Painful shoulder

Question 1

Differential diagnosis

Answer 1

Shoulder impingement
Frozen shoulder (adhesive capsulitis)
Septic arthritis
Shoulder OA
Rotator cuff tear
PMR

Question 2

Questions to ask in HPC

Answer 2

SOCRATES
Any trauma to the shoulder?
Pain in other joints

Is there any stiffness?
Any restricted range of movement?

Red flags - other joints, pins and needles, fever, weight loss unexpected

Impact on life
Impact on sleep - are they getting pain at night too?

Question 3

PMH

Answer 3

Any previous shoulder or joint pain?
Especially any arthritis

Do you have Diabetes?
Any surgery to the shoulder?

Question 4

SH

Answer 4

What do you do as a job?

Are you a throwing athlete?

Question 5

Examination and investigations

Answer 5

Shoulder examination to assess range of motion

• restriction of both active and passive shoulder movement, esp at the end of external rotation = frozen shoulder
• Pain occurs in a limited arc of abduction - shoulder impingement

Special tests e.g.:

• Jobe’s test to test for rotator cuff injury
• Neer test to test for shoulder impingement

Temperature and obs if suspect Septic arthritis

X-ray may be indicated for shoulder OA but not needed for other pathologies here

Question 6

Explanation and management of shoulder impingement

Answer 6

The tendon (band of tissue) inside your shoulder rubs or catches on nearby tissue and bone as you lift your arm

Treatment:

• Leaflet
• Keep shoulder moving but avoid doing too much activity or carrying heavy weights
• Pillows to support arm and stop you rolling at night
• Paracetamol and ibuprofen from the chemist
• If these don’t work then can consider a stronger painkiller e.g. naproxen, co-codamol or steroid injection
• Refer for 6w of physio

Question 7

If physio doesnt work for shoulder impingement

Answer 7

Refer onwards to ortho if there is no response to 6 weeks of treatment

Question 8

Explanation and management of frozen shoulder

Answer 8

Frozen shoulder happens when the tissue around your shoulder joint becomes inflamed.

Can take up to 3 years to resolve but can be managed in the meantime.

Management:

• Leaflet
• Avoid movements which make the pain worse
• Pillows at night to stop you rolling onto affected shoulder
• Paracetamol and ibuprofen
• Consider stronger analgesia or steroid injection if above doesnt work
• Refer to physio
• If physio doesnt work then refer to orthopaedics for further treatment