LOEL Z. PAYNE, M.D.

    The history is a very important component of developing an appropriate treatment plan. Unfortunately, it is often neglected or abbreviated during a busy office schedule. Failure of a physician to ask the appropriate questions or a patient to provide an accurate history can lead down a path towards an inadequate treatment. Be prepared to tell your doctor as much information as you can about your shoulder pain. Some common questions are:

1. Where does it hurt?

As in real estate, it is location, location, location. Certain conditions cause pain in defined areas.

• Pain over the top of the shoulder is often from the acromioclavicular (AC) joint.

• Pain over the side of the shoulder and upper arm is often due to rotator cuff disorders.

• Pain in the shoulder blade is frequently due to parascapular muscle spasms.

• Pain over the front of the shoulder is usually from the glenohumeral joint or biceps tendon.

• Pain radiating below the elbow is often not from the shoulder and may be from the neck.

2. How long has it been painful?

The treatment for shoulder pain that has been present for only one or two weeks will be different than if the pain were present for years. Some shoulder conditions such as bursitis or tendinitis will often gradually improve with time. Even a frozen shoulder will often resolve after several years. Rotator cuff tear pain may or may not improve with time. Arthritis pain typically worsens as time goes by. 

3. What factors aggravate the pain?

Certain movements often aggravate shoulder conditions.

• Pain at the extremes of all movements such as trying to put on a bra, reaching out the window at a toll booth, trying to reach the top shelf, etc. is usually due to a frozen shoulder. With this condition, there is minimal pain during the mid-range of motion so people typically avoid stretching the arm.

• Pain primarily with overhead movement is frequently due to rotator cuff pathology. The rotator cuff helps elevate the arm and may impinge on a bone spur as the arm is lifted.

• Pain with the arm cocked to throw is more commonly due to a torn labrum or instability as the humeral head tries to sublux out of the glenoid.

• Pain over the front of the shoulder with lifting or carrying heavy objects may indicate damage to the biceps tendon.

• Night pain when laying flat is a classic symptom for a possible rotator cuff tear. While all shoulder conditions are worse with laying flat, a torn rotator cuff is usually worse.

4. Does the shoulder make noises or feel unstable?

The most common cause of noises in the shoulder (crepitance) is shoulder arthritis in the elderly, a torn cartilage in the younger athlete or the rotator cuff inflamed or torn in the middle aged. I tell patients that noises that are not painful are usually no reason for concern.

Instability of the shoulder or feeling of it slipping out of joint is characteristic for either a torn labrum or laxity of the shoulder ligaments. Most other shoulder conditions do not cause this sensation.

5. What activities do you like to do?

​This is an important question to ask. Some examples are:

• A weightlifter has a higher likelihood of developing shoulder arthritis.

• Someone who does repetitive overhead lifting at work may be more likely to develop problems with their rotator cuff.

• There is no reason to operate on a rotator cuff tear in an elderly patient who has minimal pain and is willing to limit their activities.

• A manual laborer is going to be out of work for at least several months after a repair and needs to plan accordingly.

6. Is this your dominate hand?

People are often surprised when their non-dominant shoulder is symptomatic. This may be due to weaker shoulder muscles because of less activity with that arm. Weaker muscles are more likely to be injured. However, the dominant arm is still the most frequently injured because of overuse. Balance is the key.

7. What other medical conditions do you have?

Certain medical conditions are known to be associated with shoulder pathology. For example:

• Frozen shoulder (adhesive capsulitis) is much more common in diabetics. People with thyroid disease, heart disease and Parkinson's disease also have an increased risk of developing this condition for reasons we do not understand.

• Left shoulder pain has a well known association with ischemic heart disease (heart attack). This is called referred pain.

• Referred pain to the right shoulder pain may be originate from gall bladder or liver disease.

• Lung cancer located at the top of the lung (apical) can cause shoulder pain.

• Neck pathology such as arthritis or nerve compression is often felt around the shoulder.

8. What other treatments have you tried? Were they effective?

Many patients have already tried some treatments prior to visiting a specialist. Anti-inflammatories such as ibuprofen, rest with activity modification and physical therapy are often the first steps in treatment. Steroid injections are frequently the second line of treatment. The location of the injection and how well it worked is important. If an injection is effective for only for a few days, the location of the injection is the source of the pain. However, since the injection only worked temporarily, the problem may be too significant to be managed by an injection alone.

9. Did you injure the shoulder? If so, how?

Traumatic injuries to the shoulder are more likely to produce a tear, fracture or dislocation.

• A fall on the point of the shoulder is often associated with an injury to the acromioclavicular (AC) joint such as a separation. It may also cause a fracture of the clavicle.

• A fall forward on the outstretched hand more commonly jams the rotator cuff against the acromion and may cause a tear in the rotator cuff tendon.

• A fall down the stairs while reaching out with the hand to grab the stair rail can place traction on the biceps tendon and tear it's origin. This is called a SLAP tear.

• An injury where the arm is pulled behind the body, especially if overhead, is more likely to produce a shoulder dislocation.