By Dr Sheldon Moniz, Orthopaedic Surgeon, Murdoch and Albany
The shoulder is one of the most complex and versatile joints in the human body, allowing for a remarkable range of motion. However, this complexity makes it particularly vulnerable to a variety of injuries and degenerative conditions.
To effectively manage shoulder issues, it is essential to understand that the shoulder is made up of three main joints or spaces – the acromioclavicular joint (ACJ), the subacromial space and glenohumeral joint.
In clinical discussions, the shoulder joint typically refers to the glenohumeral joint. It is important to recognise that there are multiple sources that can contribute to pain within the shoulder.
Identifying specific areas is crucial for targeted injections, which serve both therapeutic and diagnostic purposes. For example, if suspecting subacromial bursitis – a targeted injection into the glenohumeral joint may be of limited benefit to the patient.
Presenting complaint is key
Diagnostic approach for shoulder disorders is structured around four key clinical domains. Systematically assessing pain, instability, weakness, and stiffness allows clinicians to effectively narrow a differential diagnosis and identify the most relevant underlying pathology within a patient age group.
Shoulder problems often correlate with a patient’s age. One of the most common age-related conditions is degenerative rotator cuff tears.
RELATED: Shoulder pain 101
Interestingly, studies show that 70% of individuals aged 70 and above will have some degree of rotator cuff degeneration, though only 5% of these patients will progress to cuff-related arthropathy. Recognising the natural history of these conditions can help guide treatment decisions and patient expectations.
Diagnostic clues
Understanding of diagnostic clues can help differentiate between various shoulder pathologies. Some key conditions to recognise include:
ACJ Disruption: Often resulting from trauma, this condition presents with localised pain and deformity at the acromioclavicular joint.
Biceps Rupture: Patients may report a “pop” followed by pain and a noticeable bulge in the upper arm – Popeye sign.
Shoulder Dislocation: Anterior dislocations are the most common and require immediate reduction and referral.
Impingement Syndrome: Caused by compression of the rotator cuff tendons and bursa, often leading to pain with overhead movements.
Instability: Can be due to repetitive microtrauma or acute dislocation, leading to shoulder subluxation or persistent laxity.
Glenohumeral Osteoarthritis (OA): Characterised by progressive pain, stiffness, and loss of external rotation.
Frozen Shoulder (Adhesive Capsulitis): Marked by progressive stiffness and pain, often idiopathic or associated with diabetes.
Investigations
Blood tests are useful for detecting infections and systemic conditions such as rheumatoid arthritis or diabetes.
Plain film X-Ray remains a crucial first-line investigation that is often underutilised. Ultrasound can diagnose rotator cuff tears, bursitis, and other soft tissue injuries.
MRI is considered the gold standard for assessing soft tissue structures, including the rotator cuff, labrum, and biceps tendon.
However, findings should always be correlated with clinical symptoms, and it is not a first-line investigation.
RELATED: Management of first-time shoulder dislocations
Certain shoulder conditions require immediate referral to an orthopaedic specialist or emergency department. These include fractures, infections, tumours, acute rotator cuff tears and unreduced dislocations.
Prompt recognition and referral of these conditions are crucial to preventing complications and ensuring the best possible patient outcomes.
Treatment options
Conservative management is often effective and includes rest, physical therapy, and anti-inflammatory medications. However, some conditions may require surgical intervention, including:
- Rotator cuff repair for significant tears, especially in younger or active patients
- Shoulder stabilisation surgery for recurrent dislocations or instability
- ACJ excision for painful ACJ arthritis
- Subacromial decompression for impingement syndrome to relieve pain and improve function
- Biceps tenotomy or tenodesis for symptomatic biceps tendon pathology
- Shoulder arthroplasty – a total or reverse shoulder replacement is considered for severe osteoarthritis or irreparable rotator cuff tears.
General practitioners play a crucial role in the early diagnosis and management of shoulder conditions.
Referral to an orthopaedic specialist is warranted in cases of persistent pain despite conservative treatment, functional limitations affecting daily activities, suspected structural damage requiring surgical intervention and urgent conditions (fractures, dislocations, infections, or tumours).
Key messages
- A structured approach that incorporates patient age and symptoms aids in narrowing the differential diagnosis and guiding appropriate management strategies
- Know your target – injections can be a useful tool for both diagnostic and therapeutic purposes and are often more judicious than MRI to guide management
- Early diagnosis, appropriate investigations, and timely referrals can significantly improve patient outcomes.
Author competing interests – Nil
This clinical update is CPD verified. Complete your self-reflection and claim your CPD time here. 
Want more news, clinicals, features and guest columns delivered straight to you? Subscribe for free to WA’s only independent magazine for medical practitioners.
Want to submit an article? Email editor@mforum.com.au