After knee pain, shoulder pain is the second most common type of orthopedic pain seen by family physicians.

Most shoulder problems are attributable to overuse and trauma. The shoulder is composed of one articulation, the scapulothoracic, and three true joints: the sternoclavicular, acromioclavicular, and glenohumeral.

Rotator Cuff Syndrome.

The rotator cuff muscles are the supraspinatus, infraspinatus, teres minor, and subscapularis, which rotate and more importantly stabilize the humoral head.

Stage I rotator cuff syndrome.

This is a rotator cuff tendinitis caused by forceful or repetitive motion, typically in those 25 years of age or younger. Pain is noted over the anterior aspect of the shoulder and is maximal when the arm is raised from 60 to 120 degrees of elevation. Treatment consists of avoiding aggravating positions and activities, applying ice packs, and taking NSAIDS.

Stage II rotator cuff syndrome.

This usually occurs in patients 25 to 40 years of age with multiple previous episodes. In addition to inflammation of the rotator cuff, some permanent fibrosis, thickening, or scarring is present. Calcific deposits may be noted within the rotator cuff on radiographs. Initial treatment is the same as that of stage I. If unsuccessful, the subacromial bursa can be injected with corticosteroids. If symptoms persist, referral to an orthopedist for a surgical consult should be considered.

Stage III rotator cuff syndrome.

This is a complete tear of the supraspinatus tendon and usually occurs after 40 years of age. The patient may relate feeling a sudden pop in the shoulder and then suffering severe pain. The patient notes increasing weakness when trying to abduct and externally rotate his or her arm. The diagnosis is confirmed by magnetic resonance imaging or a shoulder arthrogram. Treatment is usually surgical repair within 6 weeks, depending on whether there is significant loss of function and other factors such as age. Many elderly patients have progressive rotator cuff loss over years as a result of the aging process.

Adhesive Capsulitis (Frozen Shoulder).

Clinical features.
This chronically stiff and painful shoulder may begin without any significant injury. The cause is prolonged immobilization from either protracted use of a sling or disuse because of pain in the arm. Shoulder motion is limited in one or more directions, with pain occurring at the limits of motion. Both passive and active range of motion are limited.

Treatment involves extended, aggressive physical therapy and

NSAIDs or mobilization under anesthesia. Symptoms may take 2 years to improve significantly.

Tendinitis and Bursitis.

The supraspinatus and long end of the biceps are especially susceptible.

Clinical features. The primary symptom is a painful, aching shoulder

of rather nondescript type. With supraspinatus tendinitis, the pain is aggravated when the shoulder is abducted and externally rotated against resistance. With bicipital tendinitis, pain is aggravated when the patient flexes forward against resistance, and pain with palpation of long head of biceps.

Treatment.
Overuse syndrome in the shoulder should be treated with NSAIDs, ice and rest for 5 to 7 days. Most shoulder conditions can be relieved by injection of 2-5 cc of 1% bupivacaine and 40mg of triamcinolone into the effected area (e.g., subacromial bursa or tendon region). Ultrasound may be useful in calcific tendonitis but is not effective for other cases. Traditional physical therapy is often of limited efficacy but mobilization is helpful.

Acromioclavicular Injuries.
Usually result from a direct blow or fall on the tip of the shoulder.

Grade I (sprain). Partial tear of the joint capsule without joint

deformity and minimal ligamentous disruption and instability. AC joint films (with and without weights) are normal. Treatment includes ice, pain medication, a sling for comfort, and early mobilization.

Grade II (subluxation). Complete tear of the acromioclavicular

ligaments. The AC joint is locally tender and painful with motion. The distal end of the clavicle may protrude slightly upward. Stress radiograph of the AC joint with the patient holding a 10-pound weight in both hands reveals widening of the joint. Treatment is symptomatic in the same manner as the grade I injury but usually requires a longer period of immobilization (2 to 4 weeks).

Grade III (dislocation). Complete tear of the acromioclavicular

and coracoclavicular ligaments with pain on any attempt at abduction. There is an obvious "step-off" on physical examination. Radiographs show superior displacement of the clavicle and complete dislocation of the joint with weights. Conservative treatment with a sling is appropriate, provided that the patient understands that permanent deformity may result. Patients usually return to normal function. Surgical treatment is important if

symptomatic treatment fails or if it will interfere with the patients life (as in an athlete or person who does heavy work).

Glenohumeral Dislocations.
Clinical features. 95% are anterior, most commonly subcoracoid and
then subglenoid. The usual mechanism is forced abduction and external rotation. Patients complain of severe pain and usually hold the arm in tightly against their body. The shoulder appears flattened laterally and prominent anteriorly. The acromion process is prominent, and so the shoulder appears to be "squared off." The examiner must check for associated injuries, including proximal humeral fractures, avulsion of the rotator cuff, and injuries to the adjacent neurovascular structures. Axillary nerve injury is most common and is associated with decreased active contraction of the deltoid muscle and hypesthesia over deltoid.

Radiographs taken in two planes (AP and lateral scapula or axillary views) will confirm the dislocation and should be done to rule out fracture if mechanism suggestive. Treatment. The dislocation should be reduced as soon as possible.
Adequate analgesia and relaxation can be obtained by a 20ml intra- articular injection of 1% lidocaine. Narcotics (e.g., IV morphine) and muscle relaxants (e.g., diazepam) are useful as well. External rotation method (Hennipen technique). The patient is placed supine, with the arm abducted and the elbow flexed to 90 degrees. The examiner holds the elbow in position and externally rotates the shoulder. No pressure is applied to the forearm to force external rotation. If necessary, the arm can be abducted while in external rotation. Reduction usually occurs silently, unnoticed by the patient. This method has the

lowest rate of complications. Modified Stimson reduction. Analgesia or relaxation as noted above. The patient is placed prone on a table with the injured shoulder hanging free. Weight (up to 10-15 pounds) is suspended from the wrist, and the patient is left for 5 to 15 minutes. Further manipulation is often required consisting of gentle internal and external rotation with downward traction. Other reduction techniques include traction-countertraction and scapular manipulation. Postreduction care. Postreduction radiographs are obtained to ensure good relocation. Classically, the patients arm is immobilized in a sling-and-swathe dressing for 6 weeks, although recently early mobilization as been found to be superior. However, this is not yet standard of care. Early orthopedic follow-up care is recommended. Recurrent dislocation or subluxation is common and may require surgical repair.