SHOULDER PAIN
SHOULDER PAIN: Excerpt from Algorithmic Diagnosis of Symptoms and Signs
Ask the Following Questions:
- Is there significant radiation of pain down the arm? The presence of significant radiation of pain down the arm would suggest thoracic outlet syndrome, herpes zoster, herniated cervical disk, spinal cord tumor, brachial plexus neuritis, myocardial infarction, sympathetic dystrophy, Pancoast's tumor, and aortic aneurysm.
- Is the radiation down the arm transient? The presence of transient radiation of pain down the arm would suggest coronary insufficiency.
- Are there hypoactive reflexes or significant dermatomal loss of sensation in the involved extremity? These findings would suggest spinal cord tumor, herniated cervical disk, and brachial plexus neuritis, among other disorders.
- Is there pain on active motion only? Pain on active motion only is more frequently found in subacromial bursitis, calcific tendinitis, and torn rotator cuff.
- Is there pain on both active and passive motion? This finding would suggest osteoarthritis, rheumatoid arthritis, gout, dislocation of the shoulder, adhesive capsulitis, shoulder-hand syndrome, aseptic bone necrosis, and osteomyelitis.
- Is there normal range of motion of the shoulder and normal neurologic examination? These findings would suggest that the pain is referred from gallbladder disease, pancreatitis, ruptured peptic ulcer, pleurisy, or tuberculosis.
- Are there diminished pulses in the involved extremity? These findings would suggest occlusion of the subclavian artery, thoracic outlet syndrome, or dissecting aneurysm.
DIAGNOSTIC WORKUP
The first thing to do is an x-ray of the shoulder. If this is normal, a trial of conservative therapy may be initiated before ordering an expensive diagnostic workup. If the pain persists, routine diagnostic studies include a CBC, sedimentation rate, urinalysis, chemistry panel, arthritis panel including ANA, x-ray of the shoulder, chest x-ray, and EKG. An MRI of the shoulder may need to be done to rule out a torn rotator cuff. Shoulder arthrography can also be used to diagnose this condition. If there are abnormal neurologic findings, EMG, nerve conduction velocity studies, and MRI of the cervical spine may need to be done. A neurologist should be consulted before ordering these expensive diagnostic tests.
If there are focal trigger points in the bursa or shoulder joints, a therapeutic trial of lidocaine hydrochloride (Xylocaine®) and corticosteroid injections should be done if the x-rays of the shoulder are negative or show only calcific tendinitis. Stellate ganglion blocks may be diagnostic and therapeutic for sympathetic dystrophy. If there are abnormalities of the brachial or radial pulses, angiography may need to be done. When there is intermittent pain down the arm, an exercise tolerance test may need to be ordered. However, it may be wise to refer the patient to a cardiologist before ordering this test. A gastroenterologist may need to be consulted to rule out cholecystitis, pancreatitis, and peptic ulcer disease.
Book Source Details
- Book Title: Algorithmic Diagnosis of Symptoms and Signs
- Author(s): R. Douglas Collins
- Year of Publication: 2003
- Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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