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Rotator cuff injuries are a common cause of shoulder pain in people of all age groups. They represent a spectrum of disease, ranging from acute reversible tendinitis to massive tears involving the supraspinatus, infraspinatus, and subscapularis. Pain, weakness, and loss of shoulder motion are common symptoms reported with rotator cuff pathology. Pain is often felt over the anterolateral part of the shoulder and is exacerbated by overhead activities. Night pain is a frequent symptom, especially when the patient lies on the affected shoulder. Diagnosis is usually made through detailed history, physical examination, and often, imaging studies (Inman & Sanders, 2016).
Shoulder dislocation may occur from a traumatic injury or from loose capsular ligaments. Different conditions may affect the stabilizing structures of the shoulder and, thus, negatively affect patients with shoulder dislocations. Patients with a dislocated shoulder report a myriad of symptoms including shoulder pain. Because most dislocations happen from trauma, patients report feeling the shoulder pop out or roll out during the incident. When dealing with shoulder instability, obtaining 2 orthogonal views of the shoulder is imperative, an AP view may not show a shoulder dislocation (Poppen & Walker, 2015).
Clavicle fractures may be caused by direct or indirect trauma. The most common mechanism is an indirect one in which the athlete falls onto the lateral shoulder, causing a compressive force across the clavicle, thus patient will present with complaint of shoulder pain. Although clavicle fractures are common and usually heal regardless of the selected treatment, complications are possible, warranting careful attention to these injuries. Laboratory studies are ordered in clavicle fractures according to the severity of trauma. With suspected vascular injury, obtain a complete blood count (CBC) to check the hemoglobin and hematocrit values (Inman & Sanders, 2016).
Angina pectoris is the result of myocardial ischemia caused by an imbalance between myocardial blood supply and oxygen demand. It is a common presenting symptom of chest pain but pain can be localized primarily in the epigastrium, back, neck, jaw, or shoulders. Chest radiograph findings are usually normal in patients with angina pectoris. Selective coronary angiography is the definitive diagnostic test for evaluating the anatomic extent and severity of coronary artery disease (Poppen & Walker, 2015).
Inman, V.T., & Saunders, J, B. (2016). Observations of the function of the shoulder joint. Journal of Bone and Joint Surgery, 2(6) 1-13.
Poppen, N.K, & Walker, P, S. (2015). Normal and abnormal motion of the shoulder. Journal of Bone and Joint Surgery, 58(2) 195-201.
Shoulder pain can be caused by a few different things such as a dislocated shoulder, arthritis, pinched nerve, or spinal issues. Sometimes people have pain in their shoulder area that is referred pain, injury pain, or even gas pains and doing some tests can help narrow down the cause.
A dislocated shoulder is when the humerus comes out of the socket. You might be able to see an obvious out of place shoulder, swelling, bruising, pain, and inability to move the joint. The patient can experience numbness, tingling, or weakness around the joint. The population in their teens/20s are most at risk from sports injuries, trauma, or even falls can cause this. If this is a repetitive injury it can cause shoulder instability, nerve/blood vessel damage, and tearing of muscles or ligaments around the joint.
Arthritis can affect the acromioclavicular joint or the glenohumeral joint and which one is affected needs to be distinguished. The differentiation between osteoarthritis and rheumatoid arthritis should be made as well because they have different treatments. The most common symptom would be pain, limited range of motion, and possibly weakness. Physical exam findings would include weakness in the muscle, tenderness upon palpation, decreased range of motion during active and passive movements, and crepitus/grinding/clicking of the joint (Shoulder, n.d.). Diagnosis can be made by x-ray by a narrowing of the joint space and possibly seeing bone spurs.
A pinched nerve is when something puts pressure on the nerve coming from the neck and can cause shoulder pain. It is also known as cervical radiculopathy and can be caused from wear and tear on the spine or by a sudden injury. Upon physical examination a provider will look at neck, shoulder, and arms looking for weakness, loss of sensation, and any changes to reflexes. X-ray can be done to look for alignment of bony structures and CT or MRI can be done to look at soft tissues that can be compressed or if bone spurs are present in the spine (Beach, et al., n.d.).
Spinal issues such as degenerative disc disease or a herniated disc that is causing shoulder pain. The discs between the vertebrae that acts as shock absorbers but during aging these discs can get smaller causing them to be proned to injury (Childress & Stuek, 2020). The pain is generally worse with movement, cause numbness and tingling in the hands, weakness in the affected arm. This is tested by doing range of motion movements, palpation of the neck and performing a MRI to determine if degenerative changes are present.
Beach, H., & Author AffiliationsFrom the Department of Family and Community Medicine. (n.d.). Clinical Examination of the Shoulder: NEJM. Retrieved January 14, 2021, from https://www.nejm.org/doi/full/10.1056/NEJMvcm1212941
Childress, M., & Stuek, S. (2020, August 01). Neck Pain: Initial Evaluation and Management. Retrieved January 14, 2021, from https://www.aafp.org/afp/2020/0801/p150.html
Shoulder Pain and Common Shoulder Problems – OrthoInfo – AAOS. (n.d.). Retrieved January 14, 2021, from https://orthoinfo.aaos.org/en/diseases–conditions/shoulder-pain-and-common-shoulder-problems/
Chronic low back pain is a common problem in all healthcare setting. A standardized clinical examination of the lumbar spine is critical in the evaluation of patients with low back pain. Progressing in an orderly fashion through the different components of the examination ensures accuracy and repeatability. Every examination should include inspection of the spine followed by active and passive range-of-motion testing, as well as manual muscle testing at the hip and spine. Finally, special testing and palpation are used to confirm findings appreciated earlier in the examination (Last & Hubert, 2019).
A history and physical examination should place patients into one of several categories: (1) nonspecific low back pain; (2) back pain associated with radiculopathy or spinal stenosis; (3) back pain referred from a nonspinal source; or (4) back pain associated with another specific spinal cause. For patients who have back pain associated with radiculopathy, spinal stenosis, or another specific spinal cause, magnetic resonance imaging or computed tomography may establish the diagnosis and guide management. Because evidence of improved outcomes is lacking, lumbar spine radiography should be delayed for at least one to two months in patients with nonspecific pain. Acetaminophen and nonsteroidal anti-inflammatory drugs are first-line medications for chronic low back pain. Tramadol, opioids, and other adjunctive medications may benefit some patients who do not respond to nonsteroidal anti-inflammatory drugs. Acupuncture, exercise therapy, multidisciplinary rehabilitation programs, massage, behavior therapy, and spinal manipulation are effective in certain clinical situations. Patients with radicular symptoms may benefit from epidural steroid injections, but studies have produced mixed results. Most patients with chronic low back pain will not benefit from surgery. A surgical evaluation may be considered for select patients with functional disabilities or refractory pain despite multiple nonsurgical treatments (Last & Hulbert, 2019).
For chronic low back pain, consistent features included supervised exercises, cognitive behavioral therapy and multidisciplinary treatment. However, there are some discrepancies for recommendations regarding spinal manipulation and drug treatment for acute and chronic low back pain. The comparison of international clinical guidelines for the management of low back pain showed that diagnostic and therapeutic recommendations are generally similar. There are also some differences which may be due to a lack of strong evidence regarding these topics or due to differences in local health care systems. The implementation of these clinical guidelines remains a challenge for clinical practice and research (McAuley & Maher, 2017).
Last, A. R., & Hulbert, K. (2019). Chronic low back pain: evaluation and management. American Family Physician, 79(12), 1067–1074. Retrieved from https://pubmed.ncbi.nlm.nih.gov/19530644
McAuley, J., & Maher, C. (2017). An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. American Spine Journal: official publication of the American Spine Society, 19(12), 2075–2094. https://doi.org/10.1007/s00586-010-1502-y
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