Differential diagnosis of

Shoulder Region
ANATOMY OF SHOULDER
Bony Anatomy
“Static Stabilizers”

1/3 -
1/4

Diameter:  9 mm
 5 mm
LABRUM
The Rotator Cuff Muscles: SITS
Teres minor ER
Supraspinatus ABD
Supscapularis IR
Infraspinatus ER

Depress humeral head against glenoid to allow full abduction

Other Anatomy
Latissimus dorsi
Biceps
Deltoid
Rotator cuff Pectoralis muscles
Teres major
 Force couple…deltoid rotator cuff force
couple
Two opposing muscular forces working togather to enable a
particular motion to occur, with these muscular forces being
synergists or agonists/antagonist pair.
Deltoid apply superiorly directed force during arm elvation.
RC must provide compressive and inferiorly directed force to
avoid impingement of RC against acromion and to minimize
superior migration.
Innervation of the RC
Supraspinatus: suprascapula nerve C4, C5, C6

Infraspinatus: suprascapula nerve C5, C6

Subscapularis: Upper and lower subscapular nerve C5,

C6, C7

Teres Minor: Axillary nerve C5, C6

Quick Review of Terminology
Flexion/extension

•IR/ER

•Abduction/ Adduction

•H.add/H.abd
Extrinsic shoulder pain causes
LEFT RIGHT BL
MI MI Body of pancreas
Ruptured spleen Gall bladder Pulmonary
Tail of pancreas Liver IHD
Left renal colic Right colic BL kidney
Left RT.
diaphragmatic diaphragmatic
dysfunction dysfunction
Ectopic
pregnancy Peptic ulcer
 Mechanism of Referred shoulder pain
• Mutisegmental innervation…C3-C5 same for shoulder and
diaphragm
Diaphragmatic irritation:
Irritation of the peritoneal (outside) or pleural (inside) surface
of the central part diaphragm dome refers sharp pain to the
ipsilateral upper trapezius, neck and/or supraclavicular fossa
and posterior portions of the shoulder.
Irritation of the peripheral portion of the diaphragm is more
likely to refer pain to the costal margins and lumbar region on
the same side.
Irritation across midline produces BL symptoms.
Source?

Shoulder pain relieved by Autosplinting?

Shoulder symptoms made worse by recumbency??

Shoulder pain with dyspnea?

Pulmo causes of shoulder pain
Pulmonary embolism
Pulmonary tuberculosis
Spontaneous pneumothorax
lung abscess
Pancoast's tumor
Pneumonia
 SCREENING FOR PULMONARY
CAUSES OF SHOULDER PAIN
Pain occurs after involvement of parietal pleura.
Pleural irritation then results in sharp, localized pain that is
aggravated by any respiratory movement.
Pneumonia causes direct pressure on diaphragm.
look for the presence of persistent or productive cough
and/or chest pain,tachypnea, dyspnea, wheezing,
hyperventilation along with shoulder pain
Chest auscultation is a valuable tool when screening for
pulmonary involvement.
Source?
Exacerbation of the shoulder symptoms when the
client increases activity like walking up stairs or riding
a stationary bicycle???
Cardiovascular causes of shoulder pain
Angina/myocardial infarct
Dissecting aortic aneurysm
Bacterial endocarditis
Pericarditis
TOS
Angina/ MI
Look for shoulder pain that starts 3 to 5 minutes after
the start of activity
presence of nausea, unexplained sweating, jaw pain or
toothache, back pain, or chest discomfort or pressure.

If the client has known angina and takes nitroglycerin,

ask about the influence of the nitroglycerin on
shoulder pain.
MI…pain is unrelieved by position change, breathing or
movements.

DD of shoulder pain from MI: by the pattern of relieving and

aggravating factors??
Aortic aneurysm
sudden, severe chest pain with a tearing sensation and
the pain may extend to the neck, shoulders, lower
back, or abdomen but rarely to the joints and arms.
Isolated shoulder pain is not associated with aortic
aneurysm
 Bacterial Endocarditis
Inflammation of cardiac endothelium & damage the tricuspid , aortic ,
mitral valve.
Bacterial

Injection drug users and Post cardiac surgical clients …. High risk
Can be consequences of renal shunt ,urinary catheter , dental treatment.

The most common musculoskeletal symptom in clients with bacterial

endocarditis is arthralgia, generally in the proximal joints. The shoulder
is affected most often, followed (in declining incidence) by the knee,
hip, wrist, ankle, metatarsophalangeal and metacarpophalangeal joints,
and by acromioclavicular involvement.

Warmth ,tenderness ,redness but NO morning stiffness..D/D from RA.

Thoracic Outlet Syndrome
Compression of the neurovascular bundle consisting
of the lower brachial plexus and subclavian artery and
vein can cause a variety of symptoms affecting the arm,
hand, shoulder girdle, neck, and chest.
Source?
Shoulder pain increased after taking NSAID?

associated signs and symptoms such as nausea,

vomiting, anorexia, melena?

effect of eating on shoulder pain?

GASTROINTESTINAL CAUSES
Peptic ulcer
gallbladder disease
hiatal hernia
LIVER AND BILIARY CAUSES
liver, gallbladder, and common bile duct
Midback, scapular, and right shoulder regions
can occur alone or in combination with other systemic
signs and symptoms.
shoulder pain caused by hepatic and biliary diseases
may in turn create biomechanical changes in muscular
contractions and shoulder movement.
Source?
Constant , progressive and night pain in shoulder
along with fever and chills?
 INFECTIOUS CAUSES
Osteomyelitis (bone infection) …Staphylococcus aureus.

Hematogenous spread from a wound, abscess, or systemic

infection (e.g., tuberculosis, urinary tract infection, upper
respiratory infection) occurs most often.
Osteomyelitis of the spine is associated with injection drug
use.
Source?
Constant , progressive and night pain in shoulder
along with weight loss?
 ONCOLOGIC CAUSES
Primary Bone Neoplasm
Pulmonary (Secondary) Neoplasm
Breast cancer
Pancoast's Tumor:
lung apex
Shoulder pain occurs if they extend into the surrounding
structures, infiltrating the chest wall into the axilla.
Occasionally, brachial plexus involvement (eighth cervical
and first thoracic nerve) presents with radiculopathy.
GYNECOLOGIC CAUSES
Shoulder pain as a result of gynecologic conditions is
uncommon, but still very possible
Normal pregnancy
Many of the breast conditions(e.g., tumors,
infections, myalgias, implants, lymph disease, trauma)
can refer pain to the shoulder either alone or in
conjunction with chest and/or breast pain.

Ectopic Pregnancy
So…what are musculoskeletal causes
shoulder pain?
 Intrinsic shoulder pain causes
•Impingement syndrome/rotator cuff 48%–85%
tendinitis (includes full and partial
tears)
•Calcific tendinitis 6%
•Rotator cuff tear
•Biceps tendinitis
•Glenohumeral instability
•Acromioclavicular syndromes
•Frozen shoulder/capsulitis 16%–22%
•Glenoid labrum tear
•Inflammatory arthritis including
rheumatoid,
•crystal-associated, reactive, etc
•Infection of joint or soft tissues
•Osteoarthritis
•Polymyalgia rheumatica
•Osteonecrosis
Pain on the tip of shoulder
Sudden history of trauma or
Gradual pain due to degenerative disease
Positive cross over test

Possible diagnosis?
Acromioclavicular syndrome
Mechanism of Injury
 Direct impact to the anterior - superior shoulder
of moderate – high force.
1. Fall from height
2. Motor vehicle accident
3. Sports injury
4. Blow to the point of the shoulder
5. Rarely, a direct injury to the clavicle
Mechanism of Injury
Acromioclavicular (A-C) Sprain
Damage to A-C joint
ligaments
Pain and/or deformity
over A-C joint
Graded I-VI
I-III usually treated non-
operatively
IV-VI referred to
orthopedic surgery
AC joint:
Crossover Test
Patient raises
affected arm to 90°
Actively adducts
arm across body
Forces acromion
into distal end of
clavicle
Isolates AC joint &
painful if positive
 A-C Shear Test
Interlock fingers with
hand on distal clavicle
and spine of scapula
Pain in A-C joint when
hands squeezed
together = (+) test
Case #2
24-year-old male
handball player
Fell onto his shoulder
after being pushed, arm in
position of abduction and
external rotation
Intense pain
Hand is tingling and arm
feels like it’s hanging
X RAYS

DIAGNOSIS???
common type of shoulder dislocation,
accounting for more than 95% of cases
 Anterior Shoulder
Subluxation/Dislocation
 Instability
Instabilities may be caused by either static or
dynamic factors.
Dynamic factors occur primarily as a result of
rotator cuff weakness
static factors include damage to the anterior
capsule and glenohumeral ligament and glenoid
labrum.
Shoulder instabilities may be classified as
traumatic, atraumatic, or acquired
Traumatic patients exhibit
Unilateral/Unidirectional instabilities, and usually
require Surgery to stabilize the shoulder joint
The second type of patient is the Atraumatic,
Multidirectional unstable patient, usually
Bilaterally involved, in whom Rehabilitation is the
first line of defense; if conservative treatment fails,
then an Inferior capsular shift procedure is
performed, which tightens the inferior capsule
Anterior Shoulder
Subluxation/Dislocation
Anterior Shoulder Subluxation/Dislocation
Mechanism:
Forced extension, abduction, external rotation
Direct blow to posterior or posterolateral shoulder
Repeated episodes of overuse (subluxation)
Anterior Shoulder Subluxation/Dislocation
Physical Exam:
Intense pain
Arm held in abduction & external rotation
Humeral head palpable anteriorly
Unable to completely internally rotate or abduct
the shoulder
Thorough neuro exam (close relation of axillary
nerve)
Anterior Instability Testing:
Apprehension Test
Supine, sitting or
standing
Arm abducted to 90°
Apply slight anterior
pressure & slowly
externally rotate
Apprehension may
indicate anterior
instability
Pain w/out
apprehension is more
likely impingement
Anterior Shoulder Dislocation
Stimson maneuver
Anterior Shoulder Dislocation
Prompt reduction
Many different
methods of
reduction

Traction-
countertraction
Posterior Instability
Mechanism of injury Posterior Apprehension Test

 Supine or sitting
 Arm in 90° abduction, 90° elbow
flexion
 Apply posteriorly directed force in
attempt to displace humeral head
posteriorly
Inferior dislocation
Inferior Instability Testing:
Sulcus Sign
Arm in neutral position
Pull downward on elbow
or wrist
Observe for depression
lateral or inferior to
acromion
Positive if > 1 cm
Indicates inferior
instability
Compare to other side
35 year old tennis player
complaining of pain in Lateral
brachial region. His Shoulder pain
developed gradualy over an year &
is exacerbated by practicing serves
and Sharp twinges felt on various
movements, such as abduction,
putting on jacket, or reaching above
shoulder level. Relatively full range
of motion is present & Often a
painful arc is present at midrange of
abduction. What is likely diagnosis?
Impingement Syndrome
It primarily involves the
coracoacromial arch
introducing on the rotator
cuff, subacromial bursa, or
biceps tendon
the mechanical-anatomic
theory;
the vascular compromise theory;
kinesiological factors that limit
scapular rotation or promote
uncoordinated muscular
activity.
the mechanical-anatomic theory, recognizes three
stages of the syndrome:
(1) a benign, self-limiting, overuse syndrome,
(2) the development of thickening and fibrosis
followed by repeated episodes of the first stage
(3) development of bony changes, including spurs
leading to possible complications such as rotator
cuff tears
Tendinitis at the shoulder is common. It occurs in
young active persons as well as in older persons
In younger ones it may be caused by activities
such as tennis, racquetball, or baseball 'which
increase the stress levels to the rotator cuff
tendons
In the older person it is more likely to be a
degenerative lesion.
Because of the relatively poor blood supply near
the insertion
The body may react by laying down scar tissue or
calcific deposits. Such calcific deposits may be
visible on radiographs; however, they are often
seen in the absence of symptoms and, conversely,
they are not always present in known cases of
tendinitis. Superficial migration of these deposits
with rupture into the underside of the subdeltoid
bursa is thought to be a major cause of acute
bursitis at the shoulder
Because of the poor blood supply to the region,
adequate repair may not occur, and the lesion may
develop into an actual tear in the tendon.
The degenerative lesions tend to be persistent
The combined effects of poor blood flow and
continued stress to the tendon do not allow for
adequate maturation of the healing tissue.
Such weakening would predispose to subacromial
impingement during elevation of the arm and
further mechanical irritation to the site of the
lesion.
Rotator Cuff Impingement/Tendinitis
Predisposing factors:
Repetitive motion of shoulder above horizontal plane
(swimming, throwing, golf, tennis, etc.)
Fatigue of rotator cuff  abnormal shoulder mechanics
Subtle instability resulting in 2° impingement
AC joint spurring/hypertrophy
Rotator Cuff Impingement/Tendinitis
History:
Pain referred to anterolateral aspect of shoulder w/
some radiation (not beyond elbow)
Aggravated w/ overhead activities
Night pain
Clicking or popping sensation
Rotator Cuff Impingement/Tendinitis
Physical Exam:
Possible atrophy of supra- & infraspinatus

Tenderness over greater tuberosity & long head of biceps

 range of motion 2° to pain

Painful arc within 70° to 120° abduction

Impingement
Impingement Signs:
Neer’s Test
Scapula stabilized
Arm fully pronated
Examiner brings
shoulder into
maximal forward
flexion
Pain 
subacromial
impingement
Impingement Signs:
Hawkins’ Test
Patient’s arm
forward flexed to 90°
Elbow flexed to 90°
Shoulder forcibly
internally rotated by
examiner
Pain  subacromial
impingement or
rotator cuff
tendinitis
40-year-old male

Recently shoveled 16”

of snow

Can hardly lift left arm

due to pain

Special Tests?
Diagnosis?
Biceps Tendonopathy
Speed Test

Yergason Test
Direct palpation
Biceps Tendonopathies
Repetitive overhead activity

Repetitive forearm
flexion/supination

Difficult to discern from

rotator cuff tendinopathy or
impingement
Case #
45-year-old weight lifter
Caught bar as it was falling
off his shoulder
Sudden pain
Severe weakness left
shoulder
Worse with overhead
activities; while sleeping at
night
Pain in anterior lateral
shoulder
Special tests?
Case # 5
Drop Arm Test Positive

Weakness with Empty Can

Sign

Normal bear hug and belly

press tests…

Diagnosis?????
Physical Exam
Strength of Subscapularis

Liftoff test Belly press test

Rotator Cuff Tear
Supraspinatus tendon most common

Acute trauma or chronic tendinopathy

Treatment dependent upon age/activity

Young, active usually require operative treatment
Older, low-activity usually respond to non-operative
treatment
Rotator Cuff sign:
Drop Arm Test
Passively abduct patient’s
shoulder
Observe as patient slowly
lowers arm to waist
If arm drops to patient’s
side, suggests rotator cuff
tear &/or supraspinatus
dysfunction
 Adhesive Capsulitis (Frozen Shoulder)
Capsular tightening at the shoulder, is usually
referred to as frozen shoulder or adhesive
capsulitis.
no specific cause can be determined for the
stiffening.
It affects women more often than men, and
middle-aged and older persons more often than
younger persons
It result from an alteration in scapulohumeral
alignment, as occurs with thoracic kyphosis and
women are also more predisposed to developing
thoracic kyphosis than men.
Patient first notices that it is difficult to comb hair
awakened at night when rolling onto the affected
side.
difficulty reaching into the hip pocket
these patients do not seek medical help until the
shoulder has lost about 90° abduction, 60° flexion,
60° external rotation, and 45° internal rotation.


Conditions that might result in capsular tightness at

the glenohumeral joint include:
Degenerative joint.
Rheumatoid arthritis
Immobilization-For example, following fracture of the arm,
forearm, or wrist, or dislocation of the shoulder
Reflex sympathetic dystrophy

Radiographs:
Routine x-rays usually normal
Arthrogram may show  joint volume
 DEGENERATIVE JOINT DISEASE OF THE
SHOULDER
Osteoarthritis of the glenohumeral joint is
uncommon, and patients with rheumatoid
arthritis can most often be managed
nonoperatively with regard to the shoulder.
It may develop after fracture of the proximal
humerus
in a younger active patient with degenerative
arthritis, joint sepsis, or loss of deltoid and rotator
cuff function
Cervical Spine:
Spurling’s Maneuver
Neck extended
Head rotated toward
affected shoulder
Axial load placed on
the spine
Reproduction of
patient’s
shoulder/arm pain
indicate possible
nerve root
compression
Onset of pain
Sudden?
trauma, tendon tears, infection, or serious acute
referred pain (eg, acute cardiac disease, ectopic
pregnancy).

Gradual:
chronic condition such as osteoarthritis or
impingement syndrome.
H/o trauma/fall
Fracture (glenohumeral, clavicular, scapular)
AC joint separation
Rotator cuff tear
Labral tear
Transient brachial plexopathy (“stinger”)
location of pain

 Anterolateral or lateral:
 impingement syndrome, which may be due to subacromial bursitis, rotator
cuff tendinopathy, rotator cuff tear, frozen shoulder, or a combination of these.
 Anterior pain:
 AC joint disease or biceps tendinitis.
 Posterior shoulder pain:
 less common and often refers to osteoarthritis or rotator cuff tendinopathy
involving the teres minor or infraspinatus.
 Superior pain:
 is often referred from the neck (ie, cervical strain or radiculopathy). AC joint
disease can also cause pain on the top of the shoulder.
 Poorly localized pain:
 often is due to extrinsic causes, but labral tears sometimes have deep poorly
localized pain.
Nature of pain
Radiating pain:
Tingling,numbness, sharp shooting pain, or burning
pain suggests neuropathic pain from cervical disease
or cervical radiculopathy

Dull aching:
impingement or rotator cuff tendinopathy..
 Aggerevating factors
Anterolateral or deltoid pain exacerbated by forward elevation of
the shoulder:
impingement/rotator cuff tendinopathy.
Pain in all planes of motion:
frozen shoulder, glenohumeral, osteoarthritis, infection, or
polymyalgia rheumatica.
Pain with flexion of the biceps (eg, lifting a bag of groceries) or
supination of the wrist:
biceps tendonitis.
Pain with flexion of arm across the front of the body:
AC joint disease.
If the pain is not associated with movement:
strongly consider referred pain.
 Aggerevating & associated factors
 reaching over your head aggravate pain:
 impingement syndrome.
 night pain or difficulty sleeping on the affected side?:
Impingement syndrome, frozen shoulder, major rotator cuff tear, or infection.
 other joints ? Bilateral shoulder pain and stiffness :
 polymyalgia rheumatica.
 Multiple joint involvement :
 osteoarthritis or systemic arthritis (eg, RA, crystal arthropathy, or diffuse
osteoarthritis).
 associated with fever, night sweats, or weight loss:
 Referred pain from the chest or abdomen A systemic disorder, especially polymyalgia
rheumatica or neoplasm Septic arthritis
 stiffness relieved by activity and worsened by rest?(gelling):
 Polymyalgia rheumatica or RA
 stiffness in the morning lasting greater than 60 minutes that improves with activity?
(morning stiffness):
 Is shoulder constantly stiff?
 Frozen shoulder
 high doses of glucocorticoids?
 Osteonecrosis
 Weak shoulder ?
 Large rotator cuff tear, Cervical radiculopathy or brachial
plexopathy
 arms feel weak? numbness, tingling, a sensation of burning, or a
pins and needles sensation?
 Cervical radiculopathy or brachial plexopathy
 shoulder unstable? Does it slip or “pop out”?
 Glenohumeral instability
 Does your shoulder catch or lock?
 Labral tear, Loose body in glenohumeral joint
Case study
A 62-year-old man comes to your office to discuss his selfdiagnosed
right “shoulder bursitis” of 6 months’ duration. The aching pain began
insidiously and has worsened over time. The pain is exacerbated by
painting (on an easel) and not relieved by acetaminophen or ibuprofen.

ADDITIONAL HISTORY

The patient has never experienced this pain before, nor does he recall
trauma to the shoulder. The pain is a dull ache over the deltoid muscle
without burning or numbness. The pain is relieved by rest and
exacerbated by overhead activities. He is otherwise healthy and works
as an accountant. He notes no discomfort with internal and external
rotation
or adduction of the shoulder. He denies swelling, morning
stiffness, fever, chills, weight loss, or a history of problems
with other joints or of arthritis. He is concerned that he will no
longer be able to paint because of the pain he experiences
while painting on the easel.

What is the most likely diagnosis?

A. Referred pain from the cervical spine
B. Rotator cuff tendinopathy
C. Acromioclavicular osteoarthritis
D. Frozen shoulder
What is the most likely diagnosis?

A 67-year-old postal supervisor comes to your office saying,

“Doctor, I think I have arthritis.” He reports intermittent left
shoulder pain gradually worsening over the past 6 months.
The pain occurs when he walks up the hill to the bus stop in
the morning and has been occurring earlier on the ascent over
time and more frequently with cold weather. It is unaffected
by arm movement and relieved by resting for 5 minutes.

A. Rotator cuff tendinopathy

B. Frozen shoulder
C. Referred pain
D. Osteoarthritis
 A 50-year-old chief financial officer comes in with a refractory
shoulder pain that has worsened gradually over the past year. He
points to his anterior shoulder to localize the pain. He is an avid
weightlifter, and the pain occurs with any motion of the shoulder.
Which of the following is most compatible with a diagnosis of
acromioclavicular osteoarthritis?
A. Pain exacerbated by horizontal cross-body adduction
B. Pain when lifting his arm above his head
C. Fear the shoulder will “pop” on external rotation and
abduction of the shoulder
D. Pain radiating into the neck
E. Unrelenting pain all day and night
A 48-year-old diabetic woman notes a 3-week history of deep
aching pain in the shoulder without swelling, chills, or fever.
It is restricting her ability to put on a jacket and hook her bra.

Which of the following suggests a frozen shoulder?

A. Global pain and loss of range of motion in all directions

B. Swelling of the shoulder
C. Morning stiffness lasting 60 minutes
D. Pain mainly with overhead activities
E. Swelling and pitting edema of the ipsilateral hand
Thanks