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Understanding Chronic Shoulder Pain: Diagnosis and Management Insights

Explore the evaluation and causes of chronic shoulder pain in a 53-year-old gentleman with diabetes and hypertension. Learn about different mechanisms and syndromes leading to inflammatory arthritis, and how to determine the source of pain.

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Understanding Chronic Shoulder Pain: Diagnosis and Management Insights

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  1. An Approach to the PAINFUL Joint Asgar Ali Kalla Professor of Rheumatology University of Cape Town

  2. Pain in the left shoulder • A 53 year old gentleman complains of a 2 month history of pain in the left shoulder. He does not recall any trauma. The pain is usually worse at the end of the day and sometimes wakes him late at night. He suffers from diabetes mellitus for 5 years and is on oral hypoglycaemic medication. • How would you determine the source of this patients’ pain?

  3. Further Information • On further enquiry it is found that the patient was recently diagnosed with hypertension. He has also experienced severe pain in the right first metatarsophalangeal joint which came on suddenly and subsided over the next 2-3 days. • What is the most likely mechanism for this patient’s inflammatory arthritis?

  4. This talk • Important anatomical concepts • Evaluation of Musculoskeletal Pain • What is the source? • What is the cause

  5. Knee (2) Frontal view Frontal view

  6. Extra-articular Structures Tendon Epimysium Perimysium Endomysium Fascicle Fibril Microfibril Enthesis Fiber Collagen

  7. What is the SOURCE SHOULDER PAIN JOINT REFERRED LOCAL CONTRACTILE ALWAYS START WITH ACTIVE MOVEMENT LIMITATION NO LIMITATION / NO PAIN NO LIMITATION / PAIN

  8. SHOULDER PAIN LIMITATION ACTIVE MOVEMENT PASSIVE MOVEMENT NO LIMITATION / NO PAIN NO LIMITATION / PAIN LIMITATION CONTRACTILE RESISTED MOVEMENT NO LIMITATION CAPSULAR PATTERN NO PAIN PAIN CONTRACTILE NON-CAPSULAR PATTERN CONTRACTILE CONTRACTILE CONTRACTED REFERRED JOINT

  9. What is the CAUSE REFERRED CONTRACTILE JOINT DEGENERATIVE Cx SPINE HEART OESOPHAGUS DIAPHRAGM REGIONAL DIFFUSE INFLAMMATORY • AUTO-IMMUNE • REACTIVE • CRYSTAL REGIONAL PAIN SYNDROME e.g. TROCHANTERIC BURSITIS PRIMARY OA SECONDARY OA FIBROMYALGIA

  10. CAPSULAR PATTERNS OF LIMITATION OF PASSIVE MOVEMENT • SHOULDER ER > ABD > IR • WRIST FL = EXT • HIP IR > ABD > ER

  11. SUMMARY • Anatomical and functional aspects of musculoskeletal system • Articular, extra-articular, referred • Cause of the Clinical Problem

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