Screening shoulder and upper extremity

Dr. AYESHA NIAZ;PT

• Shoulder being the center are of arm and neck, becomes the
area of referred pain due to systemic or somatic disorders.
• Some of the common disorder include heart issues,
aneurysms, atherosclerosis, DM etc.
• Cardiac relates shoulder pain have the area of shoulder and
upper chest as the source of pain.
USING THE SCREENING MODEL TO EVALUATE
SHOULDER AND UPPER EXTREMITY
• CLINICAL PRESENTATION; Clinical examination should depend
upon clinical presentation and hx.
• Visceral or systemic conditions tend to elicit unilateral shoulder
pain.
• Shoulder pain could develop post surgical conditions like CABG,
pacemaker placement or any intervention/hosp causing
prolonged immobility could lead to local soft tissue
contractures and could lead to adhesive capsulitis.
 Shoulder Pain Is Unique
• Shoulder pain is difficult to diagnose because any pain
felt in the shoulder will affect the joint as though the
pain was originating in the joint.
 Shoulder Pain Patterns

Three possible mechanisms for referred pain patterns from the

viscera to the soma
• Embryologic development,
• Multisegmental innervations,
• Direct pressure on the diaphragm
 Multisegmental innervations;
shoulder is innervated by the same spinal nerves that
innervate the diaphragm (C3-C5), any messages to the
spinal cord from the
diaphragm can result in referred shoulder pain.
The nervous system can only tell what nerves
delivered the message. It does not have any way to
tell if the message sent along via spinal nerves C3
to C5 came from the shoulder or the diaphragm
DIAPHRAGMATIC IRRITATION;
• Peritoneal or pleural irritation in central area tends to refer pain to ipsilateral
shoulder. Pain usually in upper trapezius, neck or supraclavicular fossa.
• Shoulder pain could be b/l if irritant area expands a bit more, or b/l lower lobes
are engaged or in cardiac ischemia
• If peripheral irritation, then it will refer pain to costal and lumbar area.
• Pain could be unilateral or b/l depending upon the viscera as well. Kehr’s sign is
one example.
• Depending upon the kidney, pain could be right or in left shoulder but will be
ipsilateral.
• You can confirm the diaphragmatic involvement by palpating diaphragm and
also observe the diaphragmatic movement during breathing.
• Also assess for area above or below the shoulder to further r/o the somatic
involvement of pain.
• ASSOCIATE S/S WITH SHOULDER PAIN;
• Exacerbation of sx in recumbence
• Pleuritic component
• Coincident diaphoresis
• Associated GI s/s
• Exacerbation of exertion unrelated to shoulder pain
• Associated urological s/s
 Screening for gynecological causes of shoulder pain
• Ruptured ectopic pregnancy with abdominal hemorrhage will refer
pain to left shoulder. Hx will include absent menses or unexplained
bleeding.
• This type of pregnancy occurs when the fertilized egg implants
in some other part of the body besides inside the uterus. It may
be inside the fallopian tube, inside the ovary, outside the uterus
Or even within the lining of the peritoneum
• The most common symptom of ectopic pregnancy is a sudden, sharp or
constant one-sidedn pain in the lower abdomen or pelvis lasting more
than a few hours. The pain may be accompanied by irregular bleeding
or spotting after a light or late menstrual period
• . Shoulder pain does not usually occur alone without preceding or
accompanying abdominal pain, but shoulder pain can be the only
presenting symptom with an ectopic pregnancy.
• Factors that put a woman at increased risk for an ectopic pregnancy
include
• History of endometriosis
• Pelvic inflammatory disease (PID)
• Previous ectopic pregnancy
• Ruptured ovarian cysts or ruptured appendix
• Tubal surgery
• SCREENING FOR PULMONARY CAUSES OF
THE PAIN;
• Sharp localized pain due to pleural irritation can occur,
especially as the disease progresses.
• Pain is alleviated by lying on the same side or by auto splinting.
MSK pain is increased by doing same.
• Pain increases with respiratory movement or deep breathing.
• Increased shoulder pain upon lying down is a yellow flag. This
can occur due to increased venous return and increased intra
abdominal pressure in cephalic direction pinching on the
diseased lung/lob to trigger the sx.
 ASSOCIATED S/S
• Persistent or productive cough
• Chest pain
• Tachypnea
• Dyspnea
• Wheezing
• Hyperventilation
• AUSCULTATE DURING EXAMINATION TO HEAR THE BREATH
SOUNDS
• CARDIAC SCREENING FOR SHOULDER PAIN;
• Increased pain with activity, not related to shoulder movt.
• Should look for nausea, unexplained weight loss, jaw pain, toothache,
backache, or chest discomfort.
• Physical examination and associated signs including physical exertion
could help identify the visceral vs somatic source of pain in shoulder
Angina or Myocardial Infarction
• Look for shoulder pain that starts 3 to 5 minutes after the start of
activity, including shoulder pain with isolated lower extremity motion
• Shoulder pain associated with myocardial
• infarction is unaffected by position, breathing, or
• movement.
 Complex Regional Pain Syndrome

• CRPS; could depend upon type I or II. Cardiac involvement in type I

clinical s/s include ( type I, stage I );
• Burning ,throbbing, aching pain
• Increased sensitivity to touch
• swelling
• .muscle spasm, stiffness and loss of ROM
• Skin changes including red, warm skin and
• Accelerated hair growth in patches
• Stage II; ( subacute 3-6 months )
• pale, cool skin
• Increased pain intensity
• Swelling increases, tissues are soft, boggy and firm in
progression
• Muscle atrophy
• Nail bed changes ( cracked, grooved, ridges )
• Early onset of osteoporosis
• Stage III ; ( 6 months and longer )
• Irreversible damage including
• Muscle atrophy and contractures
• Shiny, thin skin
• Brittle nails
• Osteoporosis
• Pain may improve, or get worst
Thoracic Outlet Syndrome
• Compression of the neurovascular bundle consisting of the
brachial plexus and subclavian artery and vein
Bacterial Endocarditis:
• There could be night stiffness and/or pain in multiple joints generally
proximal joints which could be due to bacterial endocarditis.
• The shoulder is affected most often, followed (in declining incidence) by the
knee, hip, wrist, ankle, metatarsophalangeal and metacarpophalangeal
joints, and by acromioclavicular involvement accompanied by warmth,
tenderness, and redness. One helpful clue: as a rule, morning stiffness is not
as prevalent in clients
Aortic Aneurysm
• pain with a tearing sensation and the pain may extend to the neck,
shoulders lower back, or abdomen but rarely to the joints and arms, which
distinguishes it from a myocardial infarction.
• Throbbing, sharp pain along with feeling of pulsation in abdomen could
indicate AA. Pain could be in b/l shoulders and also in abdomen and back.
Pericarditis:
• The subsequent chest pain of pericarditis closely mimics that of a
myocardial infarction because it is substernal, is associated with
cough, and may radiate to the shoulder. It can be differentiated from
myocardial infarction by the pattern of relieving and aggravating
factors. For example, the pain of a myocardial infarction is unaffected
by position, breathing, or movement, whereas the chest and shoulder
pain associated with pericarditis may be relieved by kneeling with
hands on the floor, leaning forward, or sitting upright.
• Discuss dvt from chap 6
SCREENING FOR GASTROINTESTINAL CAUSES OF SHOULDER
PAIN
• Laparoscopy can also trigger pain in the left shoulder. Pain could last for
several days. This is due to introduction of air into peritoneum to move the
abdominal contents out of the way
• Shoulder pain that is worse 2 to 4 hours after taking the NSAID is a yellow
flag.
• The therapist must also ask about the effect of eating on shoulder pain
• Upper abdominal or gastrointestinal problems with diaphragmatic irritation
can refer pain to the ipsilateral shoulder. Peptic ulcer, gallbladder disease,
and hiatal hernia are the most likely GI causes of shoulder pain seen in the
physical therapy clinic. Usually there are associated sign and symptoms
such as nausea, vomiting, anorexia, melena, or early satiety but the client
may not connect the shoulder pain with GI upset.
 Screening For Renal Causes Of Upper Quadrant Pain
• Kidney problems like distension of renal cap will also trigger pain
ipsilateral due to irritation of diaphragm
• Pain can be referes on the same shoulder as affected kidney
• Dull and aching pain
• It could be ishemic or from organ distention.
• Changes in urine smell colour and amount and shoulder pain must be
reported to physician
• Check for presence of constitutional symptoms
 SCREENING FOR LIVER AND BILIARY CAUSES OF
SHOULDER PAIN
• The musculoskeletal symptoms associated with hepatic and biliary
pathologic conditions are generally confined to the midback, scapular,
and right shoulder regions.
• shoulder motion is not compromised and local tenderness is not a
prominent feature
Carpel Tunnel syndrome:
 SCREENING FOR RHEUMATIC
CAUSES OF SHOULDER PAIN
• The HLA-B27-associated spondyloarthropathies (diseases of the joints of
the spine), such as ankylosing spondylitis, most frequently involve the
sacroiliac joints and spine. Involvement
of large central joints, such as the hip and shoulder, is common, however.
Rheumatoid arthritis and its variants likewise frequently involve the
shoulder girdle
• Other systemic rheumatic diseases with major shoulder involvement
include polymyalgia rheumatica and polymyositis (inflammatory disease
of the muscles). Both may be somewhat asymmetric but almost always
appear with bilateral involvement and impressive systemic symptoms.
 SCREENING FOR INFECTIOUS
CAUSES OF SHOULDER PAIN
• Osteomyelitis (bone infection) is caused most commonly by
Staphylococcus aureus
• Mononucleosis is a viral infection that affects the respiratory
tract, liver, and spleen. Splenomegaly with subsequent rupture is
Primary Bone Neoplasm

a rare but serious cause of left shoulder pain (Kehr's sign).

Palpation of the upper left abdomen may reveal an enlarged and
tender spleen
• Septic Arthritis of AC joint and hands can manifest as shoulder
pain
 SCREENING FOR ONCOLOGIC
CAUSES OF SHOULDER PAIN
• CANCEROUS SCREENING; localized warm area in shoulder,
scapular area could indicate a metastatic involvement, diffused
sx including muscle weakness, localized pain, swelling and
localized MSK could be due to metastasis.
•
• Primary Bone Neoplasm

• Pulmonary (Secondary) Neoplasm

• Pancoast's Tumor
• RED FLAGS; presence of suspicious and/or aberrant lymph nodes
especially with previous hx of CA.
• Ectopic pregnancy
• Left shoulder pain post abdominal surgery, trauma
• Shoulder pain in women with absent menses and
unexplained/unexpected bleeding
• YELLOW FLAGS; pain in other joints
• GI, Urological, Respiratory and Cardiac associated sx
• Shoulder pain increased after 2-4 hours of taking NSAIDS
• Pain increases in lying position
• Pain increased upon deep inspiration or breathing pattern
 Scenario:
• .

Jesse, a 17-year-old student who’s active in football and track, came in during track season
complaining of severe left shoulder pain.
He denied any traumatic event or previous
injury to the shoulder, but reported that any
motion involving the shoulder caused pain.
It hurt at night, the patient said, when he lay on
his left side.
• The physical: No muscle atrophy, redness, or swelling was evident, nor
was there any indication of asymmetry or ecchymosis in the affected
area. Jesse’s neck range of motion was normal; he had a very hard time
with any active motion of the shoulder, however, because of the pain.
• Evaluation of scapular motion demonstrated scapular dyskinesis3,4
 without winging. Passive motion of the glenohumeral joint was much
better than active motion. Strength testing appeared to be grossly
intact but was limited by the pain. Shoulder impingement testing was
positive. Sensation and deep tendon reflexes were intact.
• Three months later, Jesse returned to our office, complaining
of weakness in his left shoulder. The pain had subsided a week
after his first appointment, so he’d never gone to physical
therapy. The weakness, which he had first noticed about 2
months after starting a lifting program in preparation for
football season, was limited to resistance exercises, especially
overhead shoulder presses and bench press. There were no
other changes in his history, and he reported no reinjuries.
• Physical examination revealed atrophy of the supraspinatus and
infraspinatus muscles (FIGURE 1) and external rotation and
shoulder abduction (in the scapular plane) resistance tests
revealed weakness of these muscles. There was no scapular
winging. The cervical spine exam was normal, and neurovascular
status was intact in both upper extremities.

• Parsonage-Turner Syndrome
• Brachial amyotrophy