Evaluating Shoulder Pain: The Latest in Diagnosis and Management, Part 2

Lindsay E. Brown, MD; Bret S. Stetka, MD; Kevin D. Deane, MD, PhD; Mary Kristen Jesse, MD; Jason R. Kolfenbach, MD

March 25, 2015

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Shoulder Pain: Introduction
Part 1 of this two-part slideshow reviewed the basics of evaluating shoulder pain while also exploring more complex conditions that can affect the shoulder. Part 2 looks at how to clinically approach additional disorders of the shoulder, along with the latest news in evaluating and managing shoulder pain and disease.

Image from Thinkstock

Slide 1.

Case 1: Referred Pain
A 56-year-old woman presented with several months of left shoulder pain. She describes the pain as a deep ache down the outside of her shoulder. The pain also seems to travel down to her left hand to the region of the thumb. Her shoulder examination was normal, while her neck demonstrated limited range of motion with lateral movement and worsening of her shoulder pain with lateral flexion of her neck to the left side. Her upper and lower extremities had normal reflexes and strength; however, she had decreased perception of light touch over the thumb. Plain films demonstrated degenerative disease of her cervical spine, most pronounced at levels C5 and C6 (yellow arrow). She was diagnosed with cervical spine disease leading to left C6 nerve impingement. This improved over time with physical therapy and a spinal corticosteroid injection.

Image courtesy of Kevin Deane

Slide 2.

Case 1: Discussion
The shoulder can be a site of referred pain. One of the most common sources of referred shoulder pain is from the cervical spine, especially from disease at the C5-6 level that can lead to impingement of the C6 nerve root that innervates the shoulder.

In addition, pain can be referred to the shoulder from the chest (eg, angina) and the abdomen (eg, gallbladder disease). Because of this, patients with shoulder pain should be carefully evaluated for disease distant to the shoulder.[1,2]

Image from Wikimedia Commons

Slide 3.

Case 1a: More on Referred Shoulder Pain
A 65-year-old man presented with diffuse shoulder pain for about 8 months. No specific activities worsened the pain. He was a heavy smoker and reported a daily cough. His shoulder examination was normal, and the lack of focal findings other than his self-reported pain led the physician to obtain a chest x-ray that demonstrated a 4- to 5-cm rounded right upper lobe infiltrate which on subsequent evaluation was diagnosed as a primary lung cancer. Just like the previous case, this case illustrates that shoulder pain may be referred from other regions and that clinicians should have a high index of suspicion when shoulder pain is not accompanied by specific examination findings indicating focal shoulder disease.

Image courtesy of Kevin Deane

Slide 4.

Case 2: Rheumatoid Arthritis
A 63-year-old woman with longstanding rheumatoid arthritis (RA) presented with increasing shoulder pain and an inability to lift her arm above her head for the past 1-2 months. On examination, she had fullness to the anterior shoulder, tenderness with internal and external rotation of her shoulder, and tenderness with shoulder flexion and internal rotation (Hawkins-Kennedy test). She is unable to extend her shoulder above 90º and she has atrophy in the supraspinatus fossa of the scapula. She has mildly active synovitis in her hands and other joints. Plain radiography demonstrates a low-riding humeral head (see image).

Image courtesy of Kevin Deane

Slide 5.

Case 2: Rheumatoid Arthritis (cont)
In the MRI above, the synovium is bright and thickened (yellow arrow), suggesting synovitis. The supraspinatus fibers are torn and retracted to the level of the glenohumeral joint (white arrow), compatible with a full-thickness tear. Of note, in musculoskeletal MRI imaging, T1-weighted imaging typically provides the best anatomy, while T2-weighted images, because they highlight fluid and edema which are typically pathologic, demonstrate the best pathology but at the expense of resolution. The patient was diagnosed with active RA of the shoulder and a chronic rotator cuff tear. She had symptomatic improvement with a corticosteroid injection of the glenohumeral joint and eventually underwent a reverse shoulder replacement.

Image courtesy of Kevin Deane

Slide 6.

Case 2: Discussion
RA can affect the synovium of the shoulder joint as well as the tendinous structures, and rotator cuff pathology is common in RA. In most cases of rotator cuff pathology, the humeral head rises in the joint; however, in this case, the synovitis and joint destruction led to an appearance of a low-riding humeral head on plain films. The differential of an inferiorly displaced humeral head includes dislocation, neuromuscular disease (eg, stroke), capsular injury, and large effusion and synovitis that could be from infection, or in this case, active RA. With this degree of joint injury and chronic rotator cuff tear, shoulder replacement may be considered. In this case, a reverse shoulder replacement was performed, in which the ball of the prosthesis is placed in the glenoid position and the socket is placed on the proximal end of the humerus, allowing the deltoid to move the shoulder since the rotator cuff muscles are retracted and fibrotic.[3-6]

Image courtesy of Kevin Deane

Slide 7.

Case 3: Pseudarthrosis
A 56-year-old homeless man fell on his side while stepping off a curb. He was unable to get medical assistance for several months but finally presented because of increasing pain in his arm. On examination, he had abnormal flexion of his mid-humeral region with tenderness in this area. He had normal movement of his hand. Plain radiographs demonstrated an old fracture mid-humerus with cupping of the proximal portion of the humerus around the distal humerus forming a pseudarthrosis (see image).

Image courtesy of Kevin Deane

Slide 8.

Case 3: Discussion
In this unusual case, an untreated fracture led to a "new" mid-humeral joint. The clinician should be aware of potential unusual manifestations of disease. Fortunately, this fracture did not damage the radial nerve or vasculature of the patient's arm, and with surgical repair (left image) he was able to regain normal function of his arm. Pseudarthrosis can also form with missed fractures of the surgical neck of the humerus (right image).

Image courtesy of Kevin Deane

Slide 9.

Case 4: RA, Glenohumeral Disease
A 58-year-old woman with RA presented with persistent left shoulder pain for the past 2-3 years. The pain had been getting progressively worse and in the past 6 months had limited exercise and other leisure activity. She was diagnosed with RA at the age of 35 but did not achieve good control with disease-modifying antirheumatic drug (DMARD) therapy until approximately age 45. Examination of her hands and wrists reveals ulnar deviation and subluxation at the metacarpal-phalyngeal joints, but no synovitis (see image). Examination of the shoulder reveals pain with active and passive range of motion, including isolated internal and external rotation (with crepitus). There is no obvious effusion, warmth, or redness on exam, nor tenderness to palpation. The remainder of the physical exam was normal.

Images courtesy of Jason Kolfenbach, MD, and Mary K. Jesse, MD

Slide 10.

Case 4: Discussion
Patients with RA presenting with monoarticular pain should be evaluated closely for septic arthritis as well as noninflammatory conditions. A monoarticular flare of their underlying systemic disease is possible but less common, and other etiologies should be ruled out first. The absence of swelling, redness, and tenderness to direct palpation is a reassuring sign that argues against septic arthritis. X-rays of this patient (see above and following images) revealed severe glenohumeral joint space narrowing (degenerative change). Osteoarthritis (OA) does not typically occur in the shoulder, and when it is present in atypical locations it may often be the result of severe prior inflammatory disease, as is the case in this patient.[7-9] (The arrow represents a "high-riding shoulder" within the glenoid cavity; the bracket represents a narrowed interval between the acromion and the humeral head.)

Images courtesy of Jason Kolfenbach, MD, and Mary K. Jesse, MD

Slide 11.

Case 4: Discussion (cont)
RA that is undertreated or resistant to therapy leads to bone erosion, destruction of hyaline and fibrocartilage, as well as damage to supporting structures such as periarticular tendons, ligaments, and musculature—hence the saying, "The end-stage of RA is OA." Continuation of the patient's existing DMARD therapy will be important to help guard against further damage to other joint areas, but it will not improve her symptoms at the left shoulder. Patients with pain that limits activity and who have not benefited from physical therapy should be referred to orthopedics. This patient's course reinforces the current treatment paradigm in RA that is supported in the literature: early recognition of disease, early institution of DMARD therapy, and aggressive treatment with a goal of low disease activity or remission.[7-9]

Images courtesy of Jason Kolfenbach, MD, and Mary K. Jesse, MD

Slide 12.

Case 5: RA, Acromioclavicular Disease
A 60-year-old woman with long-standing erosive RA presented for routine follow-up. She has chronic, moderate discomfort in the fingers, wrists, shoulders, and feet that she feels has been stable. On exam she had chronic, severe deformities at the hands, wrists, elbows, and feet with no active joint swelling. Examination of her shoulder revealed no pain with isolated internal and external rotation (starting position: patient lying flat on back, arm abducted to 90º at shoulder along with arm bent at 90º at elbow). There is mild discomfort with impingement testing (Hawkins-Kennedy test) but more significant pain with the cross-arm adduction test that is localized to the acromioclavicular (AC) joint. Radiographs were obtained to further delineate her source of pain on exam (see image).

Image courtesy of Sterling West, MD

Slide 13.

Case 5: Discussion
RA is the most common rheumatic etiology of disease at the distal clavicle (erosive disease, distal clavicular osteolysis). In the general population, OA and traumatic injury are far more common causes of pain. Septic arthritis at the AC joint is relatively rare. Osteolysis of the distal clavicle represents a unique finding that can be seen in RA as well as other conditions: hyperparathyroidism, myeloma, systemic sclerosis (which can more commonly cause digital osteolysis), post-traumatic osteolysis, and atraumatic osteolysis (often from repetitive sports activities). Massive osteolysis of the distal clavicle and other parts of the shoulder can be idiopathic as well, a condition known as Gorham-Stout disease. In this situation, joint sepsis and Charcot joint should be excluded. Additional cases of distal clavicular disease (not from this patient) can be seen above.[10-13]

Images courtesy of Mary K. Jesse, MD, and Sterling West, MD

Slide 14.

Case 6: Hyperparathyroidism
A 20-year-old man with no past medical history presented with 6 months of fatigue, weight loss, vague abdominal pain, and diffuse arthralgias. On exam he appeared ill, with a heart rate in the 50s and a blood pressure of 156/88. Abdominal exam revealed diffuse, mild tenderness to palpation without guarding or rebound tenderness. Musculoskeletal exam revealed mild weakness of the upper and lower extremities, with diffuse joint achiness by report and without tenderness to palpation or swelling of individual joints of the hands, wrists, and elbows. Range of motion at the bilateral shoulders was decreased with internal and external rotation, as well as abduction, with crepitus on the left. No synovitis was evident on exam. An x-ray of the left shoulder was obtained (see image) which revealed advanced degenerative disease.

Image courtesy of Sterling West, MD

Slide 15.

Case 6: Hyperparathyroidism (cont)
In follow-up to this finding, hand and wrist films were obtained (despite the absence of swelling on exam) to search for evidence of occult involvement from an underlying inflammatory disease such as RA (see image). In addition, the presence of several nonarticular symptoms such as weight loss and abdominal pain prompted laboratory evaluation to identify nonrheumatologic etiologies. His labs revealed significant anemia as well as a serum calcium of 20 mg/dL. Additional radiographs and laboratory work were obtained, and a diagnosis of primary hyperparathyroidism was made (the yellow arrows indicate sites of resorption).

Image courtesy of Sterling West, MD

Slide 16.

Case 6: Discussion
Hyperparathyroidism can result in a generalized decrease in bone density in addition to characteristic skeletal changes known as osteitis fibrosa cystica (with the latter now rare in developed nations). Radiographic evidence supportive of osteitis fibrosa cystica was seen in this case: advanced degenerative arthritis at the shoulder, distal osteolysis of the clavicles, subperiosteal resorption of the radial aspect of the middle phalanges, and salt-and-pepper changes at the skull. The patient was found to have parathyroid cancer requiring immediate surgery. The image above represents significant regional osteopenia of the distal clavicle as well as local bone resorption, leading to a tapered appearance of the distal tip (pencil point).[14,15]

Image courtesy of Sterling West, MD

Slide 17.

Case 7: Hemophilic Arthropathy
An 18-year-old man came in to establish care with a general internist. He had a history of hemophilia marked by recurrent hemarthrosis, primarily at the knee, ankle, elbow, and shoulder. These episodes of joint bleeding occurred predominantly between the ages of 2 and 10 years old. He had not had an episode of joint bleeding in the past 4 years and was taking factor VIII replacement. He complained of mild discomfort at the shoulders and knees that was worse with activity. On exam he had limited range of motion at the shoulders, elbows, and ankles. There were no obvious joint effusions on exam, but joint capsule thickening (synovial hypertrophy) was present at the knees and ankles bilaterally. Baseline films were obtained at several sites because of his exam findings (see images).

Image courtesy of Sterling West, MD

Slide 18.

Case 7: Discussion
Degenerative arthritis that is seen in very young patients without rheumatic disease may often stem from metabolic and/or congenital disorders. The shoulder x-ray shows advanced degenerative disease with loss of joint space, irregular contour of the humeral head surface, and numerous subchondral cysts (none of which are specific to hemophilia). Knee imaging (see image) shows the sequelae of chronic synovitis in a growing child: periarticular osteoporosis, epiphyseal enlargement (which can also be seen in juvenile idiopathic arthritis), and widening of the intercondylar notch, all of which result from chronic joint hyperemia. The latter finding is relatively specific for hemophilic arthropathy.

Approximately 50% of patients with hemophilia develop chronic joint damage from repetitive hemarthrosis; it affects the large and medium-sized joints most commonly, especially the load-bearing joints of the knees and ankles. Blood within the joint serves as a direct irritant to the articular cartilage, and repetitive bleeding leads to the development of chronic synovitis, which in turn can cause additional joint damage.[16,17]

Image courtesy of Sterling West, MD

Slide 19.

Case 8: Juvenile Idiopathic Arthritis
A 22-year-old woman came in to establish care in an adult rheumatology clinic. She has a long-standing history of juvenile idiopathic arthritis (JIA), diagnosed at the age of 8. She has serum antibodies to anticyclic citrullinated protein as well as rheumatoid factor, and has known erosive disease. She was initially treated with nonsteroidal anti-inflammatory drugs (NSAIDs), followed by methotrexate, both of which were largely ineffective. Over time her therapy progressed to the TNF inhibitor adalimumab, starting at the age of 16. With this medication she has achieved significant relief of joint stiffness and pain, but still has problems with many activities of daily living secondary to joint dysfunction. The x-ray above shows extensive erosion of the articular surface of the glenoid fossa with medial migration of the humeral head.

Image courtesy of Sterling West, MD

Slide 20.

Case 8: Juvenile Idiopathic Arthritis
On exam she had chronic synovial hypertrophy at the MCPs and wrists bilaterally. She had subluxations at the MCPs and the wrists, with ulnar deviation of the fingers. In addition, she had flexion contractures at the PIP joints in both hands. There were slight contractures at the elbows bilaterally. Shoulder range of motion was moderately decreased on the left and markedly decreased on the right. Examination of the knees and ankles was normal, with cock-up deformities at the toes bilaterally. Other than pain and crepitus with movement of the right shoulder, there was no other joint tenderness on exam. The above x-ray shows severe disease at the metacarpophalangeal and wrists joints, with central-appearing erosions.

Image courtesy of Sterling West, MD

Slide 21.

Case 8: Discussion
These films demonstrate the severely destructive nature of JIA for some young patients and highlight the importance of early intervention and aggressive management of patients with inflammatory arthritis. Advancements in drug therapy have resulted in a significant improvement in the quality of life for many patients with JIA and other forms of inflammatory arthritis, but there are scant data to suggest that these medications reverse joint damage that has already occurred. Continuation of therapy will be important to help treat the significant symptoms of arthritis and guard against further joint damage, but there probably will be residual pain in joint areas already affected by secondary osteoarthritic change and potential need for orthopedic surgery.

Slide 22.

Shoulder Disease: The Latest Research
Numerous recent advances have been made in evaluating and managing shoulder pain and pathology. Three-year data[18] published last year suggest that total shoulder arthroplasty improves range of motion and ability to perform activities of daily living in patients with degenerative glenohumeral OA. 2014 also saw the identification of a new disease that affects baseball players.[19] The condition is called acromial apophysiolysis and is characterized by incomplete fusion and tenderness at the acromion. Finally, recent advances are poised to improve the management of torn rotator cuffs: augmenting surgical repair with a polypropylene patch was associated with better 3-year outcomes than using an absorbable collagen patch.[20] Reverse shoulder arthroplasty (see case 2) is also being recommended as a reasonable approach to shoulder repair in patients who have significant rotator cuff disease.

Image from Dreamstime

Slide 23.

Conclusion
Shoulder pain is a common musculoskeletal complaint. The underlying etiology often stems from periarticular tissues but can also be the result of trauma, degenerative disease, referred pain, or an underlying inflammatory condition. Recognition of an underlying systemic process is important to avoid progressive joint damage and potential spread to extra-articular sites, and to allow targeted drug therapy. A careful history and examination can guide the clinician to the primary site of shoulder pathology and help uncover the underlying etiology of shoulder pain. Cases of acute swelling, especially if associated with joint redness and warmth, often require joint aspiration to rule out crystalline disease, infection, or hemorrhage. Patients with more chronic presentations often require additional information in order to arrive at the diagnosis: a detailed medical history, recognition of associated extra-articular symptoms, and pattern of joint involvement by examination and radiographic findings. We hope the information in this presentation will be helpful to clinicians who evaluate shoulder pain.

Image from Thinkstock

Slide 24.

Contributor Information

Bret S. Stetka, MD
Editorial Director
Medscape Rheumatology

Lindsay E. Brown, MD
Rheumatology Fellow
Division of Rheumatology
University of Colorado School of Medicine
Denver, Colorado

Disclosure: Lindsay E. Brown, MD, has disclosed no relevant financial relationships.

Kevin D. Deane, MD, PhD
Associate Professor of Medicine
Division of Rheumatology
University of Colorado School of Medicine
Denver, Colorado

Disclosure: Kevin D. Deane, MD, PhD, has disclosed the following relevant financial relationships: Receiving grant funding from: NIH for the study of genetic and environmental factors that may influence the future development of rheumatoid arthritis therapies

Mary Kristen Jesse, MD
Assistant Professor of Radiology and Orthopedics
Department of Radiology
University of Colorado School of Medicine
Denver, Colorado

Disclosure: Mary Kristen Jesse, MD, has disclosed no relevant financial relationships.

Jason R. Kolfenbach, MD
Assistant Professor of Medicine
Division of Rheumatology
University of Colorado School of Medicine
Denver, Colorado

Disclosure: Jason R. Kolfenbach, MD, has disclosed no relevant financial relationships.

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