How to Diagnose Shoulder Pain

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WASHINGTON, D.C.—A 70-year-old woman had been diagnosed with rotator cuff disease three years earlier and received an array of treatments.

What she hadn’t received was an X-ray. She’d had an MRI, and her doctor—not an orthopedist or a rheumatologist, but a primary care physician—had zeroed in on degenerative changes in her rotator cuff.

The problem, said Andrew Neviaser, MD, director of shoulder and upper extremity surgery at George Washington University, is that “everyone has degenerative changes in their rotator cuff when they’re 70 years old.”

The woman finally got an X-ray and was found to have “garden variety osteoarthritis”—something a total shoulder replacement would help, said Dr. Neviaser in the ACR Review Course at the 2016 ACR/ARHP Annual Meeting.

It was a cautionary tale that Dr. Neviaser used to drive home the importance of ordering X-rays when, as a rheumatologist, you are seeing a patient with shoulder pain and are trying to differentiate a rheumatic condition from an orthopedic one.

Be Systematic in Your Approach

Many clinical exam techniques exist for this, but the best accuracy rate is only in the 70% range.

“You really have to work this systemically, consider the age, consider the symptoms, consider where and how much pain a patient had when you’re testing them and get an internal control so you can reliably tease out things like rotator cuff, adhesive capsulitis and calcific tendonitis,” Dr. Neviaser said. “And then get an X-ray.”

Clinical exams tend to have poor specificity and sensitivity because “most of the pathology in the shoulder is going to be positive. When you take the arm and try to push it up over their head, arthritis will give you pain, adhesive capsulitis will give you pain, rotator cuff, labral problems, instability will all give you pain when you move the shoulder around.”

Several research groups have found that a telling measure could be the “critical shoulder angle,” which accounts for the inclination of the glenoid—the “socket” part of the shoulder joint—and the acromion, a bony extension of the shoulder blade. Bigger angles have been associated with rotator cuff disease and smaller ones with osteoarthritis.^1,2

“It’s an interesting idea that we are investigating now and may be something that’s very useful for us as clinicians because this is a very inexpensive test,” Dr. Neviaser said.

Clinical exams tend to have poor specificity & sensitivity because ‘most of the pathology in the shoulder is going to be positive.’ —Dr. Neviaser

To Surgically Intervene or Not?

Whether to move to surgery remains a question in many patients. It’s generally been thought that those with symptomatic rotator cuffs tend to be at risk for an increasingly large tear over time and, therefore, should be candidates for surgery, but there have been conflicting studies on this, he said.