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Shoulder Pain Differential Diagnosis

Condition

Findings on History that affect likelihood of this diagnosis

Findings on Physical Exam that affect likelihood of this diagnosis

Findings on Imaging that affect likelihood of this diagnosis

Experience teaches

Impingement (tendinopathy, bursitis, PASTA)

  • Age usually 35-55; if younger and really looks like impingement, think instability
  • Overhead work or play (tennis, pitching)
  • Pain rolling on shoulder in bed/ night pain
  • Needs FROM to exclude dx of concomitant frozen shoulder
  • Positive impingement sign(s)
  • Assess ER strength to exclude posterior cuff tear
  • Plain films exclude DJD
  • Plain films showing big spur
  • MRI exclude full-thickness tear (Note: Pre-test probability of tendinopathy is very high, so that alone on MRI is not really meaningful)
  • Weakness may be due to pain or torn tendon

Full-thickness rotator cuff tears

  • Age usually a bit older than impingement
  • Pain rolling on shoulder in bed/night pain
  • Weakness
  • Lateral arm pain, near deltoid insertion, but does not radiate below elbow
  • Passive motion typically greater than active motion
  • Decreased strength in elevation, abduction,
  • Drop arm
  • Plain films exclude DJD
  • MRI to document extent of tear
  • MRI to assess repairability of the tear (look at muscle atrophy on T1 oblique sagittal sequence)
  • Some people have no problem despite full tears

Suprascapular neuropathy

  • Presents like impingement
  • Constant, unrelenting pain
  • Examines like cuff tear but has atrophy of supra- and infraspinatus (NOT SEEN THROUGH A SHIRT!)
  • MRI can be pretty normal, except for atrophy (muscle atrophy in setting of intact tendons)
  • EMG needed

Multi-directional instability

  • History of dislocation, subluxation
  • Other joints lax
  • May present with impingement symptoms
  • Sulcus sign
  • Laxity in other joints
  • Apprehension sign
  • +/- Scapular dyskinesia/ weakness
  • Patulous capsule
  • Often normal labrum/rotator cuff
  • Psych overlap?

Uni-directional instability – anterior

  • History of dislocation with or without need for manual reduction
  • Usually younger patients
  • + Apprehension sign
  • + Relocation test
  • Pain in abduction/external rotation with Bankart lesion
  • If acute, MRI may be diagnostic (MRI arthrogram increases sensitivity/specificity in chronic cases)
  • Plain radiographs help to exclude bone lesions (Bankart/Hill Sachs)
  • CT may help evaluate osseous structures if bone deficiency is suspected
  • Acute "dislocation" should refer to only confirmed cases requiring relocation

Uni-directional Instability - Posterior

  • May present with multi-directional instability
  • Posterior shoulder pain
  • May have history of dislocation, more likely recurrent posterior subluxation (RPS)
  • May be seen with seizures/ electrocution
  • Pain with jerk test
  • +/- Kim test
  • Pain with adduction and internal rotation
  • MRI with or without arthrogram is helpful to evaluate posterior labrum
  • Radiographs/CT scan can evaluate for glenoid/humeral retroversion

Labral/SLAP tears

  • May have traumatic origin (distraction injury)
  • History of repetitive trauma (throwing motion, overhead athletes)
  • May be associated with instability of the glenohumeral joint
  • + Mayo Shear Test (Dynamic labral shear)
  • + O'Brien's test
  • MRI demonstrates detachment or tear of the superior labrum at the biceps anchor
  • MRI arthrogram may help in indeterminate cases
  • SLAP and pain may both be present but not causally related
  • Evaluate and manage posterior capsule tightness

Paralabral cyst

  • Typically presents with deep seated shoulder pain
  • Weakness in external rotation may be present
  • May have provocative SLAP tests (O'Brien's, Mayo Shear test)
  • Atrophy of infraspinatus
  • MRI helps determine the size of cyst and impingement of spinoglenoid notch

Biceps tendinopathy

  • Anterior shoulder pain
  • May also have pain with supination
  • Tenderness to palpation over tendon in bicipital groove
  • Speed's test
  • O'Brien's test
  • Typically a clinical diagnosis as imaging may be normal

Proximal biceps ruptures or subluxation

  • Pop
  • Popeye deformity
  • May be associated with subscapularis tears
  • MRI helps to determine status of the rotator cuff and subscapularis which can be associated with this diagnosis

AC arthropathy (including old fractures)

  • History of AC separation or distal clavicle fx
  • Weight lifter
  • May have prominent distal clavicle or large AC joint
  • Tenderness on ac joint
  • Pain with x-body adduction
  • Bell-van Riet test
  • Relief from injection
  • Arthrosis
  • Osteolysis
  • Evidence of old fx or separation
  • Plain radiographs or MRI are diagnostic

AC instability

  • Anterior shoulder pain after a direct fall or contusion to the shoulder
  • Clinical evidence of elevated clavicle relative to acromion
  • May have posterior subluxation with cross body adduction
  • Stress radiographs are helpful in subtle cases
  • Evaluation of the coraco-clavicular distance (compare to contralateral side)

Os acromiale

  • Pain over anterior shoulder
  • May be present after fall or direct contusion
  • Tenderness over acromion
  • Axial cuts of MRI best to see

Glenohumeral joint DJD

  • Older patient
  • Typical arthritis complaints
  • Decreased motion
  • May have weakness secondary to pain
  • Goat's beard on x-ray
  • Joint space narrowing less common than in lower extremity DJD (ie, can't have a "standing" film of arm)

Humeral OCD

  • Presents like DJD ??
  • May have vague complaints (achy pain)
  • May present with instability symptoms
  • Maybe no findings
  • Seen on MRI, CT

Gout, etc. (inflammatory arthritides)

  • Presents like DJD
  • Pain can be at rest especially with infection (which is very rare in normal host)
  • Presents like DJD
  • Micromotion pain rare, but seen in gout (presents like infection)
  • Absence of osteophytes is classic presentation on x-rays
  • Decreased joint space and sclerosis is primary finding

Scapulo-thoracic dyskinesis

  • Achiness in shoulder, decreased velocity in throwing
  • Must have patient remove shirt and observe scapula from back
  • SICK scapula findings (dyskinesia, infera, etc.)
  • Clinical examination is key
  • Radiographs, MRI may be normal

Long thoracic nerve palsy

  • Weakness, diffuse shoulder pain
  • May be present after viral illness
  • Winging on wall-pushup
  • Radiographs may show abnormal position of scapula (chest xray)

Bone tumor

  • Pain can be at rest

Humeral head AVN

  • Pain can be at rest
  • May present like DJD
  • Restriction in range of motion and pain
  • Seen on MRI

Syrynx

  • Presents like AVN---it's a "neuropathic arthropathy"
  • Loss of shoulder range of motion
  • Painless range of motion - less pain than expected based on amount of destruction
  • MRI of neck
  • Radiographs of shoulder show Charcot arthropathy of the joint

Parsonage Turner Syndrome

  • Burning pain
  • Weakness
  • May be post-viral
  • Atrophy of supra/infraspipnatus may be present
  • Weakness on external rotation testing
  • MRI helps to evaluate the muscle and rule out rotator cuff pathology
  • Consider MRI of brachial plexus or EMG

Radiculopathy

  • Radiating pain, respecting dermatomal borders
  • Decreased/painful range of motion of the neck
  • Sensory disturbance along dermatome
  • Radiation below elbow
  • MRI of the cervical spine evaluates for disc herniation/compression of the nerve root

Malingering

  • In litigation
  • Wears sunglasses during exam despite no recent eye surgery
  • Active motion better than passive motion
  • Elevates arm less than would be possible after arthrodesis
  • Resistance against passive range of motion
  • Radiographs, MRI typically normal or non-specific to clinical examination

Lung cancer

  • Smart alecks will tell you that a smoking history should be enough, but too many people smoke for that to be useful. Chronic cough, weight loss, cachexia may be more specific
  • Overall assessment of the patient, Horner's syndrome
  • Apical tumor seen on x-ray of the shoulder



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