Chronic Shoulder Pain:

Part I. Evaluation and Diagnosis

Shoulder pain is defined as chronic when it has been present for longer than six months. Common conditions that
can result in chronic shoulder pain include rotator cuff disorders, adhesive capsulitis, shoulder instability, and shoulder arthritis. Rotator cuff disorders include tendinopathy, partial tears, and complete tears. A clinical decision rule
that is helpful in the diagnosis of rotator cuff tears includes pain with overhead activity, weakness on empty can
and external rotation tests, and a positive impingement sign. Adhesive capsulitis can be associated with diabetes
and thyroid disorders. Clinical presentation includes diffuse shoulder pain with restricted passive range of motion
on examination. Acromioclavicular osteoarthritis presents with superior shoulder pain, acromioclavicular joint tenderness, and a painful cross-body adduction test. In patients who are
older than 50 years, glenohumeral osteoarthritis usually presents as
gradual pain and loss of motion. In patients younger than 40 years,
glenohumeral instability generally presents with a history of dislocation or subluxation events. Positive apprehension and relocation
are consistent with the diagnosis. Imaging studies, indicated when
diagnosis remains unclear or management would be altered, include
plain radiographs, magnetic resonance imaging, ultrasonography,
and computed tomography scans. Plain radiographs may help diagnose massive rotator cuff tears, shoulder instability, and shoulder
arthritis. Magnetic resonance imaging and ultrasonography are preferred for rotator cuff disorders. For shoulder instability, magnetic
resonance imaging arthrogram is preferred over magnetic resonance
imaging. (Am Fam Physician. 2008;77(4):453-460. Copyright 2008
American Academy of Family Physicians.)
This is part I of a two-part
article on chronic shoulder
pain. Part II, Treatment,
appears in this issue of
AFP on page 493.

houlder pain is responsible for

approximately 16 percent of all
musculoskeletal complaints,1 with a
yearly incidence of 15 new episodes
per 1,000 patients seen in the primary care
setting.2 Part I of this two-part article will
provide the primary care physician with a
simple, effective approach to the diagnosis of chronic shoulder disorders such as
rotator cuff pathology, adhesive capsulitis,
acromioclavicular osteoarthritis, glenohumeral osteoarthritis, and instability. Part II,
which appears in this issue of AFP (p. 493),
discusses the treatments of chronic shoulder
pain that are consistent with recent evidencebased guidelines.3,4 Shoulder pain is defined
as chronic when it has been present for

longer than six months, regardless of whether

the patient has previously sought treatment.
It can be divided into six diagnostic categories: (1) rotator cuff disorders, including
tendinosis, full or partial thickness tears, or
calcific tendinitis; (2) adhesive capsulitis;
(3) glenohumeral osteoarthritis; (4) glenohumeral instability; (5) acromioclavicular
joint pathology; and (6) other chronic pain,
including less common shoulder problems
and non-shoulder problems.
Clinical Diagnosis
Medical history

Table 15-11 summarizes the history and

potentially associated shoulder conditions
for patients with chronic shoulder pain.

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ILLUSTRATION BY john w. karapelou

Kelton M. Burbank, MD, Leominster, Massachusetts

J. Herbert Stevenson, MD, University of Massachusetts, Fitchburg, Massachusetts
Gregory R. Czarnecki, DO, University of Connecticut, Hartford, Connecticut
Justin Dorfman, DO, Southboro, Massachusetts

Shoulder Pain Evaluation

SORT: Key Recommendations for Practice
Clinical recommendation

Evidence
rating

References

All patients should receive radiographs as part of the initial work-up for chronic shoulder pain.

23

Further testing of chronic shoulder pain, using imaging*, should be performed when the diagnosis remains
unclear or the outcome would change management.

23, 24

If acromioclavicular osteoarthritis is suspected, the acromioclavicular joint should be assessed for tenderness,
and a cross-body adduction test should be performed to help confirm the diagnosis.

16, 18

When rotator cuff injury is suspected, assess for night pain and pain with overhead activity.

10

When the patient has a painful shoulder with severely limited active and passive ranges of motion,
a diagnosis of adhesive capsulitis should be considered.

8, 9

* Imaging options include magnetic resonance imaging, arthrography, computed tomography scan, and ultrasonography.
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, diseaseoriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 410 or http://
www.aafp.org/afpsort.xml.

Table 1. History Findings and Associated

Shoulder Disorders
History

Associated condition

Age

If younger than 40 years: instability,

rotator cuff tendinopathy

5,6,7

If older than 40 years: rotator cuff tears,

adhesive capsulitis, glenohumeral
osteoarthritis
Diabetes or thyroid
disorders8,9

Adhesive capsulitis

History of trauma10

If younger than 40 years: shoulder

dislocation/subluxation
If older than 40 years: rotator cuff tears

Loss of range of
motion

Adhesive capsulitis, glenohumeral

osteoarthritis

Night pain10

Rotator cuff disorders, adhesive

capsulitis

Numbness, tingling,
pain radiating
past elbow

Cervical etiology

Pain location

Anterior-superior shoulder pain associated

with acromioclavicular joint pathology
Diffuse shoulder pain in deltoid region
associated with rotator cuff disorders,
adhesive capsulitis, or glenohumeral
osteoarthritis

Pain with overhead

activity10

Rotator cuff disorders

Sports
participation11

Shoulder instability associated with

overhead sports (e.g., baseball,
softball, tennis), and collision sports
(e.g., football, hockey)
Acromioclavicular joint pathology
associated with weight lifting

Weakness

Rotator cuff disorders, glenohumeral

osteoarthritis

Information from references 5 through 11.

454 American Family Physician

The age of the patient is an important initial consideration. Patients younger than 40 years are more likely
to present with shoulder instability or mild rotator
cuff disease (impingement, tendinopathy), whereas
patients older than 40 years are at an increased risk
for advanced, chronic rotator cuff disease (partial or
complete tear), adhesive capsulitis, or glenohumeral
osteoarthritis.3-5, 12-14
The occupational and recreational interests of the
patient are also important in the evaluation of shoulder
pain. A history of collision sports or weight lifting might
make instability or acromioclavicular osteoarthritis
more likely, whereas overhead sports or work activities
might make rotator cuff pathology more likely.
The location of the pain can be helpful for diagnosis. Anterior-superior pain often can be localized to the
acromioclavicular joint, whereas lateral deltoid pain is
often correlated with rotator cuff pathology. Neck pain
and radiating symptoms should be explored because cervical pathology can mimic shoulder pain. Typically, pain
that radiates past the elbow to the hand is not related to
shoulder pathology. However, it is not uncommon to
have pain that radiates into the neck because the trapezius muscle often spasms in patients with underlying chronic shoulder pathology. The presence of both is
more likely to be related to cervical pathology. Dull, achy
night pain is often associated with rotator cuff tears or
severe glenohumeral osteoarthritis.
Previous treatments and factors that aggravate or alleviate the pain can be important clues to the diagnosis.
Night pain from sleeping on the affected shoulder, as well
as a history of trauma, has been associated with rotator
cuff tears.10 A painful arc, noted by pain with overhead
activity, is associated with mild rotator cuff disease and
tendinopathy as well as rotator cuff tears.10,15 A history of
previous shoulder surgery is important because adhesive
capsulitis and glenohumeral osteoarthritis can be early
or late complications of surgery.

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Shoulder Pain Evaluation

Table 2. Selected Tests of the Shoulder

Examination maneuver

Associated condition

Sensitivity
(%)

Chronic rotator cuff tear

56

Acromioclavicular joint OA or chronic sprain

Specificity
(%)

LR+

LR-

73

2.07

0.60

96

10

1.07

0.4

Rotator cuff disorder

30

78

1.36

0.90

Hawkins impingement15

Impingement/rotator cuff disorder

72

66

2.1

0.42

Drop-arm15

Large rotator cuff tear

27

88

2.25

0.83

Empty-can supraspinatus15

Rotator cuff disorder involving supraspinatus

44

90

4.4

0.62

Lift-off subscapularis17

Rotator cuff disorder involving subscapularis

62

100

> 25

0.38

External rotation/infraspinatus strength15

Rotator cuff disorder involving infraspinatus

42

90

4.2

0.64

Cross-body adduction18

Acromioclavicular joint OA or chronic sprain

77

79

3.50

0.29

Apprehension19

Glenohumeral instability

72

96

20.22

0.29

Relocation19

Glenohumeral instability

81

92

10.35

0.2

Inspection
Supraspinatus or infraspinatus atrophy10
Palpation
Acromioclavicular tenderness16
Range of motion
Restrictive active10
Provocative tests

LR+ = positive likelihood ratio; LR- = negative likelihood ratio; OA = osteoarthritis.

The recommended progression of shoulder examination maneuvers is inspection, palpation, range of motion and strength tests, and provocative tests.
note:

Information from references 10 and 15 through 19.

The patients medical history, including joint problems, can help to narrow the differential diagnosis.
Autoimmune diseases and inflammatory arthritis can
affect the shoulder, resulting in erosions and wear in the
glenohumeral joint, whereas diabetes and thyroid disorders can be associated with adhesive capsulitis.8,9
Physical Examination

Table 210,15-19 summarizes some of the shoulder maneuver tests and the associated conditions. The preferred
order of the examination is: inspection, palpation, range
of motion and strength tests, and provocative tests.
Inspection should involve the entire shoulder, with
proper exposure of the anterior, lateral, and posterior
shoulder. A scar can indicate previous surgery or trauma.
The presence of deformity, particularly of the acromioclavicular joint, often indicates an old trauma. Atrophy
of the supraspinatus, and less commonly the infraspinatus, may be present with a chronic rotator cuff tear.
Palpation can identify areas of pathology, especially
with the acromioclavicular joint. Isolated tenderness
that is localized to the acromioclavicular joint is often
indicative of acromioclavicular osteoarthritis. Subacromial tenderness may suggest rotator cuff pathology.
Multiple trigger points around the shoulder may indicate non-shoulder pathology such as fibromyalgia. It
is important to palpate both shoulders because certain
structures can be painful (e.g., coracoid process, long
head of biceps tendon), even in a healthy shoulder. The
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Volume 77, Number 4

presence of a disproportionate amount of discomfort is

helpful for diagnosis.
Range of motion should be evaluated in flexion,
abduction, internal rotation, and external rotation. If the
patient has a full active range of motion, a passive range
of motion need not be assessed. Loss of active and passive
ranges of motion is the hallmark of adhesive capsulitis,
but it also can be found with moderate to severe osteoarthritis of the glenohumeral joint. Loss
Pain that radiates past the
of an active range
elbow to the hand is usuof motion, with a
ally not related to shoulder
relatively preserved
pathology.
passive range of
motion, is often
present in patients with rotator cuff pathology. Pain with
an active range of motion between 60 and 100 degrees of
abduction is known as the painful arc and is associated
with rotator cuff disease.20
There are numerous provocative tests for the shoulder. Although knowledge of all the tests can be helpful to
diagnose pathology, the primary care physician should
be familiar with a standard set of tests that should be
performed on every shoulder. The Hawkins test is used
to determine impingement (Figures 1a and 1b). Tests for
rotator cuff pathology are the drop-arm rotator cuff
test (Figures 2a and 2b); the empty-can supraspinatus
test (Figure 3); the lift-off subscapularis test (Figure 4);
and the external rotation test (Figure 5). The cross-body

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American Family Physician 455

Shoulder
Pain Evaluation
A

Figures 1a and 1b. Hawkins Impingement Test. Forward flex the arm to 90 degrees with the elbow bent to 90 degrees.
The arm is then internally rotated. A positive test, noted by pain on internal rotation, may signify subacromial impingement including rotator cuff tendinopathy or tear.
A

Figures 2a and 2b. Drop-Arm Rotator Cuff Test. The arm is passively raised to 160 degrees. The patient is then asked to
slowly lower the arm to the side. A positive test, noted by an inability to control the lowering phase and a dropping or
giving way of the arm, may indicate a large rotator cuff tear.

adduction test (Figure 6) is used to determine symptomatic acromioclavicular joint osteoarthritis, and the
apprehension and relocation tests (Figure 7) are used to
determine shoulder instability.
Clinical decision rules

Clinical decision rules have been developed to determine if a patient has a rotator cuff tear.21 A prospective
analysis of 400 patients found that the triad of weakness
found with the empty-can supraspinatus and external
rotation tests, along with a positive impingement test
(e.g., Hawkins impingement test), had a 98 percent
probability of being a rotator cuff tear (partial or complete).5 Patients older than 60 years who had two out
of three findings also had a 98 percent probability of a
rotator cuff tear. A retrospective analysis of 191 persons
found that the combination of being older than 65 years,
456 American Family Physician

having weakness on external rotation testing, and experiencing night pain resulted in a 91 percent probability of
having a rotator cuff tear (partial or complete).10 However,
54 percent of asymptomatic persons older than 60 years
have been shown to have a partial or full thickness rotator
cuff tear by magnetic resonance imaging (MRI).22
Diagnostic Imaging
Initial imaging

Radiographs are indicated as part of the initial workup for all chronic shoulder pain. The standard series
includes anteroposterior, scapular Y, and axillary views.
Plain radiographs are the tests of choice to assess osteoarthritis of the acromioclavicular and glenohumeral
joints. Secondary signs of a large rotator cuff tear may be
observed with superior migration of the humeral head.
Cystic changes of the humeral head and sclerosis of the

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Shoulder Pain Evaluation

Figure 3. Empty-Can Supraspinatus Test. The arms are

abducted to 90 degrees and forward flexed 30 degrees.
With the thumbs turned downward, the patient actively
resists a downward force applied by the examiner. A positive test is indicated by weakness compared with the contralateral side and may indicate rotator cuff pathology,
including supraspinatus tendinopathy or tear.

Figure 5. External Rotation/Infraspinatus Strength Test.

The patients arms are held at their sides with the elbows
flexed to 90 degrees. The patient actively externally
rotates against resistance. A positive test is indicated by
weakness compared with the contralateral side and may
be associated with infraspinatus or teres minor tendinopathy or tear.

Figure 4. Lift-Off Subscapularis Test. With the arm intern

ally rotated behind the patients lower back, the patient
internally rotates against the examiners hand. A positive
test is indicated by the inability to lift the hand off of the
back and may indicate subscapularis tendinopathy or tear.

Figure 6. Cross-Body Adduction Test. The arm is passively

adducted across the patients body toward the contralateral shoulder. Pain may indicate acromioclavicular joint
pathology, including chronic sprain or osteoarthritis.

inferior acromion can indicate chronic rotator cuff disease. Plain radiographs can also diagnose calcific tendinitis. A large Hill-Sachs lesion (an indentation into the
posterior aspect of the humeral head that occurs when
the shoulder dislocates anteriorly and the back of the
humeral head contacts the anterior edge of the glenoid)
or an avulsion fracture off the inferior glenoid may indicate previous instability.

Further imaging

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Further testing of chronic shoulder pain should be utilized when the diagnosis remains unclear or the outcome
would change management. Imaging options include
MRI, arthrography, computed tomography (CT), and
ultrasonography. The preferred test for diagnosing
rotator cuff disorders is MRI, which can assess rotator
cuff tendinopathy, partial tears, and complete tears.23

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American Family Physician 457

Shoulder Pain Evaluation

The CT scan is the preferred imaging study for bony

disorders of the shoulder, including arthritis with significant erosion; instability with significant bone loss of the
humeral head or the glenoid; tumors; and occult fractures. CT arthrography may play a role for patients with
suspected rotator cuff tears who cannot undergo an MRI.
Diagnostic Approach
Applying the findings from the patients history, physical
examination, and radiographs should enable the physician to formulate a diagnosis (Table 4). Potential problem
diagnoses include patients with more than one underlying problem (such as a rotator cuff tear and symptomatic
acromioclavicular osteoarthritis) or a less common cause
of the pain. The typical presentations for the most common causes of chronic shoulder pain are discussed below.
Figure 7. Apprehension and Relocation Tests. With
the patient supine, the patients arm is abducted to
90 degrees and the elbow is flexed to 90 degrees. Pain
and a sense of instability with further external rotation
may indicate shoulder instability. Relief of these symptoms with a posteriorly directed force on the proximal
humerus is a positive relocation test and further supports
diagnosis of shoulder instability.

MRI arthrography has become the preferred test for the

imaging of suspected labral pathology that may be found
in chronic shoulder instability.24
Ultrasonography is emerging as a cost-effective alternative to MRI, with advantages over MRI23 that include
better patient tolerance, dynamic assessment, and
improved resolution in the face of previous surgery.
Ultrasonography is technician-dependent and, therefore, has not yet gained widespread acceptance. Table 323
summarizes the sensitivity, specificity, and positive and
negative likelihood ratios for MRI and ultrasonography
in the diagnosis of rotator cuff tears.

Acromioclavicular osteoarthritis

Acromioclavicular joint pathology is usually well localized. A history of an injury to the joint (shoulder separation), heavy weight lifting, tenderness to palpation
at the acromioclavicular joint, pain with cross-body
adduction testing, extreme internal rotation, and forward flexion are consistent with the diagnosis.3,4,14
Radiographs may be difficult to interpret because most
patients have acromioclavicular osteoarthritis by the
age of 40 to 50 years.3,4,14 A distal clavicle lysis or an
elevated distal clavicle supports the diagnosis, whereas
the absence of tenderness to palpation at the acromioclavicular joint is inconsistent with the diagnosis.3,4,14
Adhesive Capsulitis

Adhesive capsulitis refers to a painful shoulder in which

the active and passive ranges of motion are severely limited. Gradual onset of pain and stiffness, loss of motion in
all planes with increased pain at the extremes of motion,

Table 3. Imaging Tests for Rotator Cuff Tears

Imaging test

Finding

Sensitivity (%)

Specificity (%)

MRI

Any rotator cuff tear

83

86

4.85

0.22

Partial thickness rotator cuff tear

44

90

3.99

0.66

Full thickness rotator cuff tear

89

93

10.63

0.16

Any rotator cuff tear

80

85

5.09

0.27

Partial thickness rotator cuff tear

67

94

8.90

0.36

Full thickness rotator cuff tear

97

96

13.16

0.16

Ultrasonography

LR+

LR-

LR+ = positive likelihood ratio; LR- = negative likelihood ratio; MRI = magnetic resonance imaging.
Information from reference 23.

458 American Family Physician

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Shoulder Pain Evaluation

Table 4. Diagnosing Causes of Chronic Shoulder Pain

Diagnosis

Findings consistent with diagnosis

Findings inconsistent
with diagnosis

Acromioclavicular
joint osteoarthritis

Pain at acromioclavicular joint; positive

cross-body adduction test; may have
history of trauma

No pain with palpation at

acromioclavicular joint;
negative cross-body adduction

Radiography shows osteoarthritis

at acromioclavicular joint, some
evidence of acromioclavicular
separation

Adhesive capsulitis

Age older than 40 years; decreased active

and passive range of motion; history of
diabetes or thyroid disease

Full passive range of motion; no

pain with movements

Radiography usually normal

Glenohumeral
instability

Age usually younger than 40 years;

history of subluxation or dislocation, or
generalized ligamentous laxity; positive
apprehension test

Negative apprehension test

Radiography usually normal

Glenohumeral
osteoarthritis

Age older than 50 years; progressive

pain; crepitus with range of motion

Age younger than 50 years;

normal radiography

Radiography shows narrowing

of joint space, spurring, and
osteophytes

Rotator cuff
pathology

Age usually older than 40 years; pain with

overhead activity; night pain; weakness;
positive Hawkins impingement test;
and rotator cuff weakness

No pain with overhead activities;

no arm pain; no weakness
with lift-off, external rotation,
or empty-can tests

Radiography may show humeral

head sclerosis or cyst, loss of
acromial-humeral interval;
acromial spur

Imaging

and a history of diabetes or thyroid disease are consistent

with the diagnosis.3,4,14 Radiographs are typically negative, and osteoarthritis on radiography is inconsistent
with the diagnosis. A normal range of motion is antithetic to the diagnosis.3,4,14

important to differentiate this group of disorders from

the other groups than it is to identify the specific diagnosis. Typically, the patients are older than 40 years and
complain of pain in the lateral aspect of the arm with
radiation no farther than the elbow. Weakness, a painful
arc of motion, night pain, and a positive impingement
Glenohumeral Instability
sign are components of the history and physical examiGlenohumeral instability refers to disorders affecting the nation that are consistent with this diagnosis.14 Findcapsulolabral complex, including dislocation and sublux- ings that are inconsistent with this diagnosis include
ation. The patients are usually younger than 40 years and being younger than 30 years, having no weakness, and
have a history of dislocation or subluxation events, which presenting no impingement signs. Positive radiographs
is often involved with collision or overhead sports.3 A can be helpful to diagnose calcific tendinitis, acromial
dead arm, numbness over the lateral deltoid, and a posi- spur, humeral head cysts, or superior migration of the
tive apprehension test are consistent with the diagnosis.20 humeral head, but are typically normal.3,4,14
Examination findings inconsistent with the diagnosis
are no history of dislocation or subluxation and a nega- Other conditions
tive apprehension test. Positive radiographs are helpful for Numerous other problems that can affect the shoulder
diagnosing Hill-Sachs lesion, dislocation, and inferior gle- are somewhat less common, such as biceps and labral
noid avulsion fracture, but are nondiagnostic if negative.
pathology (e.g., SLAP tearsuperior labrum anterior
to posterior tearan avulsion injury to the root of the
Glenohumeral osteoArthritis
long head of the biceps tendon) and multidirectional
Glenohumeral osteoarthritis usually presents as gradual instability. Other conditions are extremely uncommon,
pain and loss of motion in patients older than 50 years.3,4,14 such as a suprascapular nerve injury, Parsonage Turner
A history of arthritis, previous shoulder surgery, pain, syndrome (brachial plexus neuritis), and a neuropathic
crepitus, and decreased motion is consistent with the shoulder from syringomyelia. The shoulder can also be
diagnosis.3,4,14 Radiographs are diagnostic. Normal radio- the area of perceived pain for many non-shoulder probgraphs and a normal range of motion are inconsistent lems, including fibromyalgia, cervical radiculopathy,
with the diagnosis.
and thoracic outlet syndrome. Fibromyalgia is notable
for classic areas of tender points. Cervical radiculopaRotator Cuff pathology
thy pain is generally posterior, with radiation to the
Rotator cuff disorders that affect the function of the neck and down the arm below the elbow. Thoracic outrotator cuff include a partial or complete tear, tendinitis let syndrome, like cervical radiculopathy, is notable for
or tendinosis, and calcific tendinitis. Initially, it is more symptoms that extend past the elbow and often into the
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American Family Physician 459

Shoulder Pain Evaluation

hand. There can be neurologic or vascular symptoms

based on the subtype. Positive radiographs are helpful
for diagnosing severe cervical osteoarthritis, but are
typically negative. Positive provocative shoulder testing (e.g., Hawkins impingement test, empty-can test,
external rotation test) that disappears after a subacromial lidocaine (Xylocaine) injection is inconsistent with
the diagnosis of fibromyalgia, cervical radiculopathy, or
thoracic outlet syndrome.3,4,14
The Authors
Kelton M. Burbank, MD, is an orthopedic surgeon in private practice in
Leominster, Mass. He completed fellowships in sports medicine at the New
England Baptist Hospital, Boston, Mass., and the Lahey Clinic, Burlington,
Mass. Dr. Burbank received his medical degree and completed a residency
in orthopedics at the University of Massachusetts, Worcester, and a residency in family practice at the University of Vermont in Burlington.
J. Herbert Stevenson, MD, serves as director of sports medicine and
director of the sports medicine fellowship for the University of Massachusetts Department of Family Medicine in Fitchburg. Dr. Stevenson received
his medical degree from the University of Vermont Medical School, Burlington. He completed a fellowship in sports medicine at the University of
Connecticut in Hartford, and a residency in family medicine at the University of Massachusetts.
Gregory R. Czarnecki, DO, is an assistant professor of internal medicine at the University of Connecticut in Hartford. He serves as assistant
director in the Department of Medicine at Hartford (Conn.) Hospital.
Dr. Czarnecki received his medical degree from New England College of
Osteopathic Medicine, Biddeford, Maine. He completed a residency in
internal medicine at the University of Connecticut in Farmington and a fellowship in sports medicine at the University of Massachusetts Department
of Family Medicine in Fitchburg.
Justin Dorfman, DO, is a sports medicine physician in private practice
in Southboro, Mass. Dr. Dorfman received his medical degree from Lake
Erie College of Osteopathic Medicine, Erie, Pa. He completed a residency
in family medicine at Christiana Care Hospital in Newark, Del., and a fellowship in sports medicine in the Department of Family Medicine at the
University of Massachusetts in Fitchburg.
Address correspondence to Kelton M. Burbank, MD, Longview Orthopaedic Center, HealthAlliance Hospital Leominster Campus, Professional Office Building, 100 Hospital Rd., Suite 3C, Leominster, MA 01453
(e-mail: kmbortho1@aol.com).
Author disclosure: Nothing to disclose.

4. Iannotti JP, Kwon YW. Management of persistent shoulder pain. a treatment algorithm. Am J Orthop. 2005;34(12 suppl):16-23.
5. Murrell GA, Walton JR. Diagnosis of rotator cuff tears [published
correction appears in Lancet. 2001;357(9266):1452]. Lancet. 2001;
357(9258):769-770.
6. Neer CS II. Anterior acromioplasty for chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg Am.
1972;54(1):41-50.
7. Yamaguchi K, Ditsios K, Middleton WD, Hildebolt CF, Galatz LM, Teefey
SA. The demographic and morphological features of rotator cuff disease. A comparison of asymptomatic and symptomatic shoulders.
J Bone Joint Surg Am. 2006;88(8):1699-1704.
8. Cakir M, Samanci N, Balci N, Balci MK. Musculoskeletal manifestations in patients with thyroid disease. Clin Endocrinol (Oxf).
2003;59(2):162-167.
9. Smith LL, Burnet SP, McNeil JD. Musculoskeletal manifestations of diabetes mellitus. Br J Sports Med. 2003;37(1):30-35.
10. Litaker D, Pioro M, El Bilbeisi H, Brems J. Returning to the bedside:using
the history and physical exam to identify rotator cuff tears. J Am Geriatr
Soc. 2000;48(12):1633-1637.
11. Cahill BR. Osteolysis of the distal part of the clavicle in male athletes.
J Bone Joint Surg Am. 1982;64(7):1053-1058.
12. Woodward TW, Best TM. The painful shoulder: part I. Clinical evaluation. Am Fam Physician. 2000;61(10):3079-3088.
13. Woodward TW, Best TM. The painful shoulder: part II. Acute and
chronic disorders. Am Fam Physician. 2000;61(11):3291-3300.
14. Stevenson JH, Trojian T. Evaluation of shoulder pain. J Fam Pract. 2002;
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15. Park HB, Yokota A, Gill HS, El Rassi G, McFarland EG. Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome. J Bone Joint Surg Am. 2005;87(7):1446-1455.
16. Walton J, Mahajan S, Paxinos A, et al. Diagnostic values of tests for acromioclavicular joint pain. J Bone Joint Surg Am. 2004;86-A(4):807-812.
17. Hertel R, Ballmer FT, Lombert SM, Gerber C. Lag signs in the diagnosis
of rotator cuff rupture. J Shoulder Elbow Surg. 1996;5(4):307-313.
18. Chronopoulos E, Kim TK, Park HB, Ashenbrenner D, McFarland EG.
Diagnostic value of physical tests for isolated chronic acromioclavicular
lesions. Am J Sports Med. 2004;32(3):655-661.
19. Farber AJ, Castillo R, Clough M, Bahk M, McFarland EG. Clinical assessment of three common tests for traumatic anterior shoulder instability.
J Bone Joint Surg Am. 2006;88(7):1467-1474.
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www.aafp.org/afp

Volume 77, Number 4

February 15, 2008