ArticleLiterature Review

Shoulder pain.

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Abstract

Shoulder pain is common in general practice and is a condition that frequently becomes chronic. Presentation includes either pain, weakness and stiffness, or a combination of these symptoms. This article presents a systematic approach to diagnosing and managing disorders of the shoulder joint and surrounding structures. Thorough history taking (including psychosocial aspects) and skilled examination are essential; special investigations rarely affect the general practitioner's management of shoulder pain. The tendency toward chronicity of shoulder pain (increased by certain biological and psychosocial risks) means that the clinician should adopt a patient centred approach in choosing from a wide range of treatment modalities.

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... Shoulder pain is a common presentation in general practice, with approximately 1% of adults visiting their doctors regarding new shoulder pain annually [2]. Shoulder complaints include rotator cuff dysfunction and tears, scapulothoracic dysfunction, adhesive capsulitis, glenohumeral instability, arthritis and fractures. ...
... More recent evidence has proposed that quadrilateral space syndrome is a clinically distinct syndrome to isolated teres minor atrophy. The two syndromes differ in expected age ranges, clinical presentations and frequency, quadrilateral space syndrome being a rarer condition typically seen in younger patients while isolated teres minor atrophy is a condition of elderly patients [2,3,15]. The clinical presentation of teres minor atrophy is variable, generally related to pain and instability, but not associated with paraesthesia or quadrilateral space point tenderness as in quadrilateral space syndrome [13]. ...
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Teres minor atrophy occurs either in isolation, associated with other rotator cuff muscle pathologies or in quadrilateral space syndrome. In the latter condition, compression of the axillary nerve is the likely cause; however, the anatomy of the nerve to teres minor and how this may relate to isolated teres minor atrophy have not been extensively investigated. In light of the significance of teres minor atrophy in shoulder pathology, we performed a combined radiological and anatomical study of teres minor and its nerve supply. Cadaveric dissection of nine shoulder specimens from eight cadavers was performed to investigate the anatomical variability in course, length and branching pattern of both the teres minor nerve and the axillary nerve. Radiological imaging and reports were analysed on all shoulder magnetic resonance images performed over a 1-week period at four radiology clinic locations in an attempt to identify the incidence of isolated teres minor atrophy and review teres minor atrophy in association with other shoulder pathology. Finally, we studied a case of isolated teres minor atrophy identified during a routine undergraduate dissection class. Considerable anatomical variation was noticed in cadaver dissections in the nerve(s) supplying teres minor muscle revealing several various points where it may be vulnerable to impingement or injury at along its course. Analysis of 61 shoulder MR images revealed two patients with shoulder complaints that had isolated teres minor atrophy. Case-based study of these two male patients revealed other associated shoulder injury but the presentation was markedly different and clinically distinct from quadrilateral space syndrome. Isolated teres minor atrophy is a relatively common shoulder pathology which appears to be clinically distinct from other syndromes with rotator cuff muscle atrophy including quadrilateral space syndrome. The exact aetiology is unknown but cadaveric dissection in this study suggests the considerable anatomical variation in both the origin and length of teres minor nerve(s) increase the risk of impingement and subsequent isolated teres minor atrophy.
... complications et pronostic 1,7,8 Seules 50% des pathologies scapulaires nouvellement diag nostiquées sont asymptomatiques après six mois, et 60% après douze mois. Leur pronostic va dépendre du type de diagnostics, dont certains sont repris ci-dessous. ...
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Scapulalgias or omalgias are a frequent complaint, with more than half of them being linked to an injury of the rotators cuff. As they often become chronic, omalgias result in higher rates of absenteeism and significant health care costs. Scapulalgias have three main causes: posttraumatic, intrinsic of the joint, or extrinsic. The extrinsic omalgias, either of neurologic, cardiovascular, pulmonary, or abdominal etiology, require swift identification, as their treatment is often an emergency. Most of the scapulalgias can be treated conservatively. Main factors of poor prognosis are old age, women gender and associated cervicalgias.
... They have an estimated 12-month prevalence of approximately 30% in some countries, and a tendency to become chronic [12,13]. Non-articular (e.g., pulmonary, diaphragmatic, abdominal) causes of shoulder pain are rare but should be considered in the differential diagnosis [14,15] as well as after drug intoxication [16] and polymyalgia rheumatic [17]. CPS and tendinopathy are progressive diseases characterized by a four-phase process (formative, resting, resorptive, restitution) that typically causes tenderness, pain and loss of function during the third phase [2,16]. ...
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Background: To evaluate the usefulness of Arnica compositum (AC) + Acidum nitricum (AN) + Hekla lava (HL) ointment in Emergency Medicine Department (EMD) as alternative non-pharmacological local treatment of patients with symptomatic calcific periarthritis of the shoulder (CPS) and to compare the effectiveness of this mixture against AC ointment alone. Methods: A series of 41 consecutive patients (20 women, 19 men, median age 49 years, range 25-80 years) with non-traumatic painful unilateral CPS were randomly assigned to receive local treatment with AC+AN+HL ointment mixture (Group A, cases, N=21) or AC ointment alone (Group B, controls, N=20). The radiological Gartner classification of the CPS, and the quantification of pre- and post-treatment pain intensity using a visual analogue scale (VAS) were obtained. The orthopedic evaluation of shoulder motion (SM) was also performed. The use of painkillers was reported as number of doses needed. Results: Age, gender distribution, Gartner type, main calcification size, baseline VAS (VAS-0) and degree of SM did not differ (p=NS) between Groups. After 3-day therapy, the reduction of pain in Group A (4.5±2.5) was superior than that observed in Group B (2.7±2.6) (p =0.03). Same result in improvement of SM in Group A (69.4±24.9) than in Group B (51.1±21.1) (p =0.015). No local or general adverse effects were noted. The number of doses of paracetamol was similar, but Group A patients used less ibuprofen (p =0.007). Conclusion: Local administration of the AC+AN+HL ointment mixture, which in our pilot study was superior to AC alone, could be safely suggested as alternative uneventfully treatment of patients with CPS.
... Current notification definitions for malaria only include microscopy and PCR as 'definitive' criteria for a diagnosis of malaria. 1 The authors do allude to this, albeit, slightly confusingly in the next line. The ICT does have a number of limitations, including lower sensitivity in diagnosing non-P. ...
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A omalgia é a terceira queixa musculoesquelética mais frequente nos cuidados de saúde primários (CSP). Este artigo pretende compreender a omalgia, a sua abordagem diagnóstica e terapêutica nos CSP. Realizou-se uma revisão narrativa. Identificaram-se 73 artigos na pesquisa e incluíram-se na revisão dados de 7 referências bibliográficas. A omalgia é mais frequente no sexo feminino, dos 45 aos 64 anos. Há pior prognóstico se idade avançada, sexo feminino, sintomatologia inicial intensa e associação a cervicalgia. As etiologias mais frequentes são: patologia da coifa dos rotadores, instabilidade e artrose gleno-umeral, capsulite adesiva e patologia da articulação acromioclavicular. Com uma anamnese completa a maioria das situações pode ser diagnosticada e gerida na primeira consulta, sem necessidade de investigação adicional. Quando necessária, a ecografia e a ressonância magnética nuclear são preferíveis. A referenciação a cuidados hospitalares deve ocorrer se queixas refratárias à terapêutica inicial (fármacos analgésicos e anti-inflamatórios e reabilitação física).
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Epidemiologically-based rheumatology healthcare needs assessment requires an understanding of the incidence and prevalence of musculoskeletal disorders in the community, of the reasons why people consult in primary care, and of the proportion of people who would benefit from referral to secondary care and paramedical services. This paper reports the first phase of such a needs assessment exercise. To estimate the relative frequency of musculoskeletal pain in different, and multiple, anatomical sites in the adult population. Three general practices in the former Tameside and Glossop Health Authority, Greater Manchester, UK, a predominantly urban area. Population survey. An age and sex stratified sample of 6000 adults from the three practices was mailed a questionnaire that sought data on demographic factors, musculoskeletal symptoms (pain in the past month lasting for more than a week), and physical disability (using the modified Health Assessment Questionnaire--mHAQ). The areas of pain covered were neck, back, shoulder, elbow, hand, hip, knee, and multiple joints. The Carstairs index was used as a measure of social deprivation of the postcode sector in which the person lived. The response rate after two reminders was 78.5%. Non-responders were more likely to live in areas of high social deprivation. People who lived in more deprived areas were also more likely to report musculoskeletal pain, especially backpain. After adjusting for social deprivation the rates of musculoskeletal pain did not differ between the practices and so their results were combined. After adjustment for social deprivation, the most common site of pain was back (23%; 95% CI 21, 25) followed by knee (19%; 95% CI 18, 21), and shoulder (16%; 95% CI 14, 17). The majority of subjects who reported pain had pain in more than one site. The prevalence of physical disability in the community rose with age. It was highest in those with multiple joint problems but was also high in those with isolated back or knee pain. Musculoskeletal pain is common in the community. People who live in socially deprived areas have more musculoskeletal symptoms. Estimates of the overall burden of musculoskeletal pain that combine the results of site specific surveys will be too high, those that do not adjust for socioeconomic factors will be too low.
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Shoulder complaints are common and have an unfavourable outcome in many patients. Only 50% of all new episodes of shoulder disorders end in complete recovery within 6 months. There is no consensus about prognostic indicators that can identify patients at high and low risk of chronicity. By a systematic search of the literature we identified 16 studies focusing on the prognosis of shoulder disorders. The methodological quality of these 16 studies was assessed. Six of these were considered to be of relatively 'high quality'. There was a wide variety among the studies in length of follow-up, study population, evaluated prognostic factors, type of outcome measure and method of analysis. Due to this large heterogeneity, we refrained from statistical pooling. Instead, we used a best-evidence synthesis. There is strong evidence that high pain intensity predicts a poorer outcome in primary care populations and that middle age (45-54) is associated with poor outcome in occupational populations. There is moderate evidence that a long duration of complaints, and high disability score at baseline predict a poorer outcome in primary care. These results need to be interpreted with caution because of the small number of studies on which these conclusions are based, and the large heterogeneity among studies regarding follow-up, outcome measures, and analysis.
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Topical glyceryl trinitrate therapy has previously demonstrated short-term pain reduction in patients with supraspinatus tendinopathy. Topical glyceryl trinitrate improves outcome measures in patients with supraspinatus tendinopathy. Randomized controlled clinical trial; Level of evidence, 1. Fifty-three patients (57 shoulders) were recruited, and the authors completed a prospective, randomized, double-blinded, placebo-controlled clinical trial of continuous topical glyceryl trinitrate treatment (1.25 mg/24-h glyceryl trinitrate). The glyceryl trinitrate group had significantly reduced shoulder pain with activity, at night, and at rest at week 24 (P = .03); reduced internal rotation impingement at week 24 (P = .02); increased range of motion in abduction and internal rotation at week 24 (P = .04); and increased force at weeks 12 and 24 with supraspinatus muscle testing (P = .001), external rotation (P = .04), internal rotation (P = .01), adduction (P = .04), and subscapularis pushoff (P = .01). Forty-six percent of patients on glyceryl trinitrate patches were asymptomatic with activities of daily living at 6 months compared with 24% of patients with tendon rehabilitation alone (P = .007, chi(2) analysis). Mean effect size for all outcome measures was 0.26. Topical glyceryl trinitrate treatment significantly improved pain scores, range of motion, internal rotation impingement, muscular force, and patient outcomes in patients with supraspinatus tendinopathy. Topical glyceryl trinitrate should be included as part of nonsurgical management of chronic tendinopathies.
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Compromised shoulder movement due to pain, stiffness, or weakness can cause substantial disability and affect a person's ability to carry out daily activities (eating, dressing, personal hygiene) and work.w1 Self reported prevalence of shoulder pain is estimated to be between 16% and 26%; it is the third most common cause of musculoskeletal consultation in primary care, and approximately 1% of adults consult a general practitioner with new shoulder pain annually.1 Occupations as diverse as construction work and hairdressing are associated with a higher risk of shoulder disorders. Physical factors such as lifting heavy loads, repetitive movements in awkward positions, and vibrations influence the level of symptoms and disability, and psychosocial factors are also important.w1 Recent studies suggest that chronicity and recurrence are common.2 3 Common shoulder disorders exhibit similar clinical features, and the lack of consensus on diagnostic criteria and concordance in clinical assessment complicates treatment choices.3 w2-w5 This review proposes an evidence based approach using a simplified classification of shoulder problems, incorporating diagnostic techniques applicable to a primary care consultation and a “red flag” system to identify potentially serious disease. We incorporated the latest consensus from systematic reviews and publications identified by a literature search through Medline, CINAHL, AMED, the Cochrane Library (Central, CDSR, HTA, DARE), Clinical Evidence, Best Evidence, Embase, British Nursing Index, PEDro,w6 Web of Science (social science and science citation indexes), and bmj.com. The search strategy included the terms “shoulder pain”, “rotator cuff disorder”, “rotator cuff tear”, “frozen shoulder”, and “primary care”. We found six published systematic reviews of interventions for shoulder disorders and one health technology assessment systematic review of diagnostic tests for the assessment of shoulder pain.4–10 A topic search within Clinical Evidence identified the section “Shoulder pain.”11 We identified and critically appraised other …
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Systemic malignancy can be manifested by musculoskeletal complaints. We review the history, physical examination, and diagnostic imaging studies of a patient whose chief complaints were neck and shoulder pain. This patient also had significant weight loss and a history of tobacco abuse. Aggressive physical therapy and appropriate medications failed to provide symptomatic relief of neck and shoulder pain. Further studies revealed lung cancer. Systemic malignancy can cause referred musculoskeletal pain without obvious metastatic involvement at the symptomatic area, and should be considered in patients with persistent symptoms.
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The histological changes found in the supraspinatus tendon have similarities with the findings in Achilles-, patellar- and extensor carpi radialis brevis (ECRB)-tendinopathy. In recent studies, we have found a vasculo-neural ingrowth in chronic painful Achilles and patellar tendinopathy, and demonstrated good short-term clinical effects with injections of the sclerosing substance polidocanol. In this collaborative two-centre pilot study, 15 patients (10 males and 5 females, mean age 46 years) with a long duration of shoulder pain (mean 28 months), and given the diagnosis chronic painful shoulder impingement syndrome, were included. They had tried rest, traditional rehabilitation exercises and multiple subacromial corticosteroid injections, without effect. We found vascularity (neovessels) in chronic painful, but not in pain-free, supraspinatus tendons, and prospectively studied the clinical effects of ultrasound (US) and colour Doppler (CD)-guided injections of polidocanol, targeting the area with neovessels. The patients evaluated the amount of shoulder pain during horizontal shoulder activity on a visual analogue scale (VAS), and satisfaction with treatment. Two (median) (range 1-5) polidocanol treatments (with 4-8 weeks in between) were given. In four patients (considered treatment failure), cortisone was injected into an inflamed subacromial bursa at one separate occasion weeks after the last polidocanol injection. At follow-up, 8 (median) (range 4-17) months after the treatment, 14 patients were satisfied with the result. Using the visual analogue scale evaluation (VAS), the pain dropped from 79 before treatment to 21 at follow-up (P < 0.05). In the short-term perspective, sclerosing polidocanol injections targeting the neovessels in the supraspinatus tendon and/or bursa wall seems to have a potential to reduce the pain during shoulder loading activity.
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Shoulder pain is a common presentation in general practice. Data on prognosis, treatment and compliance for acute shoulder pain are lacking but would be valuable for guiding decision making. This study collected data on acute shoulder pain and its outcome over 6 months. A prospective observational study of 100 acute shoulder pain patients from 21 general practices in southeast Queensland. Disability levels at presentation were the best predictor of outcome at 6 months. Patients who had not fully recovered at 6 months had higher risk of depression at presentation. The biggest improvements in pain and disability scores occurred in the first month of management, with almost 60% of patients fully recovered at 6 months. Over 40% of patients had at least one radiological investigation for their pain. Measuring disability, pain and mood levels in acute shoulder pain patients gives the best prognostic data. The use of radiological investigations may be higher than is clinically necessary. Early multimodal management of acute shoulder pain patients needs consideration.