Clinical Problems of the Shoulder.
Last updated Tuesday, January 25, 2005
Figure 1 - Ages different diagnoses are most prevalent: the percent distribution by decade of age at presentation of shoulder problems. Types of shoulder problemsDiagnosis of shoulder problems Mechanical problems of the shoulder are common. Such problems are often revealed by the answers to some simple questions:
- Is the shoulder stiff: can the arm be put in all normal positions?
- Is the shoulder unstable: does it feel like it is going to pop out or slide out of the socket?
- Is the shoulder weak: does it have the strength to carry out desired activities?
- Is the shoulder rough: does it catch and grind with use?
Non-mechanical problems There is another group of shoulder problems which is not related to
shoulder mechanics. These include conditions such as arthritis of the
neck, nerve irritation, bone infection, bone tumors, and various pain
syndromes. These conditions typically produce pain whether or not the
shoulder is being used. Persistent non-mechanical problems of the
shoulder require a thorough evaluation which is not covered here.Shoulder problems and age Certain conditions are most common during certain times in our lives.
Based on the ages at which patients present to the University of
Washington Shoulder and Elbow Service, we can show graphically, at
which ages the different diagnoses are most prevalent. The youngest
ages are dominated by problems of traumatic anterior instability and
atraumatic instability. The middle ages includes all the major
diagnoses. The older ages are dominated by degenerative joint disease,
cuff tears, and frozen shoulders. Diagnoses other than instability are
uncommon under the age of 30. Complete cuff tear are rare under the age
of 30.Conditions without definitive treatments While we are used to thinking that every clinical problem has a
diagnosis and every diagnosis has a treatment, this is not the case for
the shoulder. Although many shoulder conditions can be managed well, a
group of shoulder problems exists that are diagnoseable but are not
amenable to definitive treatment. Examples include such diagnoses as
brachial neuritis, habitual dislocations, mid-substance muscle tears,
anterior sternoclavicular subluxation, generalized ligamentous laxity,
instability from movement disorders, and massive rotator cuff tears in
individuals with paraplegia. In these situations the effectiveness of
existing treatment methods is limited. The available resources can be
directed to patient education, exercises, and vocational rehabilitation.Conditions that are difficult to diagnose Some shoulder complaints are not even diagnoseable, no matter how
many tests are ordered. An unlimited amount of resources can be spent
in vain pursuit of a treatable cause for vague shoulder problems. A
risk in ordering diagnostic tests when the basic evaluation suggests no
shoulder pathology is that these tests may yield "findings" which do
not relate to the individual's complaint. Findings of "labral fraying"
on arthroscopy, "abnormal signals in the cuff tendons" on MRI, or
"laxity" on examination under anesthesia do not help in the evaluation
or management of nonspecific shoulder complaints.
From the standpoint of resource allocation, it is important to
define which shoulder problems do not need expensive diagnostic
evaluations. A good guideline is that when the basic evaluation (a
careful history and physical examination along with appropriate plain
radiographs) does not suggest the existence of a definable problem, one
need not proceed to advanced imaging, electrodiagnostics, arthroscopy
or examination under anesthesia because the yield is so low under these
circumstances. A repeat clinical examination after several months often
provides additional insight into the nature of the problem. The
diagnosis for "shoulder pain without identified pathology" should be
just that. Assigning a label with minimal therapeutic significance,
such as fibromyalgia, myofasciitis, or trigger points, does not help
determine a curative treatment. Usually these situations can best be
managed by shifting the expenditure of resources from evaluation to a
program of physical, vocational and social support. Disclaimer
This resource has been provided by the University of Washington Department of Orthopaedics and Sports Medicine as general information only. This information may not apply to a specific patient. Additional information may be found at http://www.orthop.washington.edu or by contacting the UW Department of Orthopaedics and Sports Medicine.
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