Refered pain shoulder

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit

Shoulder pain is common affecting at least 20 per cent of people at some point. Not all shoulder pain though arises directly from the shoulder.

The shoulder is a partial ball and socket joint with the head of the humerus held in place inside the shallow cup of the glenoid labrum of the shoulder blade. Stability of the humeral head is achieved by ligaments, tendons, and muscles of the rotator cuff. The shoulder joint is extremely mobile but it is also less stable than other joints such as the hip. In addition, because the space between the roof of the shoulder and the humeral head is narrow, there is the potential for compression of muscles and tendons.

The shoulder is surrounded by a series of fluid-filled sacs (bursae) which act to cushion the joint.

So… it is easy to see that shoulder pain can arise from many different structures including the tendons, bursae, muscles, ligaments, and nerves.

Disorders of the rotator cuff are probably the most common cause of shoulder pain seen in clinical practice. Rotator cuff problems include: tendonitis to tearing; impingement syndrome (pinching of the rotator cuff between the acromion of the shoulder blade and the humeral head); and adhesive capsulitis (frozen shoulder).

Arthritis (degenerative or inflammatory) may attack the shoulder. Rheumatoid arthritis and pseudogout are the most common inflammatory types to do this.

Bone disease like fracture or avascular necrosis can also affect the shoulder.

Nerve entrapment disorders (brachial plexus injury) can present with shoulder pain.

Brachial plexus neuritis (Parsonage-Turner syndrome) is an inflammatory problem that affects the large nerve trunks in the shoulder. This can cause severe shoulder and arm pain.

Cervical spine arthritis can cause referred pain to the shoulder. Lung tumors, heart attacks, liver and gall bladder disease, and polymyalgia rheumatica can also lead to shoulder pain.

The history often provides valuable information. Primary shoulder pain is aggravated by movement. Night pain is common and patients often have difficulty finding a comfortable position in which to sleep.

A history of overuse (“weekend warrior syndrome”) may point towards a diagnosis of bursitis or tendinitis.

Trauma might indicate the presence of fracture, dislocation, or rotator cuff tear.

Physical examination can determine range of motion as well as the possibility of rotator cuff dysfunction. Patients who have significant arthritis in any of the shoulder joints (glenohumeral=joint between the humerus and scapula; acromioclavicular=the joint between the scapula and the clavicle; sternoclavicular=joint between the sternum and the clavicle) will have tenderness and possible swelling localized to that joint. Patients with severe glenohumeral arthritis will have marked reduction in range of motion and even grinding with movement of the arm.

As noted earlier, a careful general physical exam is needed because of the possibility of pain referral from other areas. In particular, referred pain from the cervical spine is important to check for and rule out.

Diagnostic testing is based on what is seen on exam and what is gleaned from history.

X-ray imaging is of value only for fracture or dislocation. Magnetic resonance imaging is the preferred method of imaging for diagnosis.

Treatment depends on the underlying diagnosis. For patients with impingement, bursitis, or rotator cuff syndrome, anti inflammatory drugs, rest with a sling, and physical therapy may be helpful. Glucocorticoid injection under ultrasound guidance can also be of immense value. More recently, ultrasound guided needle tenotomy with platelet-rich plasma (PRP) has been shown to be the procedure of choice for healing tendonopathy of the shoulder. It also has been used for other disorders of the shoulder with success.

For more information on tenotomy and platelet rich plasma, contact the Arthritis Treatment Center at (301) 694-5800 or reach us on the web at

For more information on tendonitis, visit our sister site: Tendonitis and PRP

Recently, visco supplements (hyaluronan) injected into the joint have shown some beneficial effects. Unfortunately, the data is sparse.

Surgery is reserved for patients with severe impingement or rotator cuff problems unresponsive to conservative measures, large rotator cuff tears, or severe arthritis.

Procedures include removal of the clavicle in the area of rotator cuff impingement (acromioplasty), rotator cuff repair, removal of inflamed synovium, or joint replacement.

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