Hello, I’m Karen Ginn. I’m a Professor in Musculoskeletal Anatomy at the University of Sydney and a musculoskeletal physiotherapist. I’m involved in clinical research related to the assessment and treatment of shoulder dysfunction, and electromyographic investigation of shoulder muscle function.
What is your approach to assessing clients or patients over the age of 40 presenting with shoulder pain?
Both the functional anatomy of the shoulder and mounting evidence from clinical research points to exercise therapy as the treatment of choice for patients who present with shoulder pain of mechanical origin.
To be able to determine the most effective, efficient exercise program for a particular patient a specific, detailed understanding of the presenting muscle dysfunction is needed.
Therefore, my interview and clinical assessment is aimed at identifying the specific shoulder muscle dysfunction underlying the presenting shoulder pain – what I might call a specific “functional diagnosis”. From my understanding of the normal functional anatomy and biomechanics of the shoulder I am aiming to identify:
- which muscle group is most implicated in the presenting signs and symptoms?
- is it the mover or stabiliser role of this muscle group most implicated?
- and in which part of range is this muscle group most affected?
How important is a specific diagnosis for shoulder pain?
The aim of a diagnosis is to aid communication between clinicians and patients regarding the reasons for the presenting problem, in this case the reasons for the presenting shoulder pain, and to direct an appropriate course of treatment.
The shoulder is designed to be able to achieve very large ranges of movement, the most mobile region in the body. To achieve this the shoulder region relies on muscles to not only produce movement in all planes but also to provide stability to the region during movement. Passive structures like joint capsules and ligaments can only contribute to joint stability by preventing further movements once end of range has been reached.
Therefore, a valid diagnosis to explain the reason for the presenting shoulder pain and to direct an appropriate treatment would be an explanation of how the underlying muscle dysfunction is causing pain in the shoulder joint.
How would you advise discussing a shoulder pain diagnosis and treatment pathway with a patient?
I would suggest explaining to the patient the crucial role muscles play in both moving and stabilising the shoulder region, and therefore how problems with how the muscles are functioning, for example weakness or tightness or lack of co-ordination, can cause shoulder joint pain. For example, subacromial impingement occurs because the humeral head (the ball of the shoulder joint) is pulled out of its socket and bangs into the acromion (the ledge above the shoulder). This occurs because the rotator cuff muscles are not working properly to hold it in the socket against the pull of the muscles moving the shoulder. Therefore, the way to stop the joint pain is to do exercises so that the rotator cuff can hold the ball in place during shoulder movement.
In which scenarios would you refer a patient presenting with shoulder pain for imaging or other investigations?
Structural deficits at the shoulder do not correlate with pain and functional deficits.
For example rotator cuff tears are common in people with no shoulder symptoms, particularly in those over the age of 60.
In addition, the rotator cuff tear size is not related to how long they’ve had the symptoms, the level of pain that they’ve experienced or the functional limitation associated with their shoulder pain. Therefore, imaging to identify soft tissue deficits particularly in the older population does not contribute to understanding the underlying cause of shoulder pain nor in determining appropriate exercise therapy and is not warranted in the majority of instances.
In addition, if structural deficits are identified it can lead to significant patient distress.
I would only suggest a referral for imaging in the following circumstances.
Following trauma involving the shoulder to rule out fracture, or to rule out rotator cuff tear in the young patient who is unable to move their shoulder immediately following the traumatic episode. And secondly to investigate red flags for example suspected neoplasm or infection.