Shoulder pain: full assessment and team management

After the low back and the knee, shoulder pain is the commonest musculoskeletal reason for consultation. It almost always resolves without surgery, but reaching the right diagnosis is not trivial: several different causes produce pain that patients describe in almost identical terms.

My role here is to carry out the full assessment — history, examination, targeted imaging — to start treatment and, when the case requires specialist shoulder surgery, to resolve it as a team with the shoulder specialist at the clinic. The patient is not left going in circles between clinics.

The commonest causes

Subacromial pain and rotator cuff tendinopathy

This is the commonest cause. It hurts to raise the arm above shoulder height, to reach something on a high shelf and, characteristically, to lie on that side. For years it was called "impingement syndrome" and was frequently operated on.

The evidence changed that practice. A Finnish trial with a sham surgical control compared arthroscopic subacromial decompression with diagnostic arthroscopy (placebo surgery) and with exercise: at two years there was no clinically relevant difference between operating and not operating. That is why today the first-line treatment is a well-directed exercise programme, not the operating theatre.

Rotator cuff tear

The tendon tears, either degeneratively (wearing away over the years, often without any injury) or traumatically (after a fall or a dislocation). The distinction matters a great deal, because the treatment is not the same.

In small degenerative tears of the supraspinatus, the Cochrane review found that surgical repair gives little or no clinically important benefit over exercise with or without injection. However — and this must be stated precisely — those conclusions do not apply to traumatic tears, to large tears involving the subscapularis, or to young patients. There, surgery does have a clear role, and it often needs to be early.

Frozen shoulder (adhesive capsulitis)

The joint capsule becomes inflamed and contracts. What distinguishes it is that movement is lost even when someone else tries to move the arm, not only when the patient moves it. It usually passes through three phases — pain, stiffness and recovery — over months. The vast majority respond to conservative treatment: adequate analgesia, injection in selected cases and sustained physiotherapy.

Dislocation and instability

The shoulder comes out of joint, typically anteriorly, after trauma or a forced movement. After a first dislocation the risk of recurrence is high, particularly in young patients and athletes, and that is the factor that weighs most when considering surgical stabilisation.

Glenohumeral osteoarthritis

Wear of the joint cartilage: deep pain, crepitus and progressive loss of movement, especially external rotation. It is managed conservatively first; in advanced stages joint replacement is considered.

Calcific tendinopathy

Calcium deposits within the tendon that can produce episodes of very severe pain of rapid onset. It tends to resolve on its own, and responds to pain management and, in selected cases, ultrasound-guided procedures.

Fractures: proximal humerus and clavicle

This ground is fully mine. A proximal humerus fracture is typical of the older person who falls from standing height. It is worth knowing that, in displaced three- and four-part fractures in older patients, the accumulated evidence shows that surgery does not give better results at one and two years than properly delivered non-operative treatment, and may increase the need for further surgery. The young patient, high-energy trauma and certain specific patterns are a different matter, where surgery is indicated.

The clavicle fracture is mostly managed without surgery; the operation is reserved for significant displacement, open fractures, skin compromise or particular functional situations.

How I assess it in clinic

• History: whether or not there was an injury, how it started, whether it hurts at night, which movements you cannot do.
• Structured examination: active and passive ranges — the key to separating frozen shoulder from a tear — cuff strength testing and instability manoeuvres.
• Targeted imaging: radiographs whenever there has been trauma; ultrasound or MRI when the result will change management.
• Initial treatment: pain control, a directed exercise programme and ultrasound-guided injections in selected cases.
• Team management: if the case requires specialist shoulder surgery, it is resolved together with the shoulder specialist at the clinic, with the work-up already complete.