Soft Tissue Shoulder Disorders Care Pathway

8. Diagnostic Criteria for Soft Tissue Shoulder Disorders

 

Diagnosis requires a thorough understanding of the patient's condition. It integrates patient stories; clinical findings; risk factor evaluations; and physical, psychological, social, and environmental aspects of pain.

 

Soft Tissue Shoulder Disorders

Includes  rotator cuff conditions (including partial tears), impingement syndrome, bursitis, calcific tendinitis, biceps tendon conditions, shoulder instability, AC joint conditions, labral tears and SLAP lesions, adhesive capsulitis, osteoarthritis.

• Definition: Shoulder pain that is not due to serious underlying pathology requiring medical attention such as infection, tumor, or fracture, and is typically amenable to conservative care (e.g., education, manual therapy, exercise).

• Prevalence: Shoulder pain is a common musculoskeletal complaint in primary care, following back pain and knee pain.

• Risk Factors: Occupational factors (e.g., repetitive movements, heavy lifting, prolonged postures), behavioral factors (e.g., physical activity, smoking, poor sleep), health-related factors (e.g., obesity, diabetes, previous injuries, mental health conditions.

• Pain Location: Localized shoulder area with or without referred pain.

• Duration: Pain can be acute (less than 6 weeks), subacute (6 to 12 weeks), or chronic (more than 12 weeks).

• Signs/Symptoms:

  • Pain can be sharp, dull, shooting, or aching.

  • Intensity varies from mild to severe.

  • Aggravated by specific movements, postures, or activities; relieved by others.

  • Referred pain into the arm may be present.

• Physical and Neurological Examination: Pain reproduced by tests. Typically, no neurological deficits.

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Note: Soft tissue shoulder disorders represent the most common causes of shoulder pain, presenting with similar mechanisms, clinical symptoms, and signs in a primary care setting. For example, impingement syndromes commonly coexist with other shoulder conditions such as rotator cuff partial tears and bursitis. However, breaking down shoulder pain into different categories helps in guiding treatment strategies and managing patient expectations.

 

 

1. Rotator Cuff Conditions (including tendinopathies and partial tears)

• Definition: Injuries to the rotator cuff tendons, including inflammation, tendinitis, tendinopathy, and partial thickness tears.

• Prevalence: Common in the general population, increasing with age.

• Risk Factors: Older age, overhead activities, trauma, genetics, smoking, poor posture.

• Pain Location: Lateral shoulder pain.

• Duration: Acute (sudden onset) or chronic (gradual onset due to degenerative changes).

• Signs and Symptoms: A dull ache in the lateral aspect of the shoulder, worsening with overhead activities and at night, weakness, limited range of motion, crepitus, night pain.

• Physical and Neurological Examination: Positive tests (e.g., drop arm, Jobe’s , infraspinatus, lift-off, belly press); no neurological deficits.

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2. Impingement Syndrome

• Definition: Pain resulting from compressed rotator cuff tendons or bursa during shoulder movements.

• Prevalence: Common condition that increases with age.

• Risk Factors: Repetitive overhead activities, older age, anatomical variations, muscle imbalance, poor posture, previous shoulder injuries.

• Pain Location: Pain in the front or lateral aspect of the shoulder.

• Duration: Acute (lasting a few days to weeks), chronic (persisting for months to years).

• Signs and Symptoms: Pain in the front or lateral aspect of the shoulder, particularly during overhead activities;’ shoulder muscle weakness; limited range of motion; night pain; crepitus.

• Physical and Neurological Examination: Positive tests (e.g., Neer’s, Hawkins-Kennedy, painful arc, Jobe’s, infraspinatus); no neurological deficits.

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3. Calcific Tendinitis

• Definition: Calcification and tendon degeneration near the rotator cuff insertion.

• Prevalence: Affects approximately 3 to 8% of the general population, with higher prevalence in people aged 30 to 60 years.

• Risk Factors: Age (30 to 60 years), female sex, metabolic diseases, repetitive shoulder movements, genetics.

• Pain Location: Localized shoulder pain.

• Duration: Acute and chronic phase (with intermittent pain and discomfort).

• Signs and Symptoms: Sharp, intense pain in the shoulder, especially with movement; tenderness; limited range of motion; night pain; swelling.

• Physical and Neurological Examination: Positive tests include inspection (swelling, redness), palpation (tenderness), limited range of motion, Neer’s, Hawkins-Kennedy, imaging (e.g., x-ray, ultrasound); no neurological deficits.

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4. Bursitis

• Definition: Inflammation of the bursa in the shoulder.

• Prevalence: Common, particularly in individuals with repetitive shoulder movements.

• Risk Factors: Repetitive overhead activities, trauma, older age, poor posture, systemic inflammatory condition.

• Pain Location: Localized shoulder pain.

• Duration: Acute or chronic.

• Signs and Symptoms: Pain with movement, tenderness, swelling, limited range of motion, night pain.

• Physical and Neurological Examination: Positive tests include Neer’s, Hawkins-Kennedy, inspection (swelling, redness), palpation (tenderness), limited range of motion; no neurological deficits.

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5. Biceps Tendon Conditions

• Definition: Inflammation or injury to the biceps tendon, including tendinitis and partial tears.

• Prevalence: Common, particularly in athletes and individuals with repetitive shoulder use.

• Risk Factors: Repetitive overhead activities, older age, poor posture, previous shoulder injuries.

• Pain Location: Anterior shoulder pain.

• Duration: Acute or chronic.

• Signs and Symptoms: Pain in the bicipital groove, tenderness, weakness, swelling, limited range of motion.

• Physical and Neurological Examination: Positive tests include Speed’s, Yergason’s, palpation (tenderness), limited range of motion; no neurological deficits.

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6. Shoulder Instability

• Definition: Excessive movement or dislocation of the shoulder joint.

• Prevalence: More common in younger, active individuals and athletes.

• Risk Factors: Trauma, repetitive overhead activities, genetics, connective tissue disorders.

• Pain Location: Generalized shoulder pain.

• Duration: Acute (following a dislocation) or chronic (recurrent instability).

• Signs and Symptoms: Pain, sensation of the shoulder “slipping out,” weakness, limited range of motion, instability.

• Physical and Neurological Examination: Positive tests (e.g., Apprehension, Relocation, Sulcus Sign); no neurological deficits.

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7. Acromioclavicular (AC) Joint Conditions

• Definition: Injuries or degeneration of the AC joint.

• Prevalence: Common, particularly in athletes and older individuals.

• Risk Factors: Trauma, repetitive overhead activities, age.

• Pain Location: Pain on the top of the shoulder.

• Duration: Acute (following injury) or chronic (degenerative changes).

• Signs and Symptoms: Pain at the AC joint, tenderness, swelling, limited range of motion, pain with horizontal adduction.

• Physical and Neurological Examination: Positive tests include Cross-Body Adduction, palpation (tenderness), inspection (swelling); no neurological deficits.

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8. Labral Tears and SLAP Lesions

• Definition: Tears of the shoulder labrum, including superior labrum from anterior to posterior (SLAP) lesions.

• Prevalence: Common in athletes and individuals with repetitive overhead activities.

• Risk Factors: Repetitive overhead activities, trauma, age.

• Pain Location: Deep shoulder pain.

• Duration: Acute (following injury) or chronic.

• Signs and Symptoms: Pain, clicking or catching sensation, weakness, limited range of motion.

• Physical and Neurological Examination: Positive test (e.g., O’Brien, Crank, Apprehension test, limited range of motion); no neurological deficits.

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9. Adhesive Capsulitis

• Definition: Characterized by stiffness and pain in the shoulder joint, also known as frozen shoulder.

• Prevalence: Common, particularly in people aged 40 to 60 years, with a higher prevalence in women.

• Risk Factors: Age (40 to 50 years), diabetes, thyroid disorders, prolonged immobilization, previous shoulder injuries.

• Pain Location: Generalized shoulder pain.

• Duration: Chronic, with symptoms persisting for months to years.

• Signs and Symptoms: Gradual onset of shoulder stiffness and pain, limited range of motion in all directions, pain worsening at night.

• Physical and Neurological Examination: Limited active and passive range of motion, particularly in external rotation; pain and stiffness during movement; positive Apley scratch test.

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10. Myofascial Pain Syndrome

• Definition: A chronic pain disorder caused by sensitivity and tightness in the myofascial tissues, which can affect the shoulder region.

• Prevalence: Common, particularly in individuals with repetitive strain or stress.

• Risk Factors: Repetitive motions, poor posture, stress, previous injuries.

• Pain Location: Localized or referred pain in the shoulder and surrounding areas.

• Duration: Chronic, with symptoms persisting or recurring over time.

• Signs and Symptoms: Tender trigger points in the muscles, muscle stiffness, referred pain patterns, limited range of motion.

• Physical and Neurological Examination: Palpation to identify trigger points, assessment of referred pain patterns, limited range of motion; no neurological deficits.

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11. Osteoarthritis

• Definition: Degenerative joint disease affecting the shoulder.

• Prevalence: Common, particularly in older individuals.

• Risk Factors: Older age, previous joint injuries, genetics, repetitive stress.

• Pain Location: Generalized shoulder pain.

• Duration: Chronic (long-lasting symptoms with intermittent pain and stiffness).

• Signs and Symptoms: Pain, stiffness, limited range of motion, crepitus, swelling.

• Physical and Neurological Examination: Inspection (swelling), palpation (tenderness), limited range of motion, crepitus during movement, imaging (e.g., X-ray); no neurological deficits.