Arizona Reynolds Program of Applied Geriatrics ELDER CARE A Resource for Providers
Pain When Reaching Overhead: Four Common Shoulder Problems in Older Adults
By Peter J Millett MD MSc Director of Shoulder Surgery Steadman Hawkins Clinic Vail CO
Shoulder problems occur frequently in older adults Patients with this condition often notice pain on Four syndromes are particularly frequent and they all reaching upward such as when putting on a sweater share the common symptom of pain when reaching or turning a steering wheel It is often painful to sleep overhead rotator cuff tendinitis or impingement on the affected side Examination shows good active syndrome rotator cuff tear osteoarthritis and and passive range of motion but active motion is frozen shoulder Each can cause pain and painful when doing things like reaching overhead
Tips for Evaluating and Treating Shoulder Problems in Older Adults • If pain occurs during abduction at o of arc a rotator cuff problem either tendinitis impingement or a tear is the likely diagnoses • Passively abduct the patient’s arm to o and ask the patient to hold the arm in that position when you let go If the arm sinks positive drop arm sign or there is weakness a rotator cuff tear is the likely diagnosis • Obtain M RI to confirm rotator cuff tear Acute c omplete tears should be repaired within weeks of injury significant long term disability clasping hands behind the neck or scratching the lower back Arm abduction will typically cause pain Many clinicians find it difficult to distinguish these between o of the arc Plain x rays should be shoulder syndromes from one another This issue of ordered and may show an offending bone spur but Elder Care will briefly review the four conditions and MRI is the best test to visualize tendons of the rotator provide an algorithm that outlines a diagnostic cuff MRI should be obtained if surgical repair is approach for distinguishing them being considered Rotator Cuff Tendinitis or Impingement Conservative treatment consist of icing the shoulder for minutes times daily non steroidal anti
inflammatory drugs NSAIDs which should be used exercises Steroid injections may also be helpful cautiously as they may cause renal impairment in though there is no strong evidence supporting their older adults plus physical therapy for range of motion effectiveness and shoulder strengthening exercises Surgery may Osteoarthritis be needed for those who do not respond to these Osteoarthritis of the shoulder often presents with measures posterior shoulder pain that can extend to the Rotator Cuff Tear muscles of the upper arm Patients may feel pain and Patients with this condition present with pain over the crepitation or grinding when lifting objects lateral deltoid They also have weakness and are Examination shows loss of both active and passive typically unable to lift even a small lb weight motion sometimes with audible or palpable crepitus overhead The key physical findings are the “lag during movement against resistance Strength is sign” or “drop arm” sign The “lag” is the difference usually preserved though limited by pain Plain x between passive range of motion which is typically rays show osteoarthritic changes of joint space unrestricted and active range of motion which is narrowing sclerosis and bone spurs Treatment limited For the drop test have the patient stand and includes ice NSAIDs acetaminophen and steroid passively abduct the patient’s arm to degrees injections into the shoulder joint The latter provides With the arm at shoulder level the patient is asked to only temporary relief but relief following the injection keep the arm in that position as the examiner lets go helps confirm the diagnosis Arthroscopic debridement If the arm sinks the drop arm sign a cuff tear is and total shoulder arthroplasty are effective likely With larger tears plain x rays will show treatments for cases refractory to non operative upward displacement of the humeral head but MRI is therapy the most accurate imaging modality and will not only Frozen Shoulder demonstrate the size of the tear but also the degree Patients with frozen shoulder have stiffness and of muscle atrophy and fatty infiltration all of which difficulty with all motion Both active and passive affect the prognosis for successful repair motion are severely limited distinguishing frozen Acute rotator cuff tears should be repaired surgically shoulder from the other conditions discussed thus far within weeks of injury For chronic tears surgery Patients often cannot put on a coat or scratch their may still be beneficial but a non operative approach back and are unable to touch their scapula from may also be considered first using ice NSAIDs and above or below Plain x rays should be obtained but physical therapy with gentle range of motion are typically normal and show a preserved joint
space With NSAIDs and physical therapy for range in the capsule For refractory cases it may be of motion and strengthening exercises most patients necessary to perform arthroscopic capsular release or will improve though recovery can take months joint manipulation under anesthesia to break up Intra articular steroid injections can be helpful in the adhesions early stages to decrease the inflammation that is seen
Algorithm for Diagnosing Common Causes of Shoulder Pain in Older Adults
Shoulder pain with overhead reaching
Red Flags Imaging or Trauma fever effusion acute onset arthrocentesis of loss of range of motio n prior
Examine passive and active range of motion ROM
• Full passive and active ROM • Passive ROM active ROM • Passive ROM and • Pain w o abduction • Posi tive “lag” or “drop arm” sign s active ROM both restricted Acknowledgement
Rotator cuff Rotator cuff tear X ray of shoulder Thank you to Peter J Millett, MD, MSc, Director of Shoulder Surgery, Steadman Hawkins Clinic, Vail CO tendinitis impingement References and Resources Osteoarthritic changes Normal • Gomoll AH, Katz JN, Warner JJ, Millett PJ. Rotator cuff disorders: recognition and management among patients with shoulder pain. Arthritis Rheum. 2004;50:3751-61. • Matsen FA Rotator cuff failure N Eng J Med Osteoarthritis Frozen shoulder • Millett PJ, Gobezie R, Boykin RE. Shoulder osteoarthritis: diagnosis and management. Am Fam Physician. 2008;78:605-11.