Diagnosing and Managing Shoulder Pain
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Show notes:
When you’re working as a primary care nurse practitioner, you are going to see —i.e. diagnosing and managing — a lot of shoulder pain.
Like, a lot of it. Musculoskeletal issues are one of the most common chief complaints in primary care, after all.
A patient might be dealing with a torn rotator cuff or adhesive capsulitis. Or maybe subacromial impingement syndrome. Or even thoracic outlet syndrome. (Zebra alert!)
As a new nurse practitioner, I used to find shoulder pain pretty overwhelming. While you can *see* all the musculoskeletal structures and how they work together, there’s a lot more going on beneath the surface and dealing with orthopedics can require a real depth of knowledge.
But I’m going to help give you a jump start on that!
Diagnosing and Managing Shoulder Pain in Primary Care
In this week’s video, I’m taking a high-level view of diagnosing and managing shoulder pain for new nurse practitioners. We’ll talk about:
Which history questions are most valuable to ask
Why traumatic vs. non-traumatic presentation differentiates treatment
The four steps to treatment used to treat *most* musculoskeletal issues in primary care (and why you might to reconsider them)
And one clinical pearl that blew my mind when I learned it!
Resources mentioned in this episode:
If you liked this post, also check out:
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WEBVTT
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Hey there, welcome to the Real World NP podcast.
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I'm Liz Rohr, family nurse practitioner, educator, and founder of Real World NP, an educational
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company for nurse practitioners in primary care.
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I'm on a mission to equip and guide new nurse practitioners so that they can feel
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confident, capable, and take the best care of their patients.
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If you're looking for clinical pearls and practice tips without the fluff, you're in
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the right place.
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Make sure you subscribe and leave a review so you won't miss an episode.
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Plus, you'll find links to all the episodes with extra goodies over at realworldnp.com
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slash podcast.
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Well, hey there, it's Liz Rohr from Real World NP.
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You are watching NP practice made simple, the weekly videos to help save you time,
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frustration, and help you learn faster so you can take the best care of your patients.
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In this week's video, I'm talking about shoulder pain, and I used to really hate
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shoulder pain as a new nurse practitioner.
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On the one hand, the structures themselves, physically you can see them, you can understand
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how they work together, however, there's a real depth of knowledge that you need
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to have to feel comfortable with orthopedics.
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So in this video, I'm going to share about shoulder pain, very like high level
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approach to shoulder pain with some really important helpful pearls of practice and
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resources as well as ways to approach the history taking as well as the physical exam
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and some special tests.
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So yeah, so first, the first thing to start off with when it comes to a shoulder pain
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is number one, is this a traumatic injury or is it a not traumatic shoulder pain?
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Like that is super important because there is a branch point there where somebody needs
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imaging versus you can kind of hold on a second, depending on the clinical presentation,
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of course.
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But that's like number one question, aside from the old card approach, which I talk
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about like all the time, onset location, duration, characteristics, et cetera, et cetera.
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So like whatever structured approach you have to your exam and history taking, traumatic
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or not traumatic is your first kind of specific question for shoulder pain itself.
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So the next piece is you're triaging, you're basically triaging, is this a medical problem,
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like an organ, another organ referred pain problem, or is it a musculoskeletal shoulder
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pain?
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Right.
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So that is one of our main kind of next steps is, is this physically the shoulder
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or is it something else?
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And the top causes of referred pain are actually cervical spine, which is still
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orthopedics, but it's not the shoulder itself.
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So is it the cervical spine?
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Is it the heart?
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Is it the gallbladder?
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Is it the spleen?
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Those are kind of like the other top ones that it could be referred pain from.
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And then the other one is thoracic outlet syndrome.
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And that's a little bit of a zebra diagnosis, but you definitely want to take a little
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read about that if you haven't already.
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That is treatable potentially with physical therapy, but may also need surgical intervention.
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So take a little peek at that.
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But that is definitely a zebra, not at the top of your list of your differential for
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referred pain.
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The other piece I want to say about triage, I've talked about this a little bit in the
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other videos I've made.
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I did an interview with a physical therapist.
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I did a video called orthopedic hacks.
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And generally speaking, broad brush, most musculoskeletal issues in primary care
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can be treated in four steps.
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Number one is non-steroidal anti-inflammatories.
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Number two is physical therapy.
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Number three is some sort of injection of some kind, usually some sort of steroid injection
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or otherwise.
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And then the fourth one is surgical intervention.
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So high level, those are the main things that you see orthopedic interventions doing.
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And so I really want you to keep that in mind when it comes to shoulder pain,
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especially the main ones that I see in primary care, which are the chronic non-traumatic
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pains like rotator cuff, tendonitis or impingement, things like that.
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Those can be, you can stop that train at physical therapy.
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They don't necessarily need injections or surgery.
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However, the main thing that I see happening in primary care, because we are so siloed
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when it comes to multidisciplinary care, physicians and nurse practitioners like medical
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providers are going to do their medicine thing because that's what they are trained
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to do and that's what they know how to do.
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And unfortunately, I see patients who go straight to either an injection or a surgical
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intervention before getting assessment and treatment by physical therapy when in fact,
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they could have been treated in the first place and been fine without the other
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stuff.
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It's case by case dependent, of course.
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I'm talking primarily about chronic non-traumatic pain, which is the main thing that I
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see in primary care.
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So definitely keep that in mind that that by itself can be really helpful.
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And they literally go to school for seven years to do only that.
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So just keep all that in mind.
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They have their doctorates and watch that interview with a physical therapist.
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If you haven't already, they're amazing.
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So anyway, our job is kind of a triage of like, is it traumatic and non-traumatic?
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Is it a medical problem or like medical organ problem or is it a musculoskeletal
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problem?
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And you can just refer them with shoulder pain with an unclear diagnosis of whether
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it's, you know, an impingement or otherwise, right?
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Just send them.
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Send them to physical therapy because that's literally their job and they can help
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you with that.
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And they actually prefer if you don't have a specific diagnosis on there and you
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just say shoulder pain, evaluate and treat.
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You don't have to say they have, you know, shoulder and the rotator cuff
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impingement and they need to twice a week for six weeks.
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Like, don't do that.
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Just just send them and it's totally fine.
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That's actually what they want you to do.
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Before I get into the history and the exams, I want to share another pearl
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practice, which is kind of blew my mind a little bit, to be honest.
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I'm in physical therapy right now for some injuries that I've had.
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But this is the more you learn about orthopedics and all of the different
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muscles and joints and how they all work together, the site of the pain is
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not necessarily the cause of the pain or like the source of the pain.
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So giving myself as an example, I have neck and shoulder pain.
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And so on video, you can see where I'm pointing right at the top of my
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shoulder, not my AC joint, but kind of like more medial to that.
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If you're listening by audio and I can feel like one particular point that
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hurts.
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And for me, if I'm a nurse practitioner, assessing myself, I'm like, um, you
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know what, I'm not quite sure what structure what's going on here.
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What's, what's contributing to that.
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It's right by my joint.
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It could be a muscle.
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Like it's, it's spoiler alert.
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It's my trapezius muscle and the insertion point is right where I'm pointing.
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And so my trapezius is very tight, my upper trapezius and it's painful
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and I stretch it out and that makes it feel better, but it keeps coming
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back, right?
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And so that's a really important like thing to keep in mind is that even
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though the source of the pain is my trapezius, the source of the problem
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is in fact, my rotator cuff muscles.
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So if you understand how all the pieces fit together, which you can
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develop over time, right?
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And again, this is the main physical therapist, like that's their job.
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I've learned all this from my physical therapist and through extra
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reading too, but like strengthen, like my course of action is actually
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to strengthen muscles that are not even related to that muscle to help it
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not do so much work because it's working for everybody else.
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So my subscapularis, my, um, super spinae, my interest spinae,
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I'm not saying that, right?
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Terus minor, like all this rotator cuff muscles in the back.
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Like that's, those are the muscles that are not working, which is
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causing the trapezius to be overactive, right?
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And how would we know that, right?
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Unless we had a super interest in orthopedics and we did a whole
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bunch of reading and, or we referred them to physical therapy and then
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they taught you that, which is what happened to me.
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So, um, anyway, sight of pain is not always the source of pain.
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And if you don't have an in-depth understanding of the pathophys and
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like how everything is working together, just send them for some
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extra help from physical therapy.
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So history, I'm going to jump into history and exam.
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I promise I'll stop ranting about physical therapy, but, um,
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history questions.
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So again, traumatic or non-traumatic, you definitely want to ask about
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what they do for work, what they do for their hobbies, especially
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if there's overhead reaching.
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The top differentials.
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I've talked about this a little bit in some of the other videos, the
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more experience you get, the more likely you are to know what the
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differential diagnoses are off the top of your head and ask questions
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targeted to those differentials.
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That comes with a lot of time, right?
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So I'm going to, I'm going to hack this for you.
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So we're talking about the main differential diagnoses to look
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out for when it comes to shoulder pain, generally speaking, with
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musculoskeletal stuff, um, rotator cuff issues, whether it's impingement,
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tendonitis, laboral tears that tends to be more or laboral issues
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that tends to be more with athletes than it tends to be with,
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um, people who are not athletes.
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Um, arthritis is always in there, um, biceps tendonitis.
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And that's right at the front of the deltoid.
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And I'm kind of like not quite lateral, but like halfway between
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medial and lateral, whatever that word is, um, there are two
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insertion points for the biceps.
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Um, and so those you can physically touch and they will hurt the person.
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And also I'm getting a little bit into getting a little bit into the exam,
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getting ahead of myself, but whatever, um, speeds test is a
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really good test for that.
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So if you put your arm, if the person puts their arm straight
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out in front of them with their palms up and you press down
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and they resist your pushing, they will feel the pain right
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at that biceps tendon.
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Anyway, um, dislocation and fracture.
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Again, those are more traumatic injuries, but the chronic non-traumatic
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we're talking about again, rotator cuff stuff, frozen shoulder, um,
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labral tears, arthritis, and biceps tendonitis.
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Like those are the main ones.
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And, um, you also, again, when I think about cervical
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radiculopathy, another musculoskeletal, but not like
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shoulder specific, but anyway, the history is important because
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the more you understand about each of those issues, the more
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you'll be able to work backwards in your history to ask those
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specific questions.
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And for the most part, it's always rotator cuff, like almost always.
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And so that tends to happen when they have pain reaching overhead.
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So you want to ask them, are they a painter?
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Um, are they in construction?
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Do they work as a house cleaner?
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Like what's going on here to help you inform that picture, just
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for history taking and for understanding, right?
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So when it comes to the physical exam, I've jumped ahead a little
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bit, but you want to do range of motion, both active and passive.
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So especially when it comes to the differential diagnosis of
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frozen, frozen shoulder, the range of motion, the little
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pearl there is that it's going to be limited whether it's
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active or passive.
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Most other shoulder issues will have limited active range of motion
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because it's painful, but you can still passively move them.
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And so you want to do abduction, adduction of, you know, of the
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upper arm, the lower arm, the forearm, uh, you want to do grip strength.
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You want to see if there's weakness at all, whether it's true
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weakness because they can't move it or it's because limited
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strength because of pain.
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Is there any numbness or tingling as well?
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I didn't put that in the history, but those are really
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important things.
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Um, and I already told you about the speeds test.
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I want to talk about the other special tests.
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So these are not sensitive or specific.
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They're not very helpful.
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There's a whole litany of them.
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They're not that sensitive or specific.
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So real talk, I have an orthopedic surgeon friend, a good
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friend who is an orthopedic surgeon.
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And he said to me that for him to feel really comfortable
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assessing those special tests, he's practiced them with patients
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who have the, the pathophysiology, the pathology that we're looking for.
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Right?
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So it's a, they're number one, they're nuanced.
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Number two, they're not that sensitive or specific.
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So, you know, just take it with a grain of salt and do your best.
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Right.
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I think they're kind of like spun as being patho-pneumonic of like, you
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do this special test and then you will get your differential diagnosis or
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you'll get your specific diagnosis.
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And that's not really the case.
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So anyway, special tests that I do recommend considering again, speeds
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test is for biceps tendonitis.
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You also have Hawkins test.
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And so it's hard to describe.
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And so I'm going to link to the in down below this video, then a
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couple of different links that have both a review of the physical
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structures, but also of the special tests.
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If you want to review those for yourself, but Hawkins test is a
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pretty good one for impingement, um, where you have your arms straight
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out in front of you and you're kind of tipping the elbow up and that
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will cause pain right at the, um, at the insertion point.
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And then the only other one is, um, uh, the Sperling's test in
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what you're checking for to see if it's cervical radiculopathy.
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So a person turns their head to the side and then you gently press
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and then you see if they get symptoms down their arm.
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Um, you could potentially also do the empty can test where they put their
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arms straight out in front of them and they tip their hands out.
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So they're holding a can and tipping it out upside down to test
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the strength of the rotator cuff.
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But like I said, most patients who have pain in that area are
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still going to get pain and that's not necessarily specific to that.
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Um, so that's, that's it.
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I'm down below this video.
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I have a whole bunch of different resources for you to look at both
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reviewing the structures as well as, um, different exam things.
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So hopefully that's really helpful for you.
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If you haven't grabbed the ultimate resource guide for the new NP, head
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over to realworldnp.com slash guide.
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You'll get these videos sent straight to your inbox every week
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I really just don't share anywhere else.
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Thank you so much for watching.
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Hang in there and I'll see you soon.
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That's our episode for today.
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Thank you so much for listening.
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Make sure you subscribe, leave a review and tell all your NP friends.
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the best care to their patients.
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new NP, head over to realworldnp.com slash guide, you'll get these episodes
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sent straight to your inbox every week with notes from me, patient
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I really just don't share anywhere else.
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Thank you so much again for listening.
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Take care and talk soon.
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