Differential diagnosis between

common shoulder conditions

Subacromial impingement
syndrome (SAIS)

MSK management

Presentation

Education and advice

Age 4060
Pain anteriorly and lateral to shoulder (often
over deltoid area)
Painful arc
Pain commonly with reaching or with
overhead activity
No pain radiating past elbow
Nocturnal pain if rolls onto affected shoulder
at night
Onset mostly insidious, occasionally related
to ongoing pain following trauma. Most SAIS
improves with rest from the aggravating activity
although pain will commonly persist if not
treated.

Treatments for SAIS may include:

Home exercise programme
Manual therapy
Subacromial steroid injection
Postural education or exercise groups

Investigations
A diagnostic ultrasound or ultrasound guided
injection may be performed by the MSK
consultants for symptoms not responding to
rehabilitation. Referral to Orthopaedics for a
subacromial decompression may be required.

Adhesive Capsulitis
(frozen shoulder)

Assessment

Presentation

Subjective assessment: pain with overhead

activities; movements of shoulder such as
pushing reaching, pulling and lifting

Age 3055

Objective assessment:

Nocturnal pain if roll onto affected side

- painful arc 90-120 degrees shoulder flexion

or abduction
- positive impingement tests (Hawkins and
Kennedy and empty can)

GP management

Frequently associated with diabetes

Stiff and painful, often severe
No neurological symptoms
Onset of primary frozen shoulder is slow and
insidious; secondary frozen shoulder may occur
following a single traumatic event such as a fall
on outstretched arm or from a pulling / traction
injury.

Prescribe appropriate analgesia

Advise relative rest from aggravating activity

Assessment

Give impingement patient information leaflet

Subjective assessment: pain at night; pain

anterior shoulder (with severe frozen shoulder
pain to wrist and hand), stiffness, difficulty
dressing etc

Referral to MSK service

Steroid injection

www.leedscommunityhealthcare.nhs.uk/msk

 Objective assessment:
- stiff all directions especially external rotation

GP management

- no crepitus

Young dislocations, <23 especially through

sport = refer to orthopaedics

- increased pain with movement eased with

rest immediately

Multiple dislocations: refer to MSK service

GP management
Prescribe appropriate analgesia
Give patient frozen shoulder information
leaflet
Not usually investigated unless age >60 to
exclude arthritis
Early intra-articular injections advisable
Refer to MSK team

MSK management
Treatments for frozen shoulder may include:
Education and advice

MSK management
Treatments for instability may include:
Education and advice
Rotator cuff strengthening
Proprioceptive exercises
Postural education
Exercise class

Investigations
An ultrasound may be performed for differential
diagnosis with symptoms that do not respond to
rehabilitation. An orthopaedic referral may by
required if instability persists.

Home exercise programme

Manual therapy
Intra-articular steroid injection to GH join
The MSK consultants provide high volume
injections for those failing to self manage
Onward referral to orthopaedics may be
required for a capsular release or MUA

Other possible causes of shoulder

pain for differential diagnosis:
Rotator cuff tears (positive Lag sign or droparm test)
Acromioclavicular joint pain (Positive Scarf
test)

Shoulder Instability

Pancoast tumour (apical lung tumour)

hoarseness, dyspnoea or cough

Presentation

Osteoarthritis

More likely under the age of 40

Cervical spine nerve root irritation posterior

shoulder pain/whole are pain +/-paraesthesia/
anaesthesia

Often present as an ongoing impingement

following dislocation due to structural
instability or poor proprioceptive muscle
control

Visceral shoulder pain

- Angina = left shoulder tip pain

Onset is almost always traumatic

- Gall bladder disease / liver = right shoulder

pain

Assessment

- Subphrenic abscess = can present as severe

rapid onset shoulder tip pain +/- unwell or
abdominal symptoms.

Subjective assessment: reports a dislocation;

apprehensive about abduction and external
rotation
Objective assessment: positive laxity tests
(sulcus sign, and apprehension and relocation
tests)

Leeds Community Healthcare NHS Trust, March 2012 ref: 0390/S

www.leedscommunityhealthcare.nhs.uk/msk