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A 62-year-old man comes to your office to discuss his self-diagnosed right "shoulder bursitis" of over 6 months. The aching pain began insidiously and has worsened over time. The pain is exacerbated by painting (on an easel) and not relieved by acetaminophen or ibuprofen.

  • What additional questions would you ask to learn more about his shoulder pain?
  • How do you classify causes of shoulder pain?
  • How can you use the patient history to distinguish between benign and serious causes requiring urgent attention?

Shoulder pain is a common reason for seeking medical attention. In Great Britain, shoulder pain is the third most common musculoskeletal complaint, representing 5% of musculoskeletal general practice visits. The incidence of shoulder pain reaches a peak in the fourth to sixth decades of life.

Although patients often think of the shoulder as an anatomic region, the clinician must not automatically equate shoulder pain with shoulder joint pain or, more narrowly, glenohumeral joint pain. Many nonmusculoskeletal disorders refer pain to the shoulder. Furthermore, shoulder range of motion involves 4 articulations—glenohumeral, acromioclavicular, sternoclavicular, and scapulothoracic—as well as the associated ligaments, tendons, bursae, muscles, and neurovascular bundles. Disorders in any of these structures can lead to shoulder discomfort.

Evidence-based literature on history in the diagnosis of specific shoulder disorders is limited. Nevertheless, most shoulder pain can be diagnosed by history and physical examination. Imaging is then often used to confirm the diagnosis or assess the severity of a given condition. Figure 52–1 shows the shoulder anatomy.

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Rotator cuffMusculotendinous structure blending into the glenohumeral joint capsule providing range of motion and strength. It is composed of the insertions of the supraspinatus, infraspinatus, teres minor, and subscapularis tendons.
Intrinsic pain (also called moving parts pain)Pain related to structures in the shoulder, including bones, joints, muscles, bursae, tendons, and ligaments. Typically exacerbated by shoulder movement.
Extrinsic pain (also called referred shoulder pain)Pain from a process in a nonshoulder area or organ perceived as shoulder discomfort. Typically, pain is unrelated to shoulder movement.
Impingement syndromeCollection of symptoms and signs resulting from compression of the rotator cuff tendons and subacromial bursa between the humeral head and lateral acromion process. Occurs in many different shoulder conditions. See Figure 52–2.
Subacromial bursitisInflammation of the subacromial bursa. Usually causes symptoms of impingement syndrome, and often coexists with rotator cuff tendinopathy.
Rotator cuff tendinopathyDegenerative changes within the rotator cuff tendons leading to pathology ranging from simple inflammation to fibrosis with resultant rotator cuff tears. Patients usually have the impingement syndrome.
Calcific tendinitisCalcification of a rotator cuff tendon, usually the supraspinatus, proposed to be part of the degenerative process of rotator cuff tendinopathy.
Biceps tendinitisOveruse syndrome of the long head of the biceps tendon, usually producing anterior shoulder pain.

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