1. Shane Cass, DO UNM Sports Medicine
Chronic Shoulder pain
Shane Cass, DO
UNM Sports Medicine

2. Objectives
Provide a comprehensive case based review of shoulder pathology
Review clinically relevant anatomy
Synthesize a diagnosis and differential
Appropriately use relevant radiological studies
Provide a rational and useful treatment plan including

3. References
To get the most out of this module go to the link below. Here you’ll find great MSK articles by the AAFP.
AAFP MSK Modules
Also please click the link below to review a complete shoulder exam
Shoulder exam video

4. High yield articles for this module
Chronic Shoulder Pain I: Evaluation and Diagnosis
Chronic Shoulder Pain II: Treatment
Adhesive Capsulitis: A Review

5. Case AC Osteoarthritis
A 55 year old construction manager comes in with shoulder pain for years. He spent many years as a construction worker before moving to a manager position. He has pain at night and can pin point his area of maximum tenderness. There is pain with cross arm abduction and direct palpation to the AC joint. His x-ray is below.
AC Osteoarthritis

6. True or false
An x-ray showing osteoarthritis of the Acromio-Clavicular Joint is always diagnostic.
False
At years of age a large proportion of people will develop AC joint OA while being completely asymptomatic
TRUE or FALSE: Absence of pain at the AC joint is inconsistent with the diagnosis of AC osteoarthrosis.
True

7. Treatment Initially conservative; NSAIDS, activity modification.
CSI can be effective for short-term pain relief or for more severe disease
Surgery (distal clavicle resection) for those with little to no response to conservative treatment.
TRUE OR FALSE: Conservative treatment in most patients is usually effective.
False
There exists no good systematic reviews or meta-analysis comparing conservative treatment to operative. Go case by case.

8. What if…?
Our 55 year old construction worker’s wife, a 53 year old diabetic, is your next patient. She has been a career artist for the past twenty years as a painter. She presents with acute pain three weeks prior to her appointment and now with noted stiffness. Her ROM is restricted globally in all her planes of motion but her strength is preserved and 5/5. She has no systemic signs of illness.
What is her diagnosis?
A. Rotator Cuff Tear
B. Glenohumeral Osteoarthritis
C. Autoimmune Disease
D. Septic Joint
E. Adhesive Capsulitis

9. True or false
If she had severe ROM loss in all but one plane of motion (ie; in internal rotation) she could still possibly have adhesive capsulitis.
False
By definition, Adhesive Capsulitis is a global range of motion loss in all planes of motion. Normal range of motion in any plane should suggest another diagnosis.

10. Adhesive capsulitis
Presents at ages 40-70’s, more common in women and in diabetics.
Pathophysiology largely unknown but capsular hyperplasia and fibrosis found in biopsies.
3 stages…
1. Painful
2. Frozen
3. “Unthawing,” or recovery stage

11. Results from contraction of the glenohumeral joint capsule and adherence to the humeral head

12. Pain and stiffness don’t always follow distinct phases.
Natural history of Adhesive Casulitisis self limiting, but pain and decreased ROM may last 1-2 years.
10% of all patients will never recover full range of motion, but it usually isn’t functionally limiting.
Occurs with ROM loss, poorly localized deep ache, and with usually preserved rotator cuff strength

13. imaging Is MRI diagnositic? NO!
MRI can show capsular thickening, especially in the rotator cuff interval, but it is not diagnostic. Always go back to your patient and physical exam. If they have preserved ROM, it is NOT adhesive capsulitis
Plain films can be done to rule out other pathology

14. treatment
You advise the patient that expectant management is reasonable, as this is often self limited. However, she is in quite a bit of pain with loss of function and needs to get back to painting. She inquires about a corticosteroid injection.
What is true about treatment for Adhesive Capsulitis?
A. Subacromial bursa injections are ineffective.
B. Intra-articular injections provide signficant short term relief of pain
C. Manipulation under anesthesia is considered the gold standard non-operative treatment
D. Oral glucocorticoids work better than injections.
E. All of the above

15. treatment
Most cases resolve spontaneously in 1-2 years. Some range of motion loss may be chronic but is usually not functional.
Treatment directed at symptoms
Initially activity modification, NSAIDS and PT for stretching
If no or slow progress after 6 weeks, consider intra-articular CSI. Thought to be helpful due to capsular distention, so may consider guided injections (fluoroscopy or ultrasound)
Subacromial Bursal injections may help if concomitant rotator cuff issues
Surgery rarely needed. Refer after 6-12 months of conservative treatment (manipulation under anesthesia versus a capsular release)

16. X-rays are obtained for our patient with suspected adhesive capsulitis
Glenohumeral Osteoarthritis

17. Yes or no: Could osteoarthritis be our patient’s diagnosis?
A. Yes. The loss of motion, pain and disability are concurrent with this diagnosis.
B. No. OA of the GH joint involves a progressive loss of motion with worsening activity related pain
The typical presenting symptom of GH OA is progressive, activity-related pain that is deep in the joint and often localized posteriorly
Conservative treatment involves activity modification, tylenol, NSAIDS and an intra- articular CSI if no benefits from other treatments. Trial of PT, but be careful of too aggressive therapy in these patients.
Surgery includes total or partial hemiarthroplasty, debridement and capsular release, and corrective osteotomies

18. Primary and secondary causes
Primary Shoulder OA is most prevalent

19. True or false Post-op total shoulder arthroplasty
Surgery is the gold standard treatment for osteoarthritis of the glenohumeral joint
FALSE: There are no randomized controlled trials comparing conservative and surgical outcomes.
Treatment should be tailored to the patient
Post-op total shoulder arthroplasty

20. Significant burden to society
Arthritis and chronic joint disease affects 1 out of 3 adults, making it the most widespread disease in America.
For a more in depth review of Shoulder OA, check out this link
Shoulder Osteoarthritis

21. What if… The x-rays on our first patient were below
Calcific Tendonosis

22. Rotator cuff syndrome/pathology
This x-ray demonstrates one of the most common causes of shoulder pathology and represents a spectrum of disease known as rotator cuff syndrome
Encompasses rotator cuff partial or complete tears, tendinosis, calcific tendinosis and sometimes biceps pathology
It is more important to recognize that the cause of pain falls into this group than determine the actual diagnosis.

23. treatment
A step wise approach with medication management, activity modification, physical therapy and subacromial bursa corticosteroid injections can be used to manage the pain in most patients.
Surgical options exist for those without benefits from conservative treatment
Rotator Cuff Repair
Biceps Tenotomy
Subacromial Bursectomy and acromioplasty

24. chronic shoulder pain review

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