Diagnosis of Shoulder Pain in the Older Adult

Evaluating pain and problems in the shoulder is different when the patient is older. The underlying causes aren't the same as in active, younger adults. Older adults have more degenerative disease or injuries from falls. Younger adults experience more injuries from sports or athletic participation.

Although the basic interview, patient history, and physical exam are similar for these two age groups, there are some important differences. The authors of this article provide a review of the recommended history and exam for older adults with shoulder pain. This is part-one of a two-part article. The second article will focus on treatment options once the diagnosis has been made.

Any good medical interview allows the patient an opportunity to tell what's wrong and how it happened. The examiner tries to fill in with questions that give him or her a full understanding of the patient's daily activities. This includes hobbies, athletic participation or other physical activity, and desires/goals from treatment.

The patient interview actually continues as the examiner begins to assess pain, inspect the shoulder complex, measure range-of-motion, and test strength. The patient may report that the shoulder locks up or catches but sometimes the examiner hears and feels this during the exam. Some provocative tests reproduce the pain. That can be very useful information when sorting through a wide range of possible reasons for shoulder pain.

There is no single test that will quickly uncover the problem. Usually, several tests combined together give the examiner information that leads to a diagnosis. Researchers have not been able to package together a group of tests that can be used routinely with each shoulder pain patient for the most accurate diagnosis.

It may be necessary to go through quite a few of the available tests before discovering what's wrong. Sometimes normal tests are more helpful than abnormal ones. At least the examiner can tell what's working right. Abnormal test results have a way of muddying the waters because there can be several possible corresponding problems.

When it's all said and done, the examiner steps back and takes a look at the big picture. Are there any other health problems? Does the patient have neck or back involvement? Are there any constitutional symptoms? Constitutional symptoms are those signs and symptoms that come in a cluster with any systemic disorder no matter which system is involved. For example, fever, chills, fatigue, unexplained perspiration, and nausea or vomiting are common constitutional symptoms.

It's important to conduct a very thorough exam -- even if the first test is positive for a specific pathology. After the patient points to the painful area, the examiner palpates or feels that area for any signs of soft tissue damage or change. Swelling, skin temperature, muscle atrophy (wasting), and soft tissue/boney bumps can be documented this way.

Pain as a diagnostic tool can be helpful. Location, quality, and aggravating and relieving factors provide useful clues. Does it hurt at the beginning, midrange, or end range of motion? The answer to that question can point to a specific soft tissue that is being pinched or compressed. Is the pain close to the surface? Skin deep?

Can the patient point to it with one finger or is it vague and diffuse? Pain deep in the shoulder may be caused by labral pathology. The labrum is a fibrous rim of cartilage around the shoulder joint. It is firmly attached to the acetabulum (shoulder socket) and provides depth and stability to the shoulder. Even tiny tears of this structure can cause intense pain.

A full range-of-motion assessment is also important. Any compensatory motions, loss of motion, or changes from one side to the other should be noted. That will help determine which shoulder-specific tests to perform.

Each muscle group can be tested for strength/weakness. Specific tests can be conducted for impingement, rotator cuff tears, labral tears, biceps tear or rupture, and nerve impingement or blood vessel compromise. Pulses, sensation, grip strength, and reflexes are useful tests to look for a neurologic or vascular (circulation) problem.

Shoulder exams take time to complete. No one test is sensitive enough or accurate enough to draw any final conclusions from it. The results of each test point to the next test to conduct or consider. Putting all the pieces together of the history and interview with the clinical findings from the tests performed can result in an accurate differential diagnosis. The examiner who uses a systematic approach with each patient will be efficient yet thorough.

Reference: 

Allison Tobola, MD, et al. Identifying Shoulder Pain in Older Patients: The History, Physical Examination, and Testing. In The Journal of Musculoskeletal Medicine. June 2009. Vol. 26. No. 6. Pp. 216-221.

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