BY IAN HORSLEY MSC, MCSP

INTRODUCTION We’ve all been there, a patient presents with an ache around the shoulder area, with possibly some pain spread around the upper arm and scapular area. The patient is convinced that it’s a “shoulder problem”, but following a general musculoskeletal examination of the patient’s shoulder we’re not so sure. So we examine the cervical spine…and again there still seems to be no definitive diagnosis. We continue our examination process testing the joints distal and adjacent to the shoulder and review the subjective history and previous medical history to evaluate whether there are any non-musculoskeletal causes of shoulder pain present. This is part of the process of differential diagnosis. It can be a difficult process as systemic disease may also present clinically as shoulder pain and to make matters worse, any pain that is felt in the shoulder will affect the joint as if the pain were originating from that joint (1). Referred pain such as this can be defined as pain experienced at a site distant from the damaged tissue (2).

POSSIBLE CAUSES OF SHOULDER GIRDLE PAIN Somatic pain Somatic pain is often characterised by

20

IS IT REALLY A SHOULDER PROBLEM? A DIFFERENTIAL DIAGNOSIS OF SHOULDER PAIN

When a patient presents with an apparent shoulder problem, the process of differential diagnosis can lead to the cause. However possible sources of the pain could be many and varied. The therapist needs to recognise musculoskeletal and non-musculoskeletal causes of pain and if patients are not responding appropriately to treatment, needs to recognise when the time has come to review the differential diagnosis and refer where appropriate. This article looks at the issue of shoulder pain, the various different possible causes and approaches to diagnosis.

a deep dull, aching pain experienced at a site distant to the area of tissue damage, which is relatively static and poorly localised. It may be generated by structures in the cervical spine which refer pain when the nerve endings within the tissues are stimulated. C5-C7 and T1 are the most commonly affected areas.

SYMPATHETIC NERVOUS SYSTEM The sympathetic nervous system is not usually involved in generating pain unless inflamed or damaged directly, but due to the close proximity of the nerves to the posterior intervertebral

joints it may be responsible for affected sensation over the shoulder girdle area.

Radiculopathy Although not responsible for producing pain itself, altered conduction along the nerve causes numbness, decreased joint position sense and/or reduced motor reflexes (if a sensory nerve is involved) and segmental muscle

RECOGNISE CAUSES OF PAIN

THE THERAPIST NEEDS TO

sportEX dynamics 2010;24(Apr):20-23