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The value of the history and physical for shoulder pain.

ALTHOUGH SOPHISTICATED imaging techniques aid in the visualization of the musculoskeletal system, most disorders about the shoulder girdle can be diagnosed by a simple yet thorough history and physical examination.' High-powered investigative aids more often confirm an established diagnosis rather than identify an unknown primary diagnosis. The basic skills of the history and physical examination are often overlooked, placing an excessive dependence on technology. This becomes glaringly obvious as more patients present to the specialist's office with a magnetic resonance image (MRI) even before plain radiographs have been taken. The key to the successful treatment of any shoulder problem is an accurate diagnosis. Several factors in the history play a major role in formulating the diagnosis and will therefore immediately guide a physician in the appropriate direction. Age, the chief complaint, and the mechanism of injury are invaluable in the diagnostic process. The history should be patterned so as to exclude the presence of referred pain, infection, or tumor. It is important to remember that the evaluation of the shoulder begins with the cervical spine because this is a common source of local referred pain and the symptom complexes of these two areas often overlap. Pain that is duplicated by range of motion or manipulation of the neck is of cervical origin despite the fact that it may be perceived about the shoulder. Pain of a radicular nature such as this often produces a pain-free examination of the shoulder. Hand dominance, occupation, and aggravating and alleviating factors are also of utmost importance. Because pain is the most common reason people seek medical attention, obtaining specific details regarding its nature, duration, and onset is helpful. As in other areas of medicine, different orthopedic disorders afflict different age groups. The most common cause of anterior shoulder pain in those older than 40 years is impingement. Impingement is most commonly caused by narrowing of the outlet formed by the acromion, coracoacromial ligament, and the acromioclavicular joint, resulting in encroachment on the underlying rotator cuff tendons.2 Typically patients will have pain on overhead elevation and internal rotation maneuvers, such