Stubborn Shoulder

Differentials

One of the peculiar challenges working with the shoulder is it’s attachments to the axial skeleton. While the glenohumeral joint forms a ball-in-socket joint like the hip (and as such there is considerable similarities in function), the formal articulation at the sternoclavicular joint and the muscular relationship of the thoracic-scapular “joint” adds notable complexity. Initial differentials include:

• Systemic: MI, visceral referral

• Neurogenic: Cervical radiculopathy, TOS of brachial plexus

• Vascular: TOS, DVT

• Muscles: Rotator Cuff (SITS), brach mm, SICK scapula

• Osseous/Joint: Csp referral, Frozen Shoulder, AC issues, SLAP tears, costal (rib) joints

Anatomy

Assessments

Depending on the presentation and initial patient interview, some conditions are more likely. For example:

• Trauma to the area - assess for fractures, dislocation, separation, muscle tearing

• Repetitive movements - think impingement syndromes, tendinitis, muscular strain

• Associated neck pain - Csp issues (e.g. spondys, discopathies, facet pain)

• Reported weakness - capsular instability, labrum tear, neurogenic causes

• Other disease histories - consider arthritides, CT disease, visceral referral

Ruling Out

Cervical distraction and Spurling progression quickly screens the cervical spine. Check out some cervical spine posts if that’s what you’re dealing with.

Dugas, Clearing, Hawkins-Kennedy, & Resisted Supination External Rotation Test are my screen for shoulder instability, impingement, and labrum tears; respectively. If you have a strong preference, swap out the “SUPER test” for O’Brien’s.

Choose a vascular AND a neurologic test for TOS. Some tests, like Eden’s, might be tempting because you’ll hit both of these with one test. However, consider the underlying anatomy of the shoulder region choose two that also place the arm into overhead abduction - like Bakody (or Reverse) and Halstead. (Quick side note: A few tests mentioned in this post might cause a bit of controversy. I’ll offer future blogs specifically addressing the sensitivity and specificity of these exams and how we tie them together clinically)

Get to it

Beyond that, it’s muscle testing and finding what activities and movement are most provocative to the patient. Pair that with your preferred matched-treatment strategy and you’re all set. Personally, I find shoulder pain is often rooted in underuse and a loss of functional ranges, especially to the scapulothoracic rhythm. I’ll write up something specially for SICK scapular assessment and treatment ideas.