Y view (less important). X-rays are indicated in order to detect or exclude pathology when diagnosis is obscure. Consider X-ray imaging if the patient has:

• Acromioclavicular joint pain
• History of trauma
• Possibility of metastases, especially in patients with a previous history of cancer (breast or lung)
• Severe pain
• A stiff, painful shoulder +/- crepitus and is an older individual
• Subacromial pain

Ultrasound
Ultrasound is a powerful tool for both diagnosis and treatment of shoulder pain. It provides both static and dynamic visualization of structures surrounding the shoulder. A high-resolution ultrasound performed by experienced radiologists and musculoskeletal specialists is a reliable, non-invasive technique for imaging the rotator cuff and adjacent muscles, the bursae, and the long head of the biceps muscle.

MRI
MRI allows for multiplanar, non-invasive examination of the shoulder and can evaluate bony injuries in detail. MRI is considered the gold standard for the evaluation of soft-tissue injuries in the shoulder. Additionally, MRI can assess the amount of fatty infiltration and muscle atrophy and provide an accurate image of the size and location of a rotator cuff tear.

CT
The CT arthrogram is an alternative to the MRI for those unable to complete one for medical reasons (pacemaker or other implanted devices, claustrophobia). It is a very accurate, but invasive, study involving injection of contrast dye into the glenohumeral joint with some associated pain and a very small risk of infection.

Red Flags for the Shoulder

A red flag should elevate suspicion of an alternative cause of pain. Any of the following conditions or diagnoses identified during the primary exam need urgent secondary care referral and/or additional testing:

• Suspected infected joint—same-day emergency referral
• Suspected tumor and malignancy—urgent referral
• Unreduced dislocation—same-day emergency referral
• Traumatic acute rotator cuff tear—urgent referral to an orthopedic surgeon. Urgent referral should be made if doubts are present for cuff integrity. Studies show that 40% of patients who are over age 40 and have a traumatic anterior glenohumeral dislocation will have a rotator cuff tear.

Indicators for Early Tertiary Referral

Multiple studies show that direct access to physical therapy is associated with improved patient outcomes and decreased costs, with minimal risk of harm to the patient. Most patients with atraumatic shoulder instability will respond to physiotherapy, but even with physiotherapy, there is a subgroup of patients who may benefit from early referral to a shoulder specialist. In addition, patients should receive a referral to a shoulder specialist when conservative physical therapy interventions of six to eight weeks have not been successful.

Management of Atraumatic Shoulder Pain

The overall treatment goal for shoulder pain is to reduce the pain to a manageable level and improve function and quality of life for the patient. Patient-reported outcome measures (PROMs) to assess pain and function—such as the Single Assessment Numeric Evaluation (SANE) score and American Shoulder and Elbow Surgeons Shoulder Score (ASES)—may be used to establish a baseline as well as response to treatment, which ultimately can be used to guide future therapies.

Lifestyle Modification

Tobacco cessation should be recommended for all patients, especially those preparing to undergo surgery due to increased risk for complications.

Mental health disorders should be appropriately identified and treated, as these patients are at higher risk of poor outcomes, including reduced pain control, decreased function and poor quality of life compared with those who do not have comorbid psychosocial factors. Patients with anxiety, depression or other mental health disorders may have a disproportionately higher degree of joint pain symptoms for a given amount of arthritic joint damage compared to patients without, affecting response to treatment and diminished outcomes.

Non-Operative Measures

Non-operative measures should focus on patient education related to control of symptoms, activity modification, physical therapy and performance of a home exercise program.

• Medications: NSAIDs, acetaminophen, topical pain relievers for short periods, steroid dose pack, corticosteroid injections. Stronger analgesia may be needed for adequate pain relief and should only be used for short periods due to risk of adverse side effects, particularly in the elderly.
• Manual therapy combined with strengthening exercises to improve shoulder passive range-of-motion (ROM) restrictions and cervical and thoracic mobility.
• Physical therapist-supervised exercises to improve shoulder girdle flexibility, rotator cuff strength, rotator cuff to deltoid balance and scapular control.
• Functional training to improve participation in work, sports and recreational activities.
• Evidence does NOT support passive modalities such as therapeutic ultrasound, transcutaneous electrical nerve stimulation and iontophoresis as first-line treatments.
• Platelet-rich plasma or stem cell injections should NOT be offered as first-line treatment due to out-of-pocket cost and limitation of supporting evidence.

Physical Therapy

Physical therapy is strongly recommended for patients with atraumatic shoulder pain to improve strength, ROM and overall function. Prior to initiating physical therapy, serious pathology for shoulder pain such as a tumor or infection should be ruled out during the history and physical examination. Clinicians should also screen for the presence of psychosocial issues that may affect treatment decision-making and clinical outcomes.

The most relevant physical impairments associated with the patient’s reported activity limitations and medical diagnosis are determined by differential evaluation of musculoskeletal clinical findings. Clusters of clinical findings often coexist in patients with atraumatic shoulder pain and are described as impairment patterns in the physical therapy community.¹ Impairment patterns are labeled according to the key impairment(s) of body function associated with a particular cluster.

Identifying impairment patterns helps shape interventions that normalize the key impairments of body function, which in turn improves the movement and function of the patient and lessens or alleviates activity limitations commonly reported by patients.² Because patients with shoulder pain often fit more than one impairment pattern, it is important to match the intervention strategy that provides the optimal outcome for a patient’s clinical findings while continually re-evaluating the patient’s response to treatment.³

Irritability is a term used to reflect the tissue’s ability to handle physical stress and is considered related to physical status and the degree of inflammation present in the tissue.⁴ Diagnosing tissue irritability is important to guide clinical decisions regarding treatment frequency, intensity, duration and type. There are three levels of irritability determined by the relationship between pain and active and passive movements. Since irritability levels often reflect the tissue’s ability to accept physical stress, providers should match the most appropriate intervention strategies to the level of irritability.⁵

Pharmacotherapy

Clinicians should select individualized therapies for those with comorbidities and/or contraindications to certain medications and presence of other types of pain (muscle spasm or neuropathic pain). Pharmacotherapy details are outlined in Table 3.

Non-steroidal anti-inflammatory drugs (NSAIDs) are the mainstay of treatment for shoulder pain and osteoarthritis. After two to four weeks of taking NSAIDs, the patient should be evaluated to reassess the need for NSAIDs and, if still needed, switched to a more selective NSAID, such as meloxicam or celecoxib, that carries a lower risk of GI bleeding. The 2016 PRECISION trial shows a similar risk of cardiovascular events for both COX-2 selective and non-selective NSAIDs. It is recommended that renal and hepatic function be reviewed or, if not available, tested at least once per year.

• Acetaminophen may provide short-term relief of symptoms. Patients should be counseled to check all OTC medications for other acetaminophen-containing products and limit their total daily intake to 4 grams/day (3 grams/day in the elderly).
• Cannabidiol (CBD) extract is not considered an herbal supplement by the U.S. Food and Drug Administration (FDA), and as such, the FDA has no oversight of the approval process for health conditions. Some animal studies have shown favorable results in reducing peripheral pain and inflammation in established osteoarthritis. Dosing is not well defined: Patients who select to pursue this treatment should be counseled to avoid inhaled use (i.e., vaping) due to acute or chronic pulmonary disease risk. CBD oil can be used topically or orally, via capsule or sublingual formulation. Patients should be counseled to start with a small dose twice daily and titrate up weekly as needed for pain relief.
• Opioids are not recommended for atraumatic shoulder pain but, if selected, should be prescribed with caution and only in very short courses (two to three days) in patients with moderate to severe pain who have failed other pharmacologic and non-pharmacologic therapies. Tramadol can lower the seizure threshold and, therefore, should be avoided in patients with epilepsy. There is a risk of serotonin syndrome when tramadol is combined with SSRIs, SNRIs, trazodone or cyclobenzaprine. Patients should be counseled that opioids may mask their pain but provide no therapeutic effect to aid in recovery.

Opioid Avoidance and Precautions

Opioid treatment requires serious assessment of the potential risks and benefits and should be used only as a last resort after other treatments have proven ineffective. Opioid overdose has been declared an epidemic by the Centers for Disease Control and Prevention, with a four-fold increase in opioid-related deaths in 2017 compared with 1999. In 2017, opioid overdose was responsible for an average of 130 deaths per day in the United States.

• Before prescribing opioids, review psychological history for any type of substance abuse, assess Prescription Drug Monitoring Program and/or Controlled Substance Monitoring Database, and perform baseline urine drug screen.
• Review patient responsibilities, risk of therapy, treatment goals and shared decision-making. Implement a pain contract when prescribing opioids long term.
• Common side effects include constipation (consider using stool softener while taking opioids), nausea (take with food), sedation and impaired cognitive ability.
• Use with caution in elderly patients and those with renal, hepatic or respiratory disease.

Avoid using opioids and benzodiazepines together. Coordinate care with other providers when necessary.

Sidebar 6 Signs of Drug-Seeking Behavior

History of substance abuse Prescription monitoring database shows controlled substances prescriptions from multiple providers Previous provider discharged the patient from the practice for breaking contract or for unclear reasons Patient may request an opioid saying they are allergic to all other conservative medications Failed drug testing (other substances or negative) Non-compliance with other aspects of care, such as completion of diagnostic studies or specialist referrals Patient reporting lost or stolen opioid prescription without a viable police report to corroborate Multiple pain-related visits to urgent care or emergency room

SUBACROMIAL Injections

• Corticosteroids are typically the first-line choice for subacromial injections, and strong evidence supports their use to reduce pain and improve function temporarily. However, for patients with rotator cuff tears specifically, the risks and benefits of corticosteroid injections remain unclear.
  • Relatively insoluble injectable corticosteroid examples:
    • Triamcinolone acetonide (Kenalog)
    • Triamcinolone acetonide extended release (Zilretta)
  • Slightly soluble injectable corticosteroid examples:
    • Methylprednisolone acetate (Depo-Medrol)
    • Methylprednisolone sodium succinate (Solu‑Medrol)

Joint Aspiration

While most patients with atraumatic shoulder pain do not require arthrocentesis, patients with symptoms of infection or microcrystalline arthropathy may benefit from joint aspiration with aspirate analysis that could help direct treatment. This procedure is typically performed by a specialist (orthopedic surgery or rheumatology).

Referrals

• Emergency/Urgent Orthopedic
  • The suspicion or diagnosis of septic arthritis should result in referral to the emergency department or emergency orthopedic consult for arthroscopic or open irrigation or debridement.
  • Unreduced dislocation and suspected malignancy are cause for same-day emergency referral.
  • Traumatic acute rotator cuff tear should generate an urgent referral to orthopedics.
• Shoulder Specialist
  • Referral on a routine basis is recommended for patients who have failed conservative physical therapy interventions of six to eight weeks.
• Integrative Medicine
  • Mindfulness/meditation
  • Acupuncture may alleviate pain and improve shoulder function, but data supporting its use are limited.
• Rheumatology
  • Referral is recommended if evidence of autoimmune disease is present.
• Infectious disease
  • Referral is recommended if evidence of septic arthritis is present.
• Mental health specialist (behavioral health, psychologist or psychiatrist)
  • Referral is recommended for those with poorly controlled mood disorder, as psychosocial factors can impede treatment.

Identifiable Factors That Negatively Affect Healing

The following factors may negatively affect healing in some individuals. It should be noted that factors that negatively affect healing do not necessarily affect outcomes. Factors that negatively affect healing are physiologic factors that may make it less likely for the tendon to heal.

• Advanced age
• Diabetes mellitus—poorly controlled
• History of infection
• Immunosuppressive drugs, catabolites or prednisone
• Multiple corticosteroid injections
• Obesity (BMI>30)
• Osteoporosis
• Parkinson’s disease
• Smoking
• Other medical comorbidities

Patient Education

Patient education is an important aspect in managing atraumatic shoulder pain. Enhanced patient understanding of the condition and treatment options may support improved function and overall outcomes. This section includes links to information that may be useful educational resources for patients.

National Resources

AAOS OrthoInfo Basics
These printable/shareable guides from the American Academy of Orthopaedic Surgeons (AAOS) explain causes, diagnosis of and treatments for arthritis, adhesive capsulitis (frozen shoulder) and rotator cuff tears.

AAOS Patient Information: Platelet-Rich Plasma
This printable/shareable three-page guide from the AAOS examines platelet-rich plasma treatment and discusses the lack of research to back up treatment efficacy.

Arthritis Foundation: Osteoarthritis of the Shoulder
This site from the Arthritis Foundation includes general information about shoulder osteoarthritis, its causes and symptoms, and available treatments.

Vanderbilt Health Affiliated Network Resources

Osteoarthritis: Injections and Surgery

Information about injections (corticosteroid and viscosupplementation) and surgeries (total joint arthroplasty, arthroscopy and other surgeries) for osteoarthritis.

Osteoarthritis: Exercise

Recommendations for exercising (aerobic, strengthening and range of motion exercises) for patients with osteoarthritis.

Osteoarthritis: Tips for Daily Living

Occupational health information about body mechanics, managing activities of daily living and assistive devices to improve function with osteoarthritis.

What Is Osteoarthritis?

General information about pathophysiology and symptoms of osteoarthritis.

Osteoarthritis: Natural and Alternative Treatments

Information about complementary therapies, including thermal therapy, meditation and relaxation, acupuncture, massage, nutritional supplements, physical therapy, weight management, and psychological treatments (CBT, biofeedback, stress management, pain coping skills training and hypnosis) used in the treatment of osteoarthritis.

Living With Osteoarthritis

Information about exercise, weight management, assistive devices and other aids, pharmacotherapy, complementary therapy, injections, and surgeries for osteoarthritis.

Other Resources

Tennessee Disability Pathfinder
A statewide database of social services, low-income medical clinics, recreational programs and other resources for disabled persons.

Applying for TennCare
Healthcare.gov
1-800-318-2596
This resource may be useful for patients with cost barriers to care. Any Department of Health and Human Services office in Tennessee can help people choose and apply for a plan.

References 

¹Non-traumatic shoulder pain in general practice: a pragmatic approach to diagnosis. MEDICINEWISE News. 2018.

²Murphy R, Carr A. Shoulder pain. BMJ Clin Evid. 2010;1107.

³Tashjian RZ. Epidemiology, natural history, and indications for treatment of rotator cuff tears. Clin Sports Med. 2012;31(4):589-604. doi:10.1016/j.csm.2012.07.001.

⁴Brun S. Shoulder injuries—management in general practice. Aust Fam Physician. 2012 Apr;41(4):188-94.

⁵Levine B, Motamedi K, Seeger L. Imaging of the shoulder. Curr Sports Med Rep. 2012;11(5):239-243. doi:10.1249/jsr.0b013e31826b6baa.