Most shoulder injuries involve soft tissue and occur during recreational activities, mainly through repetitive movements or trauma.  Unless direct trauma is the cause, most people present with problems involving their dominant extremity.

History

Pain pattern, character, duration and aggravating factors need to be assessed.

• Was trauma involved?
• A dull aching, discomfort often felt at night corresponds with r/c tears, whereas stabbing burning pain is more typical of a bursitis or tendinitis.
• Pain over the A/C joint?
• Deep pain may come from RC involvement, synovitis or a labrum tear.
• A history of instability – ‘giving way’ or ‘slipping out’ suggests subluxation or dislocation.
• Neck problems need to be eliminated.

History

Diagnoses can be difficult due to the lack of definite signs and symptoms.  US, CT and MRI can be useful in assisting diagnosis by identifying pathology.

The most common disorders seen in practice are

• Rotator Cuff disorders indicating tendonitis,
• Partial and complex rupture.
• Impingement
• Subluxation / dislocation
• Frozen shoulders
• OA

Complete Rupture

A history of sudden jarring, a fall or sharp movement leading to localized sharp pain in the subacromial area followed by an inability to actively raise the arm but with little pain should alert to a complete rupture. Older age brackets make this more likely.

On examination these patients have a loss of active movements into flexion or abduction above 50º, little pain, full passive ROM and weakness with static contraction.  If the rupture is chronic, wasting of the shoulder muscles will be present.

Partial Rupture

Differentiation between classical partial rupture and in tendonitis is frequently impossible based on clinical examination alone.

Partial rupture tends to occur in middle to older aged patients unless associated with significant trauma or excessive over use, particularly in throwing sports whereas tendonitis is most common in a younger age group.

Patients with partial rupture may describe a distinct incident, which precipitated symptoms; pain is generally great and does not settle quickly.  The ability to raise the arm over the head will be restricted by pain more than loss of power and full or near full range of movement may be available.  With a painful arc through mid range particularly abduction, patients will describe catches of pain with quick movements.  Abduction tends to be involved more than flexion as a result of impingement.

Tendonitis

Onset of tendonitis is more likely to involve overuse, apparent spontaneous onset following a minor incident rather than frank trauma.  Both conditions are associated with impingement so it is not a good indicator.

Impingement

Many cuff disorders are associated with Impingement and in the subacromial space and occasionally the AC joint. 

The classical presentation is one of pain felt in the lateral upper arm/ deltoid insertion.  Pain is often felt at rest, frequently worse at night mainly due to inflammation.  The patient may complain of catches of pain through range, particularly with overhead activity.  Leaning on the elbow or outstretched arm may also aggravate pain. 

The history is usually one of overuse and/or excessive overloading. Clinical signs include a painful arc on abduction and/or flexion, crepitus in the subacromial area with movement, full or near passive ROM with pain at upper movements.  Impingement testing is non-specific at localising impingement. Ultrasound is useful in confirming diagnoses of impingement.

Instability

Instability secondary to significant trauma of the glenohumeral joint is well recognized.  Relatively minor trauma with the arm in the position of abduction/ lateral rotation may cause significant injury to the anterior lateral/capsular complex causing potential instability especially if the shoulder has a normal tendency to capsular laxity.

Overuse and over stretching in the position of the abduction/lateral rotation e.g. Tennis serving may cause alteration of the lateral/ capsular complex. Patient presentation is similar to those with impingement syndrome. If a diagnosis of minor instability is suspected and conservative management is not achieving satisfactory results, orthopaedic consultation is desirable.

Adhesive Capsulitis

Adhesive Capsulitis or frozen shoulder is a condition of the glenohumeral joint capsule that causes pain and global restriction of the glenohumeral joint. Primary Capsulitis occurs spontaneously while secondary Capsulitis occurs following a precipitate event.

Hydrodilation in combination with physiotherapy mobilisation is most effective management.