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