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Shoulder pain in primary care
In shoulder pain ask two questions: is passive movement restricted (frozen shoulder or arthritis) or preserved (a tendon problem), and does the pain come from the shoulder at all (neck, heart, lung, diaphragm)?
Why it matters in the exam
Exam questions describe a diabetic woman with restriction in all directions (frozen shoulder), an athlete with a "painful arc" on raising the arm (impingement), weakness on elevation after a fall (rotator cuff tear), or a dislocated shoulder with a question about the injured nerve. They also ask about the effective treatment and the expected course.
Remember that bilateral shoulder pain with morning stiffness in an adult over 50 is a systemic inflammatory disease (polymyalgia) and not a "shoulder problem".
The first step of the examination is always comparing active with passive movement, and the second is testing strength. These two steps, together with age and the mechanism of injury, are almost always enough to reach a diagnosis without imaging. Further questions describe an athlete with shoulder pain on throwing, and ask about testing strength and movement and the need for imaging.
Key points
- Passive restricted — frozen shoulder or arthritis; passive preserved — tendons.
- Painful arc between 60 and 120 degrees — impingement.
- Frozen shoulder is linked to diabetes; injection and physiotherapy, recovery within 1–3 years.
- Anterior dislocation — check the axillary nerve; recurrence is common in young patients.
- Pain unrelated to movement — look for a referred source.
Summary table
| Condition | Key sign | Work-up | Treatment |
|---|---|---|---|
| Rotator cuff impingement and tendinopathy | Painful arc between 60 and 120 degrees, night pain, passive movement preserved | Clinical; ultrasound if no improvement | Physiotherapy, NSAIDs, subacromial steroid injection |
| Rotator cuff tear | Weakness in elevation or external rotation, "drop arm" | Ultrasound or MRI | Acute tear in a young patient — surgical referral; in an older patient — usually conservative |
| Frozen shoulder (adhesive capsulitis) | Active and passive restriction, mainly external rotation; diabetes and hypothyroidism | Clinical; normal X-ray | Intra-articular steroid injection and physiotherapy; usually recovers within 1–3 years |
| Anterior shoulder dislocation | Fall on an outstretched hand, "squared-off" shoulder | X-ray before and after reduction | Reduction, check the axillary nerve; in a young patient — high risk of recurrence |
| Glenohumeral osteoarthritis | Gradual pain and crepitus in an older adult, restriction in all directions | X-ray | Analgesia, physiotherapy, joint replacement |
| Referred pain | Pain unrelated to shoulder movement | According to suspicion: neck, ECG, chest X-ray | According to the source |
A free exam question
בן 49 ש נפגע בתאונת דרכים, הועבר מחדר ניתוח למחלקה אור ת ופדית לאחר ניתוח לשבר מורכב בכתף ימין. זמן קצר לאחר קבלתו נמצא ל"ד 92/54 , טכיקרדיה 110 .לדקה עלה חשד כי לחץ הדם הנמוך המתואר נגרם עקב היפוולמיה. מה מבין הבאים יכול להעיד על הצורך במתן נוזלים בצורה הטובה יותר לחולה? (the question as examined, in Hebrew)
- א. ביצוע Passive Leg Raising המדגים עלייה ב - Mean arterial Pressure
- ב. רמת לקטט מעל 4 mmol/l בנוכחות המוגלובין מעל 9 gr/dl
- ג. תפוקת שתן פחותה מ- 60-80 סמ"ק לשעה בנוכחות אוסמולריות של השתן מעל 300 mmol/l
- ד. pH < 7.2 בנוכחות PCO2 > 35 mmHg
In the full version for subscribers
- A simple algorithm
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- Exam traps
- 5 review cards
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Sources
- Goroll AH, Mulley AG. Primary Care Medicine, 8th edition (2020) — Evaluation and management of shoulder pain
- American Academy of Orthopaedic Surgeons, 2019–2023 — Clinical practice guidelines on rotator cuff injuries and glenohumeral joint osteoarthritis
- British Elbow and Shoulder Society, 2015 (updated) — Patient care pathways: frozen shoulder, subacromial pain, shoulder dislocation
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.