SHOULDER PAIN

SHOULDER PAIN: Excerpt from Differential Diagnosis in Primary Care

The differential diagnosis of shoulder pain, like other forms of pain, is best established by anatomy, working from the outside in (Table 51). Beginning with the skin, one immediately thinks of cellulitis and herpes zoster. The muscles and tendons come next, and epidemic myalgia and the myalgias secondary to many infectious diseases lead the list. However, trichinosis, dermatomyositis, fibromyositis, and trauma must always be considered. Proceeding to the blood vessels, keep in mind thrombophlebitis, Buerger disease, vascular occlusion from periarteritis nodosa, and other forms of vasculitis.

SHOULDER PAIN, SYSTEMIC CAUSES

SHOULDER PAIN, LOCAL CAUSES

Inflammation of the bursae is probably the most common cause of shoulder pain. This should be considered traumatic because in most cases the torn ligamentum teres rubs the bursa and causes the inflammation. Interestingly enough, aside from gout, the bursae are rarely involved in other conditions. The shoulder joint itself is also a frequent site of pain. Osteoarthritis, rheumatoid arthritis, gout, lupus, and various bacteria all may involve this joint, but dislocation of the shoulder, fractures, and frozen shoulder should be considered. If the bone is the site of pain, there is usually a fracture involved. Osteomyelitis and metastatic tumors, however, ought to be ruled out.

Neurologic causes are not the last to be considered just because anatomically they come last. The brachial plexus may be compressed by a cervical rib, a large scalenus anticus or pectoralis muscle, or the clavical (costoclavicular syndrome). When the cervical sympathetics are irritated or disrupted, a shoulder–hand syndrome develops. The cervical spine is the site or origin of shoulder pain in cervical spondylosis, spinal cord tumors, tuberculosis and syphilitic osteomyelitis, ruptured disks, or fractured vertebrae.

It would be a grave error to omit the systemic causes of shoulder pain. Thus, coronary insufficiency, cholecystitis, Pancoast tumors, pleurisy, and subdiaphragmatic abscesses should be ruled out.

Approach to the Diagnosis

The approach to ruling out various causes is most often clinical, provided x-rays of the shoulder and cervical spine have negative findings. If a torn rotator cuff is strongly suspected, an MRI or arthrogram should be done. In the classical case of subacromial bursitis, in which passive movement is much less restricted than active movement and a point of maximum tenderness can easily be located, lidocaine and steroid injections into the bursa (at the point of maximum tenderness) may be done without x-rays. Cervical root blocks, stellate ganglion blocks for shoulder–hand syndrome, and aspiration and injection of the shoulder joint with lidocaine and steroids may also be useful in establishing the cause. Adson maneuvers will help establish the diagnosis of scalenus anticus syndrome, but the clinician must bear in mind that there are many false-positives for this test and the job is not finished until tests for pectoralis minor and costoclavicular compression are done. The history will help diagnose systemic causes, but checking for dermatomal hyperalgesia or hypalgesia and other sensory changes will be most helpful in diagnosing disease of the cervical spine. Remember that a negative cervical spine x-ray does not rule out a herniated disk. If the pain is increased by pressure on the top of the head or by coughing and sneezing, then a disk must be ruled out by an MRI.

Other Useful Tests

1. CBC
2. Sedimentation rate (collagen disease, infection)
3. Chemistry panel (gout, pseudogout)
4. Arthritis panel
5. ANA analysis (collagen disease)
6. Exercise tolerance test (coronary insufficiency)
7. Nerve blocks (radiculopathy)
8. EMG (radiculopathy)
9. Bone scan (small fractures, osteomyelitis)
10. Arteriogram (thoracic outlet syndrome)
11. Chest x-ray (Pancoast tumor)

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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