Painful shoulder syndromes: diagnosis and management

Painful shoulder conditions are common primary care problems. Providers should learn the topographical landmarks about the shoulder and understand shoulder mechanics. A careful clinical evaluation will usually provide a likely diagnosis. In unclear cases with marked pain, weakness, and reduced mobility, or with a suspected rotator cuff tear or rupture, arthrography or MRI will usually establish a diagnosis. Therapy of bursitis/tendinitis consists of a steroid injection into the inflamed subacromial area or a 14-day trial of an NSAID. Therapy of bicipital tendinitis, largely empiric because definitive studies are unavailable for any specific treatment, includes judicious peritendinous steroid injections and avoiding aggravating activities. In the management of patients with suspected tendon tears or rupture, primary care practitioners can confirm the diagnosis by ordering MRI or arthrography before referring these patients to an orthopedist for definitive surgical therapy. Optimal management of adhesive capsulitis remains unclear, but an intraarticular steroid injection appears beneficial at least in temporarily diminishing pain. Pendular motion exercising is also an integral part of therapy. Deleterious effects of peribursal or intraarticular steroid infiltration appear minimal; but injections into the tendon or frequent, repetitive injections are contraindicated. Each shoulder condition has a variable course, depending on the structure(s) and extent of involvement.