History

A clear history guides further work up. The timing of onset of pain should be reported as accurately as possible, especially if pain started after a traumatic event. Any activities that provoke pain, such as overhead activities or sporting events should be noted, especially if there is a very particular trigger, such as the cocking phase of throwing, or the pull-through phase in swimming. The quality of pain should be described, for example, if the pain is burning, sharp, dull, or piercing. Any associated symptoms, such as numbness, tingling, and weakness should be reported as well as radiation to the arm, forearm, or hand. Clicking, catching, popping, swelling, and feeling the joint is unstable are also important to note.

Physical Exam

The physical examination guides further diagnostic work up. The practitioner assesses the general appearance of the shoulder, looking for asymmetry between shoulders, loss of muscle tone, changes in the bony structures, and overall posture. Range of motion and strength of the muscles of the upper extremities will be tested as well. The function of the nerves of the upper extremity will be tested grossly with strength, sensory, and reflex testing. Finally, several special tests may be performed to specifically evaluate for disorders of the shoulder joint, the rotator cuff, the labrum, etc.

Work Up

After the history and physical examination, further evaluation with a plain radiograph, or x-ray, is often obtained. Radiographs allow visualization of the bony structures of the shoulder. Bony derangements such as fractures, dislocations, and signs of osteoarthritis may be seen. Radiographs do not evaluate soft tissue structures, such as the rotator cuff. However, this relatively inexpensive test can provide some information regarding soft tissue problems; for example, a rotator cuff tear might be suggested by the position of the humeral head in the glenoid fossa.  

If further information is desired, Magnetic resonance imaging, or MRI is often the test of choice. MRI provides cross sectional images of a body part. The area of interest, in this case the shoulder, is placed in a large magnetic field. The resonance of hydrogen in the body is detected and converted into images by a computer. Both bony structures and soft tissues such as muscles, tendons, and nerves are visualized. Some suggest obtaining an MRI if pain persists after 3 months of physical therapy.

MR arthrography uses magnetic resonance technology to view the shoulder, but in this case, imaging is enhanced with contrast material injected in the joint (“direct arthrography”) or near the joint (“indirect arthrography”). Contrast is a liquid that has been formulated to “light up” and highlight certain structures on MRI. While not every painful shoulder requires this type of study, selected issues such as tears may be better evaluated with arthrography. If MRI is not available because the patient has a magnetic implant, Computed tomography or CT may also be used in conjunction with arthrography. CT uses x-ray technology to generate cross-sectional images. CT often provides better images of bone than MRI.  

In some areas, high-resolution ultrasound may be used to evaluate the rotator cuff, bursae, and other soft tissues near the shoulder. Ultrasound provides imaging without conferring radiation to the patient. Also, the examiner may place the patient in various positions to further assess sites of impingment. Although widely used in Europe, there are relatively few experienced musculoskeletal ultrasound operators in the U.S., making this study unavailable in some areas.

Arthroscopy is the “gold standard” for shoulder evaluation. In this procedure, an orthopaedic surgeon inserts a camera inside the shoulder joint to directly visualize the structures. This procedure also provides the opportunity to repair some structures such as the labrum, if indicated. Arthroscopy is considered a surgical procedure and carries the same risks of other surgeries, including complications of anesthesia, bleeding, and infection.