Shoulder Differential Diagnosis

• Step 1 - subjective evaluation pt 1:

  • what brings them to see you today
  • what do they want from their assessment and treatment
  • what is their social context and medical background
  • who are they - get to know the person in front of you
  • find the history of pts/pain, determine the mechanism of injury and perform subjective and objective evaluation
  • find out pts limitations

  
• Step 1 - subjective evaluation pt 2:

  • regarding clinical guidelines, important to identify if origin of the problem is coming from the local tissues (e.g. shoulder) or referred from the cervical spine - figure this via ROM assessment for cervical spine and shoulder to identify origin of the symptoms
  • need a cervical screening and identify any red flags
  • trauma, pain and weakness - acute cuff tear?
  • mass or swelling - tumour?
  • red skin, fever or systemically unwell - infection?
  • trauma/epileptic fit/electric shock leading to loss of rotation and abnormal shape - unreduced dislocation?

  
• Step 1 - subjective evaluation - questions to ask pts:

  • does moving your neck change your symptoms
  • any headaches, blurred visions, numbness or tingling to your arms
  • do you ever feel unstable during arm movement
  • when you do actions with your arms over your head, does this aggravate your pain level
  • is it difficult to move your arm
  • when performing action with your arms over hear head, do your arms feel heavier
  • have you been in a car accident recently
  • any recent falls or trauma to your arms
  • any surgies
  • any recent infections
• Step 1 - examples of questions to ask your patient:

  • does moving your neck change your symptoms
  • any headaches, blurred vision, numbness or tingling to your arms
  • do you ever feel unstable during arm movement
  • when you do actions with your arms over your head, does this aggravate pain level
  • is it difficult to move your arm
  • when performing actions with your arms over your head, do your arms feel heavier
  • have you been in a car accident recently
  • recent falls/trauma to arms
  • any surgeries
  • recent infections
• Step 2 - Is the source of pain from the neck or shoulder pain?

  • if you suspect its from the neck, you may prioritise a cervical exam
• Step 2 - Is the source of pain from the neck or shoulder pain? pt1

  • with the shoulder, youd want to see if theres pain with shoulder range of motion, both active and passive
  • want to think about potential trauma - suspecting dislocation or an instability
  • if MOI is atraumatic, you may want to try physiotherapy
  • if MOI is traumatic or you have ongoing symptoms that arent resolving, you may want to refer to a shoulder clinic for further investigation, or even diagnostic testing

  
• Step 2 - Is the source of pain from the neck or shoulder pain? pt2

  • if theres no instability or trauma, you can start to try localise where the pain is coming from - decide if this person is appropriate for physiotherapy or do they require a referral
  • ask if they've had previous treatments, what kind, were they successful or not

  
• Step 2 - suspect neck as source of pain?

  • yes = can this be managed in physiotherapy, if not, follow local spinal service guidelines -> referral
  • no = clear cervical spine (dermatomes, myotomes, reflexes, stability tests, 5D), focus on evaluation of shoulder and upper limbs -> shoulder evaluation
  • CHECK FOR RED FLAGS - URGENT REFERRAL!
  • trauma, pain, weakness - rotator cuff tear?
  • mass or swelling - tumour?
  • red skin, fever or system unwell - infection?
  • trauma/epileptic fit/electric shock leading to loss of rotation and abnormal shape

  
• Step 2 - suspect shoulder as source of pain? pt1

  • Instability:
  • history of instability
  • does the shoulder ever partly or completely come out of the joint
  • is your patient worried that their shoulder may dislocate during sport or certain activities
  • if not any of the above, move to the second possibility/chain on the roadmap

  
• Step 2 - suspect shoulder as source of pain? pt2

  • Acromioclavicular joint
  • is the pain localised to the acromioclavicular joint and associated with tenderness
  • is there a high arc of pain
  • is there a positive cross arm test
  • if not any of the above, move to the third possibility/chain on the roadmap

  
• Step 2 - suspect shoulder as source of pain? pt3

  • Glenohumeral joint
  • is there reduced passive external rotation
  • if not any of the above, move to the fourth possibility/chain on the roadmap

  
• Step 2 - suspect shoulder as source of pain? pt4

  • Rotator cuff
  • is there a painful arc of abduction
  • is there pain on abduction with the thumb down, worse against resistance
  • A HISTORY OF TRAUMA WITH LOSS OF ABDUCTION IN A YOUNDER PATIENT = RED FLAG
  • if not any of the above, the pain may not be due to the shoulder, but other cervical or arm pain