SHOULDER PAIN
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.
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.
SHOULDER PAIN
|
| V | I | N | D |
|
| Vascular | Inflammatory | Neoplasm | Degenerative |
|
| | | | and Deficiency |
|
|
Skin |
|
Herpes zoster |
Muscle and Tendons |
|
Epidemic myalgia Trichinosis
Tendonitis biceps |
|
Blood Vessels |
Arterial thrombosis Buerger disease
Dissecting aneurysm |
Phlebitis |
|
Bursae |
|
Bursitis | |
|
Shoulder Joint |
|
Purulent arthritis |
|
Osteoarthritis |
| |
| |
|
Bone |
Aseptic bone necrosis |
Osteomyelitis |
Primary and metastatic tumors |
Brachial Plexus and Sympathetics |
|
Neuritis |
Lymphoma |
|
Cervical Spine |
|
Osteomyelitis Tuberculosis Syphilis |
Cord tumor (primary and metastatic) |
Osteoarthritis |
|
Systemic Causes |
Coronary insufficiency Aortic aneurysm |
Cholecystitis Pleurisy Subdiaphragmatic abscess |
Pancoast tumor |
|
HAND AND FINGER PAIN
|
| I | C | A | T | E |
| Intoxication | Congenital | Autoimmune | Trauma | Endocrine |
| Idiopathic | | Allergic | | |
|
| |
|
Fibromyositis |
| Dermatomyositis |
Contusion Ruptured tendon | |
| |
|
| Hemophilia | Vasculitis |
| |
| |
|
Gout | | | | Pseudogout |
|
Gouty arthritis Frozen shoulder |
|
Rheumatoid arthritis Rheumatic fever Lupus |
Shoulder dislocation Shoulder separation
Torn ligament |
|
| | |
Fracture |
| |
|
Shoulder–hand syndrome |
Cervical ribs Scalenus anticus syndrome | |
Traumatic neuroma |
|
Cervical spondylosis |
Klippel–Feil syndrome | |
Ruptured disc Fracture |
| |
|
| |
| |
| |
|
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
clavicle (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 to 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 to 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 disc. If the pain is increased by pressure on the top of the
head or by coughing and sneezing, then a herniated disc must be ruled out by
an MRI.
Other Useful Tests
-
CBC
- Sedimentation rate (collagen disease, infection)
- Chemistry panel (gout, pseudogout)
- Arthritis panel
- ANA analysis (collagen disease)
- Exercise tolerance test (coronary insufficiency)
- Nerve blocks (radiculopathy)
- EMG (radiculopathy)
- Bone scan (small fractures, osteomyelitis)
- Arteriogram (thoracic outlet syndrome)
- Chest x-ray (Pancoast tumor)
Pictures
Book Source Details
- Book Title: Differential Diagnosis in Primary Care
- Author(s): R. Douglas Collins MD, FACP
- Year of Publication: 2007
- Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Shoulder symptoms
Read excerpts from these other book chapters related to Shoulder symptoms:
Medical Books Excerpts
- Shoulder Pain
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2008 Williams & Wilkins.
More About Causes of Shoulder symptoms
» Next page: Videos relating to Shoulder symptoms
Rate This Website
What do you think about the features of this website?
Take our user survey and have your say:
Website User Survey
Medical Tools & Articles:
Next articles:
Tools & Services:
Medical Articles:
Forums & Message Boards
- Ask or answer a question at the Boards:
