Transcript: Diagnosing and Managing Shoulder Pain

Liz Rohr:
Well, hey there, it's Liz Rohr from Real World NP. You are watching NP Practice Made Simple, the weekly videos to help save you time, frustration, and help you learn faster so you can take the best care of your patients. In this week's video, I'm talking about shoulder pain. I used to really hate shoulder pain as a new nurse practitioner. On the one hand, the structures themselves physically, you can see them, you can understand how they work together. However, there's a real depth of knowledge that you need to have to feel comfortable with orthopedics. So in this video I'm going to share about shoulder pain, very high-level approach to shoulder pain with some really important helpful pearls of practice and resources as well as ways to approach the history taking as well as the physical exam and some special tests.

Yeah. So the first thing to start off with when it comes to a shoulder pain is number one, is this a traumatic injury, or is it a not traumatic shoulder pain? That is super important because there is a branch point there where somebody needs imaging versus you can hold on a second, depending on the clinical presentation, of course. But that's like number one question aside from the OLD CART approach, which I talk about all the time, onset, location, duration, characteristics, et cetera, et cetera. So whatever structured approach you have to your exam and history taking, traumatic or not traumatic is your first specific question for shoulder pain itself.

So the next piece is you're basically triaging is this a medical problem, like an another organ referred pain problem, or is it a musculoskeletal shoulder pain? Right? So that is one of our main next steps is is this physically the shoulder, or is it something else? And the top causes of referred pain are actually cervical spine, which is still orthopedics, but it's not the shoulder itself. So is it the cervical spine? Is it the heart? Is it the gallbladder? Is it the spleen? Those are the other top ones that it could be referred pain from. And then the other one is thoracic outlet syndrome, and that's a little bit of a zebra diagnosis, but you definitely want to take a little read about that if you haven't already. That is treatable potentially with physical therapy but may also need surgical intervention. So take a little peek at that, but that is definitely a zebra, not at the top of your list of your differentials for referred pain.

The other piece I want to say about triage, I've talked about this a little bit in the other videos I've made, I did an interview with a physical therapist, I did a video called Orthopedic Hacks, and generally speaking, broad brush, most musculoskeletal issues in primary care can be treated in four steps. Number one is non-steroidal anti-inflammatories. Number two is physical therapy. Number three is some sort of injection of some kind, usually some sort of steroid injection or otherwise. And then the fourth one is surgical intervention. So high-level, those are the main things that you see orthopedic interventions doing, right?

And so I really want you to keep that in mind. When it comes to shoulder pain, especially the main ones that I see in primary care, which are the chronic non-traumatic pains like rotator cuff, tendonitis, or impingement, things like that, you can stop that train at physical therapy. They don't necessarily need injections or surgery. However, the main thing that I see happening in primary care, because we are so siloed when it comes to multidisciplinary care, physicians and nurse practitioners, medical providers are going to do their medicine thing because that's what they are trained to do and that's what they know how to do.

And unfortunately, I see patients who go straight to either an injection or a surgical intervention before getting assessment and treatment by physical therapy when in fact they could have been treated in the first place and been fine without the other stuff. It's case by case dependent, of course. I'm talking primarily about chronic non-traumatic pain, which is the main thing that I see in primary care. So definitely keep that in mind that that by itself can be really helpful. And they literally go to school for seven years to do only that. So just keep all that in mind. They have their doctorates. Watch that interview with the physical therapist if you haven't already. They're amazing.

So anyway, our job is a triage of is it traumatic or non-traumatic? Is it a medical problem, like medical organ problem, or is it a musculoskeletal problem? And you can just refer them with shoulder pain with an unclear diagnosis of whether it's an impingement or otherwise, right? Just send them. Send them to physical therapy because that's literally their job and they can help you with that. And they actually prefer if you don't have a specific diagnosis on there and you just say, "Shoulder pain. Evaluate and treat." You don't have to say, "They have rotator cuff impingement and they need twice a week for six weeks." Don't do that. Just send them, and it's totally fine. That's actually what they want you to do.

Before I get into the history and the exams, I want to share another pearl of practice, which blew my mind a little bit, to be honest. I'm in physical therapy right now for some injuries that I've had, but the more you learn about orthopedics and all of the different muscles and joints and how they all work together, the site of the pain is not necessarily the cause of the pain or the source of the pain. So giving myself as an example, I have neck and shoulder pain. And so on video, you can see where I'm pointing, right at the top of my shoulder, not my AC joint, but more medial to that if you're listening by audio, and I can feel one particular point that hurts.

And for me, if I'm a nurse practitioner assessing myself, I'm like, "You know what? I'm not quite sure what structure, what's going on here, what's contributing to that. It's right by my joint. It could be a muscle." Spoiler alert, it's my trapezius muscle, and the insertion point is right where I'm pointing. And so my trapezius is very tight, my upper trapezius, and it's painful. And I stretch it out and that makes it feel better, but it keeps coming back, right? And so that's a really important thing to keep in mind is that even though the source of the pain is my trapezius, the source of the problem is in fact my rotator cuff muscles.

So if you understand how all the pieces fit together, which you can develop over time... And again, this is the main physical therapist, that's their job. I've learned all of this from my physical therapist and through extra reading too. But my course of action is actually to strengthen muscles that are not even related to that muscle to help it not do so much work because it's working for everybody else. So my subscapularis, my supraspinatus, my infraspinatus, I'm not saying that right, teres minor, all the rotator cuff muscles in the back, those are the muscles that are not working, which is causing the trapezius to be overactive, right? And how would we know that unless we had a super interest in orthopedics and we did a whole bunch of reading and/or we referred them to physical therapy and then they taught you that? Which is what happened to me. So anyway, site of pain is not always the source of pain. And if you don't have an in-depth understanding of the pathophys and how everything is working together, just send them for some extra help from physical therapy.

So history, I'm going to jump into history and exam. I promise I'll stop ranting about physical therapy. But history questions. So again, traumatic or non-traumatic? You definitely want to ask about what they do for work, what they do for their hobbies, especially if there's overhead reaching. The top differentials, I've talked about this a little bit in some of the other videos, the more experience you get, the more likely you are to know what the differential diagnoses are off the top of your head, and ask questions targeted to those differentials. That comes with a lot of time, right? So I'm going to hack this for you.

So we're talking about the main differential diagnoses to look out for when it comes to shoulder pain. Generally speaking with the musculoskeletal stuff, rotator cuff issues, whether it's impingement, tendonitis, labral tears or labral issues, that tends to be more with athletes than it tends to be with people who are not athletes. Arthritis is always in there. Biceps tendonitis, and that's right at the front of the deltoid and not quite lateral but halfway between medial and lateral, whatever that word is. There are two insertion points for the biceps. And so those you can physically touch and they will hurt the person.

And also, I'm getting a little bit into the exam, I'm getting ahead of myself but whatever, Speed's Test is a really good test for that. So if the person puts their arm straight out in front of them with their palms up and you press down and they resist your pushing, they will feel the pain right at that biceps tendon. Anyway, dislocation and fracture. Again, those are more traumatic injuries, but the chronic non-traumatic, we're talking about, again, rotator cuff stuff, frozen shoulder, labral tears, arthritis, and biceps tendonitis. Those are the main ones. And you also again want to think about cervical radiculopathy, another musculoskeletal but not like shoulder specific.

But anyway, the history is important because the more you understand about each of those issues, the more you'll be able to work backwards in your history to ask those specific questions. And for the most part it's always rotator cuff, almost always. And so that tends to happen when they have pain reaching overhead. So you want to ask them, are they a painter? Are they in construction? Do they work as a house cleaner? What's going on here to help you inform that picture, just for history taking and for understanding, right?

So when it comes to the physical exam, I've jumped ahead a little bit, but you want to do range of motion, both active and passive. So especially when it comes to the differential diagnosis of frozen shoulder, the range of motion, the little pearl there, is that it's going to be limited whether it's active or passive. Most other shoulder issues will have limited active range of motion because it's painful, but you can still passively move them, right? And so you want to do abduction, adduction of the upper arm, the lower arm, the forearm. You want to do grip strength. You want to see if there's weakness at all, whether it's true weakness because they can't move it or it's because limited strength because of pain. Is there any numbness or tingling as well? I didn't put that in the history, but those are really important things.

I already told you about the Speed's Test. I want to talk about the other special tests. So these are not sensitive or specific. They're not very helpful. There's a whole litany of them. They're not that sensitive or specific, so real talk. I have an orthopedic surgeon friend, a good friend who is an orthopedic surgeon, and he said to me that for him to feel really comfortable assessing those special tests, he's practiced them with patients who have the pathophysiology, the pathology that we're looking for, right?

So number one, they're nuanced. Number two, they're not that sensitive or specific. So just take with a grain of salt and do your best, right? I think they're spun as being pathognomonic of like, you do this special test and then you'll get your differential diagnosis or you'll get your specific diagnosis, and that's not really the case. So anyway, special tests that I do recommend considering, again, Speed's Test is for biceps tendonitis. You also have Hawkins Test. And so it's hard to describe, and so I'm going to link to down below this video then a couple of different links that have both a review of the physical structures but also of the special tests if you want to review those for yourself. But Hawkins Test is a pretty good one for impingement where you have your arm straight out in front of you and you're kind of tipping the elbow up, and that will cause pain right at the insertion point.

And then the only other one is the Spurling's Test, where you're checking to see if it's cervical radiculopathy. So a person turns their head to the side, and then you gently press, and then you see if they get symptoms down their arm. You could potentially also do the Empty Can Test where they put their arms straight out in front of them and they tip their hands out, so they're holding a can and tipping it out upside down to test the strength of the rotator cuff. But like I said, most patients who have pain in that area are still going to get pain, and that's not necessarily specific to that.

So that's it. Down below this video I have a whole bunch of different resources for you to look at both reviewing the structures as well as different exam things. So hopefully that's really helpful for you. If you haven't grabbed the Ultimate Resource Guide for the new NP, head over to realworldnp.com/guide. You'll get these videos sent straight to your inbox every week with notes from me, patient stories and bonuses. I really just don't share anywhere else. Thank you so much for watching. Hang in there, and I'll see you soon.