Anterior Shoulder Pain

References: Arab Health Conference, 2014

Anterior shoulder pain is common and more frequent than posterior pain. It is probably easiest to consider the differential diagnoses on an anatomical basis, with specific anatomical pathologies giving rise to specific pain patterns [Bayam & Funk, Am J Orthop, 2011].

In this presentation, I will summarise our work on shoulder pain mapping, concentrating on the common, and also rare, causes of anterior shoulder pain. I will also present an approach to diagnosis that can assist with differentiation and treatment.

Before considering pain patterns, the cause of the pain, it’s nature and onset is essential. A traumatic onset offers a host of different diagnoses to an atraumatic, insidious onset. I will only concentrate on atraumatic aetiologies in this presentation. 

The conditions to consider and discuss are summarised below, with their specific nature, distribution and aetiologies.

  1. Anterior join line pain - localised and tender, often aching and dull in nature - consider capsulitis (early frozen shoulder) - x-ray and MRI scan
  2. Biceps groove pain - localised and tender, worse with lifting and carrying - consider biceps tendonitis - ultrasound scan
  3. Anterolateral pain - diffuse and radiates down arm - aching, but sharp pain with overhead activities (eg. brushing hair) - consider rotator cuff pathology (impingement, tendon tear, calcific tendonitis) - ultrasound scan
  4. AC Joint pain - very specific and localised - dull ache, but sharp with extreme overhead activities - consider ACJ Arthritis in older, osteolysis in younger - x-ray and MRI scan
  5. Pain over trapezius - persistant, dull ache - can radiate down arm and unaffected by shoulder movements - consider cervical radiculopathy - MRI cervical spine
  6. Coracoid pain - rare - localised tenderness over coracoid and sharp pain with shoulder adduction - consider coracoid impingement, but capsulitis may be more likely; also pec minor tightness secondary to other shoulder pathology (eg. impingement, instability) - MRI scan
  7. Sternoclavicular join pain - localised and tender, increased with overhead and adduction - consider SCJ arthritis in older, osteitis in young - MRI scan

Anterior shoulder pain is common and by careful understanding of the nature and distribution of the pain, one can more easily diagnose, investigate and treat appropriately. If there is uncertainty, then guided diagnostic local anaesthetise injections are extremely beneficial. I also find MRI scans with fat suppression or STIR sequences that enhance areas of inflammation useful in certain circumstances. For more information please see  Bayam & Funk, Am J Orthop, 2011.


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