ALGORITHM FOR THE DIAGNOSIS AND TREATMENT OF SHOULDER DISORDERS FOR HEALTH CARE PROVIDERS
Approach to the Shoulder
Seven entities account for the pain experienced by an estimated 95% of patients who present with shoulder pain. Rotator cuff disease is far and away the most important accounting for about 75% overall. The list below shows these entities in descending frequency.
- Rotator cuff disease – Tendinitis, Strain, Partial Tear or Complete Tear: Diagnosed through History and MRI
- Glenohumeral Joint Arthritis: Diagnosed through physical exam and Grashey view X-Ray
- A-C joint inflammation: Diagnosed through Physical Exam
- Glenoid Labrum Superior (SLAP) Tears: Diagnosed through history and MRA
- Frozen Shoulder: Diagnosed through physical exam and Grashey view X-Ray
- Cervical Radiculitis, Trapezius and Neck Strain: Diagnosed through physical exam
- Shoulder dislocation: Diagnosed through history, X-Ray and MRI
Much Less Common
Thoracic Outlet Syndrome; Tumor: benign or malignant; Pectoral Tendon Tear; Scapular Winging
Diagnosis of Shoulder Problems
The following is an algorithm for accurate diagnosis of shoulder pain.
![How Diagnosed](images/diagnose-1.jpg)
The grid shows a stepwise progression to diagnose the patient’s shoulder pain.
- Take History of trauma or overuse
- View Grashey and Y X-Ray views
- Palpate the AC joint
- Perform Hawkins Maneuver
- Test Passive supine shoulder ROM
- Direct patient to perform Wall pushup
If Clinically Indicated May Also:
- Test triceps strength
- Do Pec Major stress test
What To Look For:
- Look at the X-Ray Grashey view:
Normal joint space = No Arthritis
Decreased joint space = Arthritis - Look at the X-Ray Y view:
Normal = No Dislocation
Abnormal = Dislocation - Palpate the AC joints:
Symmetrically Tender = Normal - One side hurts more = AC Joint Inflammation
- Perform Hawkins Maneuver:
Normal = No RC Disease
Abnormal = RC disease - Examine ROM supine:
Decreased with normal Grashey = Frozen shoulder
Decreased with abnormal Grashey = Arthritis - If History of traction or impaction of affected arm may be SLAP lesion. If pain is posterior this is likelier. If no other diagnosis exists must get MRA.
- If patient has pain in neck, medial scapular and radiating down posterior arm, lateral forearm and numb fingers and an asymmetrically weak triceps on the affected side it is cervical radiculitis.
- If they have discomfort and limitation with leftward and rightward neck rotation it is cervical strain.
- If they have pain in the trapezius it is trapezius strain - But Often This is Secondary to AC Inflammation, which is diagnosed by AC palpation as above.
- If Y or Grashey view x-ray is positive for dislocation, then it is an unreduced dislocation. If a patient has a history of feeling shoulder come completely out of joint and then going back in then it is reduced shoulder dislocation. MRI can confirm dislocation.
- If x-ray is positive for lytic or blastic lesion it is tumor, which should be confirmed by MRI. All suspected tumors should be immediately referred to an orthopaedic surgeon.
- If a patient has traumatic history, usually an eccentric pec contraction as with a bench press with the bar going down, and physical exam is positive for webbing then pectoral rupture
- If posterior scapular discomfort, and on winging present when performing a wall pushup, then winging scapula.
Treatment of Shoulder Problems
![Shoulder Treatment Algorithm](images/diagnose-2.jpg)
The above chart is labeled with the appropriate treatments to try first (1), second (2) or third (3) for each diagnosed problem.