Osteopathic Diagnosis of the Shoulder Region

Neck pain is one of the most common complaints in the general population. Depending on symptom duration, it can be acute, subacute, or chronic. There are many causes of neck pain, including degenerative disease, trauma, rheumatologic disease, and infections. Musculoskeletal conditions can range in severity from simple strain to radiculopathy and myelopathy. A careful history and physical examination is essential in discovering the etiology and guiding therapy. Treatment of the majority of cases of neck pain is conservative and activity-based.

Acute shoulder injuries are a common reason for visits to primary care physicians and EDs. Common acute shoulder injuries include acromioclavicular joint injuries, clavicle fractures, glenohumeral dislocations, proximal humerus fractures, and rotator cuff tears. Evaluation of acute shoulder pain requires an understanding of the mechanism of injury, as well as the appropriate physical examination and radiologic studies needed in the acute setting. A focused history and physical examination is essential and should include inspection, palpation, and a thorough neurovascular exam. Imaging begins with plain radiographs and is occasionally supplemented by MRI or CT imaging. Management includes pain control and varies based on diagnosis.

Shoulder pain is considered chronic when present for > 6 months. Common conditions resulting in chronic shoulder pain include rotator cuff disorders, adhesive capsulitis, shoulder instability, and joint arthritis. Shoulder pain can be intrinsic or extrinsic to the joint. The potential of serious causes of referred pain to the shoulder such as cardiovascular and abdominal etiologies should be considered. A focused history and physical examination is essential and should include inspection, palpation, range of motion (ROM), and provocative testing. Imaging often includes plain radiographs occasionally supplemented with MRI. Management varies related to specific disorders and frequently requires physical therapy.

Thoracic outlet syndrome (TOS) is a broad term used for a spectrum of syndromes related to the general region of the thoracic outlet, which involves the compression or irritation of elements of the brachial plexus, subclavian artery, or subclavian vein. The most common etiology involves structural abnormalities. Thoracic outlet syndrome can present as the neurogenic, arterial, or venous type. The neurogenic type is the most common among the 3 variants and mainly involves the inferior trunk of the brachial plexus (C8–T1). Signs and symptoms vary based on the structure that is involved. The diagnosis of TOS is clinical and supported by radiography and a number of provocation maneuvers. Untreated TOS can lead to various complications such as a frozen shoulder. Management of TOS is using pharmacological and surgical methods.

The shoulder complex comprises the glenohumeral joint, sternoclavicular joint, acromioclavicular joint, and the scapulothoracic articulation, and connects the upper limb to the trunk. This group of joints consists of the clavicle, scapula, and humerus bones, multiple muscles and supporting ligaments, cartilage, and bursae. The muscles ensure the mobility and stability of the shoulder and upper limb and are divided into 3 groups: anterior axioappendicular, posterior axioappendicular, and scapulohumeral muscles.

The arm is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior) and houses numerous structures, including the humerus; the brachial and profunda brachii arteries; the basilic, cephalic, and brachial veins; the radial, median, ulnar, and musculocutaneous nerves; and the flexor and extensor muscles of the arm.