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Monday, August 18, 2025

Shoulder pain


Introduction

Shoulder pain is one of the most common musculoskeletal complaints, affecting up to 25% of the general population at some point. It can arise from a wide spectrum of causes ranging from minor sprains to systemic diseases. The shoulder is a complex anatomical joint with the greatest range of motion in the human body, and this mobility makes it susceptible to injury, degeneration, and instability.

Shoulder pain may be acute or chronic, localized or referred, and can significantly impair activities of daily living, occupational tasks, and quality of life.

Anatomy and Biomechanics of the Shoulder

The shoulder complex consists of:

  • Glenohumeral joint (humerus with glenoid cavity).

  • Acromioclavicular joint.

  • Sternoclavicular joint.

  • Scapulothoracic articulation.

Supporting structures:

  • Rotator cuff muscles (supraspinatus, infraspinatus, teres minor, subscapularis).

  • Labrum, capsule, and ligaments.

  • Bursae (subacromial, subdeltoid).

This complexity allows flexibility but predisposes to injury and overuse.

Etiology of Shoulder Pain

1. Musculoskeletal and Mechanical Causes

  • Rotator cuff disorders: Tendinitis, tears (partial/full thickness).

  • Subacromial bursitis.

  • Frozen shoulder (adhesive capsulitis).

  • Shoulder impingement syndrome.

  • Acromioclavicular joint arthritis.

  • Glenohumeral osteoarthritis.

  • Shoulder instability/dislocation.

  • Fractures (clavicle, humerus, scapula).

2. Referred Pain

  • Cervical spine disorders (disc herniation, cervical spondylosis).

  • Diaphragmatic irritation (gallbladder disease, subphrenic abscess).

  • Myocardial ischemia (can present as left shoulder pain).

  • Pulmonary conditions (apical lung tumor, pneumonia).

3. Systemic/Inflammatory Causes

  • Rheumatoid arthritis.

  • Polymyalgia rheumatica.

  • Gout, pseudogout.

  • Septic arthritis.

4. Other Causes

  • Postural strain.

  • Overuse from repetitive activity (sports, manual work).

  • Post-surgical stiffness.

Clinical Presentation

  • Pain characteristics: Dull, aching, sharp, or radiating.

  • Aggravating factors: Lifting, overhead movements, lying on the affected side.

  • Associated symptoms:

    • Stiffness (adhesive capsulitis).

    • Weakness (rotator cuff tear).

    • Clicking/catching (labral tear).

    • Numbness/tingling (cervical radiculopathy).

  • Red flags: Night pain, systemic symptoms (fever, weight loss), trauma, history of cancer.

Diagnostic Evaluation

1. History

  • Onset: acute vs gradual.

  • Precipitating factors: trauma, repetitive motion.

  • Functional limitations.

  • Systemic conditions (RA, diabetes, heart disease).

2. Physical Examination

  • Inspection: Deformity, atrophy, swelling.

  • Palpation: Tenderness over joints, bursa, muscles.

  • Range of motion (ROM): Active vs passive.

  • Special tests:

    • Neer and Hawkins test (impingement).

    • Drop arm test (rotator cuff tear).

    • Apprehension test (instability).

3. Imaging

  • X-rays: Fractures, arthritis, calcific tendinitis.

  • Ultrasound: Rotator cuff tears, bursitis.

  • MRI: Gold standard for soft tissue injuries.

  • CT scan: Complex fractures.

4. Laboratory Tests

  • CBC, ESR, CRP (if infection or inflammatory arthritis suspected).

  • Rheumatologic markers (RF, anti-CCP, ANA).

  • Serum uric acid (gout).

Management

Treatment depends on the underlying etiology and severity.

1. General Conservative Measures

  • Rest and activity modification.

  • Ice or heat application (15–20 minutes, 3–4 times daily).

  • Physical therapy: strengthening and stretching of rotator cuff and scapular stabilizers.

  • Postural correction and ergonomic adjustments.

2. Pharmacological Management

A. Analgesics

  • Paracetamol (acetaminophen): 500–1000 mg orally every 6–8 hours (max 4 g/day).

B. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

  • Ibuprofen: 400–600 mg orally every 8 hours.

  • Naproxen: 250–500 mg orally twice daily.

  • Diclofenac: 50 mg orally twice daily or 75 mg intramuscularly once daily.

  • Topical NSAIDs: Diclofenac gel 1% applied 3–4 times daily.

C. Corticosteroids

  • Local corticosteroid injection into subacromial bursa or glenohumeral joint:

    • Triamcinolone acetonide 20–40 mg per injection.

    • Methylprednisolone acetate 20–40 mg per injection.

  • Systemic corticosteroids may be used in severe inflammatory arthritis:

    • Prednisone 10–20 mg orally once daily (short course).

D. Disease-Specific Agents

  • Rheumatoid arthritis: Methotrexate 7.5–25 mg orally once weekly, folic acid supplementation.

  • Gout: Colchicine 0.6 mg orally once or twice daily during flares; allopurinol 100–300 mg orally daily for prevention.

  • Infection: IV antibiotics tailored to culture (e.g., Ceftriaxone 1–2 g IV once daily for septic arthritis).

3. Surgical and Interventional Management

  • Arthroscopic repair: Rotator cuff/labral tears.

  • Arthroplasty (joint replacement): Severe arthritis.

  • Capsular release: Adhesive capsulitis not responding to conservative treatment.

  • Open reduction and internal fixation (ORIF): Fractures.

Special Considerations in Common Shoulder Disorders

A. Rotator Cuff Tendinitis/Tear

  • Conservative therapy (NSAIDs, physiotherapy) for partial tears.

  • Surgical repair for complete or large tears.

B. Frozen Shoulder (Adhesive Capsulitis)

  • Painful progressive stiffness, often in diabetics.

  • Physical therapy, corticosteroid injection.

  • Resistant cases: manipulation under anesthesia or arthroscopic release.

C. Shoulder Impingement Syndrome

  • Activity modification, physiotherapy, subacromial steroid injection.

  • Surgery if severe.

D. Osteoarthritis

  • NSAIDs, intra-articular steroids.

  • Shoulder replacement in advanced cases.

E. Septic Arthritis

  • Urgent joint aspiration and culture.

  • IV antibiotics (e.g., ceftriaxone, vancomycin depending on organism).

  • Surgical drainage may be needed.

Precautions and Patient Counseling

  • Avoid overuse; use proper ergonomics at work and sports.

  • Stress compliance with physiotherapy.

  • Explain risks of repeated corticosteroid injections (tendon weakening, cartilage damage).

  • Instruct on warning signs: persistent night pain, fever, unexplained weight loss (seek urgent care).

  • Emphasize strict control of diabetes in patients with frozen shoulder.

Drug Interactions

  • NSAIDs: Increase risk of GI bleeding with anticoagulants (warfarin), antiplatelets (aspirin, clopidogrel), corticosteroids, SSRIs. Reduce effect of antihypertensives (ACE inhibitors, diuretics).

  • Corticosteroids: May increase blood glucose in diabetics; risk of immunosuppression. Interact with CYP3A4 inhibitors (ketoconazole, ritonavir).

  • Methotrexate: Interacts with NSAIDs (risk of toxicity); contraindicated in liver disease.

  • Colchicine: Interacts with macrolide antibiotics (clarithromycin, erythromycin) leading to toxicity.

  • Allopurinol: Interacts with azathioprine and mercaptopurine (risk of bone marrow suppression).

Prognosis

  • Acute mechanical injuries generally resolve with conservative management.

  • Rotator cuff tears and frozen shoulder may take months to recover, and some cases need surgery.

  • Arthritis-related pain is chronic and progressive but can be managed with multimodal therapy.

  • Infectious causes can be life-threatening if untreated but respond well to timely antibiotics and drainage.




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