Differential Diagnosis of the Shoulder Complex

1. Are there factors present in the patient's medical history that can mimic shoulder pain? (Did they say yes to any screening questions?)

2. Does their history appear consistent with a MSK issue?

3. Can I reproduce their comparable sign in my examination?

4. Did I screen adjacent joints that may produce musculoskeletal pain at the shoulder complex?

What are Ideas to Consider As You Are Completing Your Shoulder Examination:

- Tumor

- Infection

- Visceral

- Systemic Arthritis

- In general people will report a non-mechanical pain presentation

What are non MSK conditions that can result in shoulder pain

- Constant pain

- General malaise or feeling unwell

- Pain that varies based on the involved system function

- More likely to have ongoing medical comorbidities

What are non-mechanical pain presentations from non-MSK conditions that can occur during shoulder pain

- Fevers

- Chills

- Sweats

- Erythema

- Edema

- Malaise

- Pain

- Loss/regression of ROM

What are clinical signs/symptoms of infection

- History of cancer*

- Unexplained weight loss

- Pain not related to mechanical stress

- No relief with rest

- Night pain

- Unexplained mass, swelling or deformity

What are common signs/symptoms associated with tumors

- Osteosarcoma

- Ewing sarcoma

- Chondrosarcoma

- Pancoast

What are examples of tumors that can lead to shoulder pain

- Shoulder and arm, C8-T2 distribution

- Horner's syndrome presentation

- Weakness/atrophy of hand

what are key points about pancoast tumors associated with shoulder pain

Intense angina followed by symptoms into the left arm, chest, and/or neck

What does the classic manifestation of referred shoulder pain from cardiac problems entail

- Elderly, women, diabetics

- Jaw, R arm, L arm

What does the non-classic manifestation of referred shoulder pain from cardiac problems entail

- Inquire about recent cardiovascular involvement

- Sweating, nausea, or chest pain coinciding with shoulder pain? Atypical locations with shoulder pain?

- Increase in shoulder pain with exertion?

- Does shoulder pain go away with medical management (nitroglycerin)?

- Do you have a family history of cardiovascular disease?

- What is your diet?

- Do you have a history of smoking?

- What are your current and recent levels of stress?

- Do you have a history of diabetes?

What are cardiac screening questions to ask when a patient presents with shoulder pain

- Shoulder pain referred due to irritation of the diaphragm by gastric juices

- Innervated by phrenic nerve (C3-5)

- Distribution to anterior and/or lateral border of right scapula

What are key points about peptic ulcers and shoulder pain

anterior and/or lateral border of right scapula

With peptic ulcers and shoulder pain, there is a distribution of pain to the __________

cholecystitis and shoulder pain

- Usually accompanied by gall stones or abdominal pain

- Referral to right shoulder, between scapula, subscapular space

right shoulder, between scapula, subscapular space

with cholecystitis and shoulder pain, there is referral to the _______________

- Eating aggravate pain and/or 1-3 hours post meal?

- Medical history include gallstones?

- Overt feeling of fullness?

- Nausea, vomiting, loss of appetite since shoulder pain?

What are some screening questions for patients with shoulder pain who have peptic ulcers

Liver disease/abscess and shoulder pain

- Right shoulder or subscapular area

- Hepatitis, cirrhosis, metastatic tumors

spleen rupture and shoulder pain

- Left shoulder

- Typically result of trauma

pancreas and shoulder pain

- Left shoulder

- Possible site for cancer

1. Have you noted discoloration of urine or blood in your stools?

2. Are your symptoms exacerbated after eating?

3. Have you vomited recently?

4. Have you experienced any changes in your bowel or bladder habits?

5. Does eating certain foods make your pain feel worse?

What are some screening questions for the GI in relation to shoulder pain

PA

_______ characterized by shoulder and hip pain, morning stiffness, and malaise

True

TRUE or FALSE: Cervical spine referred pain into the shoulder region very common.

secondary impairment (regional interdependence)

Thoracic spine/ribcage may be involved as a ____________ to shoulder pain

thoracic and periscapular

Cervical facet joints and discs refer pain to the _____ and _____ area

periscapular

Cervical radiculopathy: patients often report ______ area pain

- Inquire about history of or current neck or upper back pain

- Inquire about aggravating factors

- Location of pain

Cervicothoracic Spine Assessment in Patients Reporting Shoulder Pain: Patient History

- Supraclavicular, upper trapezius, periscapular

- Do you have any pain below your shoulder? In the shoulder blade region?

What are history screening points of focus for Cervicothoracic Spine referred shoulder pain

- Cervical AROM +/- overpressure

- Thoracic AROM +/- overpressure

- Cervical and thoracic PA spring testing

Cervicothoracic Spine Assessment in Patients Reporting Shoulder Pain: Physical Examination

- Falls

- Blunt trauma

- Sudden loading/eccentric contraction

what are common mechanisms of traumatic shoulder pain

- Humeral Fractures

- GH Dislocations +/- labral tear

- Shoulder separation/ACJ sprain

- RTC tears

- Other tendon tears: biceps, pecs

what are common traumatic shoulder pain related conditions

- Establish mechanism of injury

- Establish timeline and previous management

- Inquire about imaging

- Traumatic conditions more likely to require a surgical opinion.

- Refer out, when necessary, such as with fractures, dislocations, and acute RTC tears.

What are key points about treating Traumatic Shoulder Pain

- Glenohumeral OA

- ACJ degeneration

- Bone stress injuries

What are boney conditions associated with Atraumatic shoulder pain

- RTC related disorders

- Instability/labral disorders

- Frozen shoulder

What are soft tissue conditions associated with Atraumatic shoulder pain

- Thoracic outlet syndrome

- Peripheral neuropathies

What are neurologic conditions associated with shoulder pain

- Axillary nerve

- Suprascapular nerve

- Spinal accessory nerve

What types of peripheral neuropathies are associated with shoulder pain

- Subacromial decompression

- Rotator cuff repair

- Labral repair

- Humeral open reduction internal fixation (ORIF)

- Shoulder arthroplasty

- Screen for infection and DVT post-op

- Understand the post-operative precautions and restrictions

Common post-operative conditions associated with shoulder pain

1. Review medical screening form, pain body diagram, and patient reported outcome measures

2. Generate initial hypotheses

3. Conduct patient interview with specific questions related to hypotheses

4. Reconsider hypotheses and conduct physical exam accordingly

What are the steps in the process of differential diagnosis for shoulder pain