Shoulder Pain

Rotator Cuff Pathology

Calcifying Tendonitis
Red Flags
•Unexplained deformity or swelling Tendinopathy
•Significant weakness not due to pain
•Suspected malignancy Rotator Cuff Tear - Partial
•Fever/chills/malaise
Rotator Cuff Tear - Massive
•Significant/unexplained
sensory/motor deficit
Shoulder Instability
•Pulmonary or vascular compromise

1st Time Traumatic Subluxation / Dislocation

Indications for Urgent Referral
•? Displaced or unstable fracture Recurrent Subluxation / Dislocation
•? Failed attempt (x2) reduction of
dislocation Atraumatic instability - Overuse
•Massive tear of rotator cuff (>5cm)
Atraumatic instability - Multidirectional
• Suspicion of dislocation GH, AC or
SC joint
Adhesive Capsulitis
•Undiagnosed severe shoulder pain
Primary
Indications for Early Referral
Secondary
•Suspected full thickness tear after 4-
6 weeks with no improvement
AC Joint Dysfunction
•2 or more traumatic dislocations
•>30years Osteolysis
•First time dislocation aged <25years
•Recurrent posterior/ other Osteoarthritis
instabilities
•Unusual presentation of shoulder AC Joint Disruption
pain
•Failure to improve within expected Labral Tear
timeframe
(NZGG, 2004)

Rotator Cuff Pathology
Calcifying Tendonitis
Tendinopathy
Rotator Cuff Tear - Partial
Rotator Cuff tear - Massive
Presentation Management
Acute: Resorbitive Phase of Healing
•Sudden onset of severe shoulder
pain •Analgesia
•Significant reduction of AROM/PROM •Rest/Graded ROM
due to pain •Education (Advice leaflet)
•Can last days/weeks •Capsular Stretching
•+ve x-ray findings
Chronic:
•+ve x-ray findings •Orthopaedic Referral
•Pain & functional restriction > 6/12
•Painful arc
•Pain>weakness
•<50years
•+ve impingement tests •Rehabilitation 3-6 months
•Advice
•Refer to Orthopaedics if ongoing functional
•Painful arc
limitations
•Weakness>pain
•>50 years
•Insidious or traumatic onset
•+ve impingement tests
•+ve lag signs Referral from Non-Orthopaedic Source:
•Immediate urgent onward referral to Orthopaedics
•Gross weakness into elevation via if younger age group/ high functional level
flexion and/or abduction
•Routine referral onto Orthopaedics + rehabilitation
•Muscle atrophy for 3-6 months
•+ve lag signs
•Gross functional alteration
•Radiological findings in more
progressive states e.g. superior Referral Orthopaedic Source:
humeral head migration, rotator cuff •Anterior deltoid program and information leaflet
arthropathy
•Pain management program
 Presentation Management
Shoulder Instability •History of trauma
•Reduction
•Sling & Analgesia (2/52)
•Usually anterior
•Advice activity modification
•Pain & muscle spasm
•Ortho referral – high risk groups
•Limitied ROM
•<30 years
1st Time Traumatic •Potential x-ray findings
•Male>female
Subluxation/ Dislocation •Bankhart
•High level activity
•Hill sachs
•Rehab / advice – low risk groups – refer to
•Light bulb sign Appendix
•+ve apprehension
Recurrent Subluxation / •Reduction
Dislocation •As above •Sling & Analgesia
•Can occur with reducing •> 2 episodes refer to Orthopaedics
amount of trauma
•If not for surgical intervention
•Advice
•Self Management
Atraumatic instability – •Overhead work / sports
Overuse •Rehabilitation 3-6 months
•Catching pain on activity
•+/- impingement signs •Advice

•+ve instability test(s) •Refer to Orthopaedics if ongoing

functional limitations and functional
•+ve laxity test(s) instability
Atraumatic instability –
Multidirectional

•Advice
•Symptomatic on instability •Rehabilitation 3-6 months (midrange
tests focus)
Involuntary
•>2 directions •Referral to Orthopaedics if ongoing
Instability/Laxity Tests: functional limitations and functional
instability
Instability Laxity

•Anterior •AP Draw •Advice re stopping vountary subluxation

apprehension •As above
Voluntary •Rehabilitation
•+/- relocation •Habitual/party tricks
•Posterior •If ongoing habitual instability, consider
apprehension psychology
•Sulcus **Laxity alone is not an indication for Orthopaedic Review
**Objective tests alone revealing instability is NOT a criterion for onward referral, patient also has to have
functional instability
 Presentation Management
Adhesive Capsulitis
Managing/Functioning with
Condition
•Physiotherapy
•Three defined stages
•1st Appointment –
•Stage 1 – increasing pain and restriction of
•Advice
movement (2-9 months)
•Stage 2 – increasing restriction in ROM, •Stretching
ongoing pain (4-12 months)
•Leaflet
•Stage 3 – pain settling and range slowly
improving (5-26 months) •Review 4-6 weeks
•?D/C
•Insidious onset
•Analgesia
•Female > Male
•Corticosteroid injection
Primary •Usually >40 years
•Normal x-ray
Not Managing/Functioning with
•Significant limitation to passive external Condition/ Pain Dominant Feature
rotation and elevation
•Physiotherapy not indicated – onward
•+/- associated night pain referral to Orthopaedics
•Unilateral, but in rare cases can be bilateral •Corticosteroid Injection
•May have associated Diabetes, Dupuytrens, •Distension Arthrogram
high cholesterol or heart disease
•Capsular release
•Pain can be in sub-deltoid region or radiate
down arm (past elbow)

•Stages as above
Secondary •Occurs after traumatic event or surgery

Key Indicators for Determining Patient Managing:

•Relative sleep disturbance
•Work status
•ADL’s
•Patient perception of problem
•Pain levels
AC joint dysfunction Presentation Management

•Younger <40 years •Specific advice re training

•Repetitive extreme loading •Load
•Common in strength & power •Technique
athletes and heavy overhead
•frequency
vocations
•Graded exercise program
•Pain localised to AC joint or C5
dermatome •Advice
Osteolysis •Scarf test +ve •Posture re-ed
•Painful arc •Analgesia
•Pain on strength tests •Corticosteroid Injection
•X-ray shows lysis (erosion) distal •Onward referral to Orthopaedics
end of clavicle if no improvement >6/12

•Older population > 40 years

•Physiotherapy Advice Sheet
•Repetitive loading / overuse
•Analgesia
•May have had old traumatic
•Corticosteroid Injection
Osteoarthritis event e.g. dislocation
•Pain localised to AC joint or C5 •Onward referral to Orthopaedics
if no improvement >6/12
dermatome
•Scarf test +ve
•Panful arc Grade I-III
•OA / degenerative changes on •Physiotherapy if any concurrent
x-ray problems
•Scapular dyskinesis
•Traumatic event •RC impairment
•Localised symptoms as above •NSAID’s & analgesia
AC joint Disruption •+ve scarf test •Conservative failure and
•Palpable step >6months of ongoing pain may
require surgery
•X-ray evidence of disruption
GradesIV-VI
•Early surgical reduction and
fixation