1. Painful Shoulder

2. Normal Anatomy

3. Definition
Shoulder pain involves any pain in or around the shoulder joint.
Considerations 
The shoulder is the most mobile joint in the
human body. The joint includes four tendons.
The purpose of a tendon is
to hold muscle to bone. Together,
these four "rotator cuff" tendons
stabilize the upper arm bone to the
shoulder socket and allow a wide
range of motion in the shoulder.

4. Mechanism of the pain
Any swelling, inflammation, tearing, or bony changes around these tendons causes pain when a person tries to move the arm above the head, behind the back, or straight out in front.

5. Reasons beyond that pain
Because of its high level of mobility, the shoulder has heavy reliance on the muscles around the shoulder to act as dynamic stabilisers during movement of the arm. Dysfunction of the stabilising mechanics, either at the shoulder joint itself or around the shoulder blade, combined with or without abnormalities in the anatomical arrangement of the structures around the joint, or biomechanical faults make the shoulder particularly prone to pain and injury.

6. How common are these conditions?
Around 11 patients out every 1000 visit their GPs with shoulder complaints each year.

7. Most Common Causes: Frozen Shoulder. (Idiopathic Adhesive Capsulitis).
Painful Arc Syndrome.

8. Frozen shoulder
Frozen shoulder is clinical syndrome charachterized by gross restriction of shoulder movement associated with contraction and thickening of the joint capsule.affect middle age.
Also associated with severe pain disturb sleeping,
There is frequently history of a minor trauma lead to shoulder cuff tearing, initiating prolonged inflammatory changes and contraction of shoulder cuff responsible of symptoms.
If there is no improvement with appropriate treatment for 4 monthes , manipulation of the shoulder under general anasthesia.

9. Other Causes
Bursitis / Rotator Cuff Tendonitis The most common diagnosis in patients with shoulder pain is bursitis or tendonitis of the rotator cuff.
Rotator Cuff Tear Rotator cuff tears occur when the tendons of the rotator cuff separate from the bone. Surgery is sometimes necessary for this condition.
Calcific Tendonitis Calcific tendonitis is a condition of calcium deposits within a tendon -- most commonly within the rotator cuff tendons. Treatment of calcific tendonitis depends on the extent of symptoms.

10. Shoulder Instability Instability is a problem that causes a loose joint. Instability can be caused by a traumatic injury (dislocation), or may be a developed condition.
Shoulder Dislocation A dislocation is an injury that occurs when the top of the arm bone becomes disconnected from the scapula.
Shoulder Separation Also called an AC separation, these injuries are the result of a disruption of the acromioclavicular joint. This is a very different injury from a dislocation!
Labral Tear A Bankart lesion is a type of labral tear most commonly due to dislocation of the joint. Bankart lesions cause problems of persistent instability.

11. SLAP Lesion The SLAP lesion is also a type of labral tear
SLAP Lesion The SLAP lesion is also a type of labral tear. The most common cause is a fall onto an outstretched hand.
Arthritis Shoulder arthritis is less common than knee and hip arthritis, but when severe may require a joint replacement surgery.
Biceps Tendon Rupture A proximal biceps tendon rupture occurs when the tendon of the biceps muscle ruptures near the joint.

12. Referred shoulder pain
Whiplash
Fractured humerus
Ruptured bicep tendon
Disc conditions
Thoracic outlet syndrome
Ectopic pregnancy
Diaphragm irritation
Diaphragm conditions
Liver abscess
Referred gallbladder pain

13. Referred shoulder pain
Gallbladder conditions - usually right shoulder pain.
Gallstones
Cholangitis
Cholecystitis
Internal bleeding (see Bleeding symptoms) - often causing shoulder-tip pain
Referred heart pain
Angina
Heart attack
Polymyalgia rheumatica

14. Diagnosis
Determining the source of the problem in the shoulder is essential to recommending the right method of treatment.
The first step is a thorough medical history.
Next, perform a physical examination including the movements

15. Shoulder movements

16. Investigation: Plain X-ray of the shoulder: - Antro-posterior.
- Lateral.
CT.Scan; provides a more detailed view of the shoulder area
MRI and ultrasound are other valuable diagnostic tools because they provide images of the soft tissues without using radiation .
Special investigations.

17. If you suspect infections :
WBC Blood culture
Chest x-ray Aspiration of joint
EMG (electromyogram), which can indicate nerve damage
an arthrogram, an X-ray study in which dye is injected into the shoulder to allow the orthopaedist to better see the joint and its surrounding muscles and tendons
Arthroscopy : is a surgical procedure in which the orthopaedist looks inside the joint with a lighted telescope. It is sometimes used to diagnose causes of shoulder pain and indicate soft tissue injuries that are not apparent in the physical examination, X-rays and other tests.

18. Normal Antro-posterior view

19. Normal Lateral View

20. Treatment It depends entirely on the cause of the problem.
Shoulder Pain Treatment Basics :
Rest:
The first treatment for many common conditions is to rest the joint, and allow the acute inflammation to subside.
Acute rotator cuff tears require immobilization in a sling. But It is important to use caution when resting the joint, because prolonged immobilization can cause a frozen shoulder.
Ice and Heat Application:
Ice packs and heat pads are among the most commonly used treatments for shoulder pain.

21. Stretching: Stretching the muscles and tendons that surround the joint can help with some causes of shoulder pain.
Physical Therapy: Physical therapy is an important aspect of treatment of almost all orthopedic conditions. Physical therapists use different modalities to increase strength, regain mobility, and help return patients to their pre-injury level of activity. Some specific exercises may help you stregthen the muscles around the joint and relieve some of the pain associated with many conditions.

22. Treatment Medications :
Anti-Inflammatory Medication
Cortisone injections

23. Common Causes of Pain and Dysfunction of the Shoulder
rotator cuff strains/tears
rotator cuff tendinitis
glenohumeral (shoulder joint) instability
glenohumeral dislocation/subluxation
acromioclavicular joint injury
fractures of the clavicle (collar bone), or scapula (shoulder blade)
adhesive capsulitis (frozen shoulder)
biceps tendinitis
referred pain from the cervical or thoracic spine
referred pain from soft tissues
nerve entrapments (eg suprascapular, long thoracic) or brachial plexus injury
levator scapula syndrome

24. Prevention
If you have had shoulder pain in the past, use ice and ibuprofen after exercising.
Learn proper exercises to stretch and strengthen your rotator cuff tendons and shoulder muscles. A doctor or physical therapist can help.

25. If you are recovering from tendinitis, continue to perform range-of-motion exercises to avoid "frozen shoulder."
In sports-related activities, learn proper technique to prevent painful and expensive shoulder problems.

26. References Clinical Orthopaedic Examination McRae
AAOS: American Academy of Orthopaedic Surgeons
Essential orthopedics and trauma