REVIEW Clinical evaluation of nonarthritic shoulder pain: diagnosis and treatment Robert E. Holmes 1 , William R. Barfield 1,2 & Shane K. Woolf 1 1 Department of Orthopaedics, Medical University of South Carolina, Charleston, SC, USA, and 2 Department of Health and Human Performance, Charleston, SC, USA Abstract Shoulder pain and dysfunction is a complex problem frequently encountered by primary care physicians. Common nonarthritic conditions seen in the primary care setting include rotator cuff syndrome, impingement, posttraumatic stiffness, adhesive capsulitis, and instability. A thorough history and physical examination can aid in the diagnosis of many common shoulder complaints. Pain and instability are the most common shoulder complaints. Pain that is sharp or burning is commonly radicular in origin, whereas pain caused by tendinitis is often dull, diffuse, and aching. Instability is frequently found in patients with a history of dislocation, but also may occur with no prior history. Imaging modalities such as magnetic resonance imaging can be helpful for more advanced pathology. However, many common shoulder conditions can be diagnosed without imaging, and may be initially treated with a short course of rest, ice, topical analgesics, nonsteroi- dal anti-inflammatory drugs, directed and supervised physical therapy, and occasionally subacro- mial corticosteroid injections. As always, a detailed history and a thorough physical exam by a primary care physician are vital for diagnosis. When conservative measures fail, referral to an orthopaedic surgeon may be necessary for further patient management. Keywords: Repetitive overhead arm activity, shoulder dysfunction, shoulder instability, shoulder pain History Received 26 February 2014 Accepted 14 April 2014 Published online 24 January 2015 Introduction The shoulder complex, specifically the glenohumeral, acro- mioclavicular, and scapulothoracic joints, can be injured in various ways including macrotrauma, attritional changes, and repetitive motion. Successful treatment of pathology involving the shoulder joint and the surrounding soft tissues demands an accurate diagnosis. Information gathered from the patient’s history of present illness, past medical history, family history, and the physical examination, based on specific complaints, facilitate arriving at a working diagnosis. The physician must be cautious, in the early stages of diagnosis, not to overlook important factors that could contribute to the patient’s shoulder problem. For example, the mechanism of injury; the onset and timing of pain, weakness, stiffness, and instability; and medical issues, such as diabetes, all must be ascertained. The patient’s lifestyle, vocation, and functional demands on the shoulder must also be considered. Treatment of shoulder pain experienced by a home ambulator may be different from that of a high-demand overhead arm athlete [1]. Among musculoskeletal complaints, shoulder pain is the third most common presenting to primary care physicians [2] and, according to a systematic review from 2004, shoulder pain affects between 7 and 26% of adults [3]. Of shoulder pain complaints, rotator cuff pathology accounts for > 60% of patient visits. Subacromial impingement syndrome is a multifactorial associated diagnosis that is often the result of kinesthetic dysfunction [4]. Normally the humeral head should remain within a few millimeters of the center of the glenoid fossa during activities that involve humeral move- ment. As the magnitude of loading increases, dyskinetic movement of the humeral head with respect to the glenoid, particularly superiorly and anteriorly, increases injury risk to surrounding structures such as the rotator cuff and biceps bra- chii. For instance, as the humeral head moves superiorly, there may be impingement between the anterior or lateral edge of the acromion and the humeral head, placing the rota- tor cuff at risk [5]. Factors other than impingement that can lead to shoulder pain complaints include capsular soft tissue imbalance, long-head biceps pathology, acromioclavicular arthritis, and radicular pain from cervical spine pathology [6]. Common factors in shoulder pain symptoms are listed in Table 1. Materials and methods This article presents a logical approach to the patient with nonarthritic shoulder pain. One of the authors (SKW) is a board-certified sports medicine physician at a large academic medical center with extensive experience in treating pathol- ogy of the shoulder. The authors reviewed the best available evidence to recommend the following approach to the workup and diagnosis of nonarthritic shoulder pain. Patient clinical presentation Shoulder issues present temporally in 1 of 3 ways: acute, chronic, and acute-on-chronic. Acute presentation is typically the result of a traumatic event such as a fall in a middle-aged Correspondence: Robert E. Holmes, MD, Department of Orthopaedics, Medical University of South Carolina, 96 Jonathan Lucas Street, Suite 708, Charleston, SC 29425, USA. E-mail: holmesre@musc.edu http://informahealthcare.com/psm ISSN: 0091-3847 (print), (electronic) Phys Sportsmed, 2015; Early Online: 1–7 Ó 2015 Informa UK, Ltd. DOI: 10.1080/00913847.2015.1005542 The Physician and Sportsmedicine Downloaded from informahealthcare.com by University of Cincinnati on 02/24/15 For personal use only.