Screening the Shoulder and

Upper Extremity
 The therapist is well aware that many primary neuromuscular and
musculoskeletal conditions in the neck, cervical spine, axilla,
thorax, thoracic spine, and chest wall can refer pain to the shoulder
and arm. For this reason, the physical therapist's examination
usually includes assessment above and below the involved joint for
referred musculoskeletal pain
 USING THE SCREENING MODEL TO
EVALUATE SHOULDER AND UPPER
EXTREMITY
 Past Medical History the most common risk factors and red flag histories you might see with
each of these conditions. For example, a history of any kind of cancer is always a red flag.
Breast and lung cancer are the two most common types of cancer to metastasize to the
shoulder. Heart disease can cause shoulder pain, but it usually occurs in an age specific
population. Anyone over 50 years old, postmenopausal women, and anyone with a positive
first generation family history is at increased risk for symptomatic heart disease
 Hypertension, diabetes, and hyperlipidemia are other red flag histories associated with cardiac
related shoulder pain. Of course, a history of angina, heart attack, angiography, stent
placement, and coronary artery bypass graft (CABG), or other cardiac procedure is also a
yellow (caution) flag to alert the therapist of the potential need for further medical screening .
Risk factors include

 • Health care workers

 • Homeless population
 • Prison inmates
 • Immunocompromised individuals (e.g., transplant recipients, long-term use of
immunosuppressants, anyone treated for long-term rheumatoid arthritis, anyone treated with
chemotherapy for cancer)
 • Older adult (over 65 years)
 • Immigrants from areas where TB is endemic
 • Injection drug users
 • Malnourished (e.g., eating disorders, alcoholism, drug users, cachexia)
Clinical Presentation

 Differential diagnosis of shoulder pain is sometimes especially difficult because any pain that
is felt in the shoulder often affects the joint as though the pain were originating in the joint.
Shoulder pain with any of the components listed in this chapter should be approached as a
manifestation of systemic visceral illness, even if shoulder movements exacerbate the pain or
if there are objective findings at the shoulder
 Many visceral diseases present as unilateral shoulder pain .Esophageal, pericardial (or other
myocardial diseases), aortic dissection, and diaphragmatic irritation from thoracic or
abdominal diseases (e.g., renal, hepatic/biliary) all can appear as unilateral pain.
 "Frozen shoulder," or adhesive capsulitis, a condition in which both active and passive
glenohumeral motions are restricted, can be associated with diabetes mellitus,
hyperthyroidism, ischemic heart disease, infection, and lung diseases (tuberculosis,
emphysema, chronic bronchitis,)
Shoulder pain pattern

 we presented three possible mechanisms for referred pain patterns from the viscera to the
soma
 1. embryologic development,
 2. multisegmental innervations,
 3. and direct pressure on the diaphragm)
MULTISEGMENTAL INNERVATIONS

 Because the 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. So it takes a guess and sends a message back to one
or the other. This means that any organ in contact with the diaphragm that gets obstructed,
inflamed, or infected can refer pain to the shoulder
DIAPHRAGMATIC IRRITATION

 Irritation of the peritoneal (outside) or pleural (inside) surface of the central diaphragm
refers sharp pain to the ipsilateral upper trapezius, neck and/or supraclavicular fossa .
Shoulder pain from diaphragmatic irritation usually does not cause anterior shoulder pain.
 Pain is confined to the suprascapular, upper trapezius, and posterior portions of the
shoulder. If the irritation crosses the midline of the diaphragm, then it is possible to have
bilateral shoulder pain.
 This does not happen very often and is most common with cardiac ischemia or pulmonary
pathology affecting the lower lobes of the lungs on both sides. Irritation of the peripheral
portion of the diaphragm is more likely to refer pain to the costal margins and lumbar
region on the same side.
 SCREENING FOR PULMONARY CAUSES
OF SHOULDER PAIN
 Extensive disease may occur in the periphery of the lung without pain until the process extends to the parietal pleura.
Pleural irritation then results in sharp, localized pain that is aggravated by any respiratory movement.
 Clients usually note that the pain is alleviated by lying on the affected side, which diminishes the movement of that side of
the chest (called "autosplinting") whereas shoulder pain of musculoskeletal origin is usually aggravated by lying on the
symptomatic shoulder.
 Shoulder symptoms made worse by recumbence is a yellow flag for pulmonary involvement. Lying down increases the
venous return from the lower extremities.
 A compromised cardiopulmonary system may not be able to accommodate the increase in fluid volume.
 Referred shoulder pain from the taxed and overworked pulmonary system may result.
 At the same time, recumbency or the supine position causes a slight shift of the abdominal contents in the cephalic direction.
This shift may put pressure on the diaphragm, which in turn presses up against the lower lung lobes. The combination of
increased venous return and diaphragmatic pressure may be enough to reproduce the musculoskeletal symptoms.
 Pneumonia in the older adult may appear as shoulder pain when the affected lung presses on the diaphragm; usually there are
accompanying pulmonary symptoms, but in older adults, confusion (or increased confusion) may be the only other associated
sign.
 The therapist should look for the presence of a pleuritic component such as a persistent or productive cough and/or chest pain.
 Look for tachypnea, dyspnea, wheezing, hyperventilation, or other noticeable changes.
 Chest auscultation is a valuable tool when screening for pulmonary involvement.
 SCREENING FOR CARDIAC CAUSES OF
SHOULDER PAIN
 Pain of cardiac and diaphragmatic origin is often experienced in the shoulder because the heart and diaphragm are
supplied by the C5 to C6 spinal segment, and the visceral pain is referred to the corresponding somatic area.
 Exacerbation of the shoulder symptoms from a cardiac cause occurs when the client increases activity that does not
necessarily involve the arm or shoulder. For example, walking up stairs or riding a stationary bicycle can bring on
cardiac induced shoulder pain.
 In cases like this, the therapist should ask about the presence of nausea, unexplained sweating, jaw pain or
toothache, back pain, or chest discomfort or pressure.
 For the client with known heart disease, ask about the effect of taking nitroglycerin (men) or antacids/acid-
relieving drugs (women) on their shoulder symptoms.
Angina or Myocardial Infarction Angina
and/or myocardial infarction

 it can appear as arm and shoulder pain that can be misdiagnosed as arthritis or other
musculoskeletal pathologic conditions
 Look for shoulder pain that starts 3 to 5 minutes after the start of activity, including
shoulder pain with isolated lower extremity motion (e.g., shoulder pain starts after the
client climbs a flight of stairs or rides a stationary bicycle).
 If the client has known angina and takes nitroglycerin, ask about the influence of the
nitroglycerin on shoulder pain. Shoulder pain associated with myocardial infarction is
unaffected by position, breathing, or movement.
 Complex Regional Pain Syndrome (CRPS)

 Complex regional pain syndrome (CRPS, types I and II) characterized by chronic extremity pain following
trauma is sometimes still referred to by the outdated term shoulder-hand syndrome
 Type I was formerly known as reflex sympathetic dystrophy or RSD.
 Type II was referred to as causalgia.
 today CRPS-I, primarily affecting the limbs, develops after bone fracture or other injury (even slight or minor
trauma, venipuncture, or an insect bite) or surgery to the upper extremity (including shoulder arthroplasty) or
lower extremity.
 Type I is not associated with nerve lesion, whereas Type II develops after trauma with nerve lesion.
 CRPS-I is still associated with cerebrovascular accident (CVA), heart attack, or diseases of the thoracic or
abdominal viscera that can refer pain to the shoulder and arm.
Clinical Signs and Symptoms of Complex Regional Pain Syndrome
(Type 1) Stage I (acute, lasting several weeks)

 • Pain described as burning, aching, throbbing

 • Sensitivity to touch
 • Swelling
 • Muscle spasm
 • Stiffness, loss of motion and function
 • Skin changes (warm, red, dry skin changes to cold (cyanotic), sweaty skin)
 • Accelerated hair growth (usually dark hair in patches)
 Stage II (subacute, lasting 3 to 6 months)
 • Severity of pain increases
 • Swelling may spread; tissue goes from soft to boggy to firm
 • Muscle atrophy
 • Skin becomes cool, pale, bluish, sweaty
 • Nail bed changes (cracked, grooved, ridges)
 • Bone demineralization (early onset of osteoporosis)
 Stage III (chronic, lasting more than 6 months)
 • Pain may stay same, improve, or get worse; variable
 • Irreversible tissue damage
 • Muscle atrophy and contractures
 • Skin becomes thin and shiny
 • Nails are brittle
thoracic Outlet Syndrome

 Compression of the neurovascular bundle consisting of the brachial plexus and subclavian
artery and vein can cause a variety of symptoms affecting the arm, hand, shoulder girdle,
neck, and chest.
Aortic Aneurysm Aortic aneurysm

 appears as sudden, severe chest 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.
 Isolated shoulder pain is not associated with aortic aneurysm; shoulder pain occurs when
the primary pain pattern radiates up and over the trapezius and upper arm(s)
 The client may report a bounding or throbbing pulse (heart beat) in the abdomen. Risk
factors and other associated signs and symptoms help distinguish this condition.
 SCREENING FOR GASTROINTESTINAL
CAUSES OF 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 signs and symptoms such as nausea, vomiting, anorexia, melena, or early
satiety but the client may not connect the shoulder pain with GI upset.
 A few screening questions may be all that is needed to uncover any coincident GI symptoms. The therapist should
look for a history of previous ulcer nonsteroidal antiinflammatory drugs (NSAIDs).
 Shoulder pain that is worse 2 to 4 hours after taking the NSAID is a yellow flag. With a true musculoskeletal
problem, peak NSAID dosage (usually 2 to 4 hours after ingestion; variable with each drug) should reduce or
alleviate painful shoulder symptoms. Any pain increase instead of decrease may be a symptom of GI bleeding.
 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.
 These musculoskeletal symptoms can occur alone (as the only presenting symptom) or in combination with other
systemic signs and symptoms. Fortunately, in most cases of shoulder pain referred from visceral processes, shoulder
motion is not compromised and local tenderness is not a prominent feature
 Referred shoulder pain may be the only presenting symptom of hepatic or biliary disease. Sympathetic fibers from the
biliary system are connected through the celiac and splanchnic plexuses to the hepatic fibers in the region of the dorsal
spine. These connections account for the intercostal and radiating interscapular pain that accompanies gallbladder
disease
SCREENING FOR RHEUMATIC CAUSES
OF SHOULDER PAIN

 A number of systemic rheumatic diseases can appear as shoulder pain, even as unilateral shoulder pain. 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

 The most likely infectious causes of shoulder pain in a physical therapy practice include
infectious (septic) arthritis , osteomyelitis, and infectious mononucleosis (mono).
Immunosuppression for any reason puts people of all ages at risk for infection

 Osteomyelitis (bone infection) is caused most commonly by Staphylococcus

aureus. Children under 6 months of age are most likely to be affected by influenzae or
Streptococcus. Hematogenous spread from a wound, abscess, or systemic infection (e.g.,
tuberculosis, urinary tract infection, upper respiratory infection) occurs most often.
Osteomyelitis of the spine is associated with injection drug use. Onset of clinical signs
and symptoms is usually gradual in adults but may be more sudden in children with high
fever, chills, and inability to bear weight through the affected joint. In all ages there is
marked tenderness over the site of the infection when the affected bone is superficial
 Mononucleosis is a viral infection that affects the respiratory tract, liver, and spleen. Splenomegaly with
subsequent rupture is a rare but serious cause of left shoulder pain (Kehr's sign).
 There is usually left upper abdominal pain and, in many cases, trauma to the enlarged spleen (e.g., sports
injury) is the precipitating cause in an athlete with an unknown or undiagnosed case of mono.
 The virus can be present 4 to 10 weeks before any symptoms develop so the person may not know mono
is present. Acute symptoms can include sore throat, headache, fatigue, lymphadenopathy, fever, myalgias,
and, sometimes, skin rash.
 Enlarged tonsils can cause noisy breathing or difficulty breathing. When asking about the presence of
other associated signs and symptoms (current or recent past), the therapist may hear a report of some or
all of these signs and symptoms.
SCREENING FOR ONCOLOGIC CAUSES
OF SHOULDER PAIN

 A past medical history of cancer anywhere in the body with new onset of back or shoulder
pain is a red flag finding. Brachial plexus radiculopathy can occur in either or both arms
with cancer metastasized to the lymphatics
 muscle wasting is greater than expected with arthritis and follows a bizarre pattern that
does not conform to any one neurologic lesion or any one muscle. Localized warmth felt
at any part of the scapular area may prove to be the first sign of a malignant deposit
eroding bone. Within 1 or 2 weeks after this observation, a palpable tumor will have
appeared, and erosion of bone will be visible on x-ray
 Primary Bone Neoplasm Bone cancer occurs chiefly in young people, in whom a causeless limitation of movement of
the shoulder leads the physician to order x-rays. If the tumor originates from the shaft of the humerus, the first symptoms
may be a feeling of "pins and needles" in the hand, associated with fixation of the biceps and triceps muscles and leading
to limitation

 Pulmonary (Secondary) Neoplasm Occasionally the client requires medical referral because shoulder pain is referred
from metastatic lung cancer. When the shoulder is examined, the client is unable to lift the arm beyond the horizontal
position. Muscles respond with spasm that limits joint movement. If the neoplasm interferes with the diaphragm,
diaphragmatic pain (C3, C4, C5) is often felt at the shoulder at each breath
 Pancoast's Tumor Pancoast's tumors of the lung apex usually do not cause symptoms while confined to the
pulmonary parenchyma. Shoulder pain occurs if they extend into the surrounding structures, infiltrating the chest
wall into the axilla. Occasionally, brachial plexus involvement (eighth cervical and first thoracic nerve) presents
with radiculopathy. this nerve involvement produces sharp neuritic pain in the axilla, shoulder, and subscapular
area on the affected side,
 Breast Cancer Breast cancer or breast cancer recurrence is always a consideration with upper quadrant pain or
shoulder dysfunction ). The therapist must know what to look for as red flags for cancer recurrence versus delayed
effects of cancer treatment.
 SCREENING FOR GYNECOLOGIC
CAUSES OF SHOULDER PAIN

 Shoulder pain as a result of gynecologic conditions is uncommon, but still very possible.
Occasionally a client may present with breast pain as the primary complaint, but most often the
description is of shoulder or arm, neck, or upper back pain. When asked if the client has any
symptoms anywhere else in the body, breast pain may be mentioned.. Many of the breast
conditions discussed (e.g., tumors, infections, implants, lymph disease, trauma) can refer pain to
the shoulder either alone or in conjunction with chest and/or breast pain. Shoulder pain or
dysfunction in the presence of any of these conditions as part of the client's current or past
medical history raises a red flag.
Ectopic pregnancy

 The most common symptom of ectopic pregnancy is a sudden, sharp or constant one-
sided 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. When these two symptoms occur together (either alternating or
simultaneously), the woman may not realize the abdominal and shoulder pain are
connected. She may think there are two separate problems. She may not see the need to
tell the therapist about the pelvic or abdominal pain, especially if she thinks it is
menstrual cramps or gas. In addition, ask about the presence of lightheadedness,
dizziness, or fainting
Physician referral

 When symptoms seem out of proportion to the injury, or they persist beyond the expected
time of healing, medical referral may be needed. Likewise pain that is unrelieved by rest
or change in position or pain/symptoms that do not fit the expected mechanical or
neuromusculoskeletal pattern should serve as red flag warnings. A past medical history of
cancer in the presence of any of these clinical presentation scenarios may warrant
consultation with the client's physician.
 Guidelines for Immediate Medical Attention • Presence of suspicious or
aberrant lymph nodes, especially hard, fixed nodes in a client with a previous history of
cancer • Clinical presentation and history suggestive of an ectopic pregnancy