Evaluation of the patient with shoulder complaints
- Karl B Fields, MD
Karl B Fields, MD
- Editor-in-Chief — Primary Care Sports Medicine (Adolescents and Adults)
- Section Editor — Biomechanics, Rehabilitation, and Recovery; Sports-Related Injuries; Symptom Assessment and Physical Examination
- Professor of Family Medicine and Sports Medicine
- University of North Carolina at Chapel Hill
- Section Editor
- Francis G O'Connor, MD, MPH, FACSM
Francis G O'Connor, MD, MPH, FACSM
- Section Editor — Sports-Related Injuries; Symptom Assessment and Physical Examination; Medical Issues Related to Sports and Exercise
- Professor of Military and Emergency Medicine
- Uniformed Services University of the Health Sciences
- Deputy Editors
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Emergency Medicine (Adult and Pediatric)
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
- Susanna I Lee, MD, PhD
Susanna I Lee, MD, PhD
- Deputy Editor — Radiology
- Associate Professor of Radiology
- Harvard Medical School
- Massachusetts General Hospital
Shoulder pain is a common musculoskeletal complaint that may be due either to intrinsic disorders of the shoulder or referred pain. The former include injuries and acute or chronic inflammation of the shoulder joint, tendons, surrounding ligaments, or periarticular structures .
An overview of common presentations and causes of shoulder discomfort and a basic clinical approach to diagnosis are reviewed. In-depth discussions of the shoulder examination and of the diagnosis and treatment of specific disorders of the shoulder are found separately. (See "Physical examination of the shoulder" and "Rotator cuff tendinopathy" and "Presentation and diagnosis of rotator cuff tears" and "Frozen shoulder (adhesive capsulitis)" and "Multidirectional instability of the shoulder" and "Glenohumeral osteoarthritis".)
ANATOMY AND BIOMECHANICS
A complex network of anatomic structures endows the human shoulder with tremendous mobility, greater than any other joint in the body (picture 1 and picture 2 and figure 1). The shoulder girdle is composed of three bones (the clavicle, scapula, and proximal humerus) and four articular surfaces (sternoclavicular, acromioclavicular, glenohumeral, and scapulothoracic) (figure 2A-C). The glenohumeral joint, commonly referred to as the shoulder joint, is the principal articulation.
Glenohumeral structures — The glenohumeral joint is loosely constrained within a thin capsule bounded by surrounding muscles and ligaments (figure 3 and figure 4 and figure 5 and figure 6 and figure 7 and figure 8 and figure 9). The shoulder's great mobility is due in large part to the shallow depth of the glenoid and the limited contact between the glenoid and the humeral head (figure 2A and figure 2B and figure 2C and table 1 and picture 1). Only 25 percent of the humeral head surface makes contact with the glenoid. The labrum, a fibrocartilaginous ring attached to the outer rim of the glenoid, provides some additional depth and stability. The shallowness and small surface area of the glenohumeral joint make it susceptible to instability and injury, and require that stability be provided primarily by extrinsic supports.
Surrounding muscles and ligaments provide these supports. The glenohumeral ligaments serve as the primary static stabilizers. They include the superior, middle, and inferior glenohumeral ligaments. The rotator cuff serves as the primary dynamic stabilizer. The rotator cuff is composed of four muscles (supraspinatus, infraspinatus, subscapularis, and teres minor) that form a cuff around the head of the humerus, to which these muscles attach.
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- ANATOMY AND BIOMECHANICS
- Glenohumeral structures
- Extraglenohumeral structures
- PATIENT HISTORY AND PAIN PATTERNS
- General approach
- Anterolateral shoulder pain
- Posterior shoulder pain
- Poorly localized pain
- Patient age
- Rotator cuff injury
- - Impingement syndrome
- - Tendinopathy
- - Tendon tear
- Labral tear
- Adhesive capsulitis
- Acromioclavicular pain
- Biceps tendinopathy/rupture
- Multidirectional shoulder instability
- Glenohumeral osteoarthritis
- Scapular instability
- Scapulothoracic bursitis
- Referred pain
- STEPWISE CLINICAL APPROACH
- Step one: Traumatic versus nontraumatic
- Step two: Extrinsic versus intrinsic
- Step three: Glenohumeral versus extraglenohumeral
- Step four: Differentiating glenohumeral pathology
- INJECTION TESTS
- Lidocaine injection test
- Local anesthetic block at the bicipital groove
- RADIOGRAPHIC STUDIES
- Plain radiographs
- Magnetic resonance imaging
- Additional ultrasound resources
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS