Upper Extremity Differential Diagnosis Flashcards
1
Q
Primary concerns and complaints for the shoulder and neck
A
- Central cord syndromes
- Ligamentous instability
- Brachial plexus neuropathies
- Pancoast’s tumor
2
Q
Describe shoulder and neck complaints
A
- Compared with the thorax, fewer serious disorders involve the shoulder & neck regions, and metastasis to the cervical region is unusual
3
Q
Myocardial infarction red flags
A
- Previous Hx of coronary artery disease
- HTN
- Smoking
- Diabetes
- Elevated blood serum cholesterol (>240 mg/dL)
- Chest pain
- Pallor, sweating, dyspnea, nausea, palpitations
- Symptoms lasting >30 min and not relieved with sublingual nitroglycerin
4
Q
Cervical ligamentous instabilities with possible cord compromise red flags
A
- Major trauma such as a motor vehicle accident or a fall from a height
- Hx of rheumatoid arthritis or ankylosing spondylitis
- Oral contraceptive use
- Long tract neurologic signs, especially present in more than one extremity: dizziness, nystagmus, vertigo with head/neck movements/positions, clonus, positive Babinski’s sign
5
Q
Cervical and shoulder girdle peripheral entrapment neuropathies red flags
A
- Paresthesias
- Pain present at rest & possibly with a retrograde distribution
- Muscles innervated can be tender to palpate
- Muscles and sensory distribution follow specific nerve pattern
6
Q
Spinal accessory nerve red flags
A
- Hx of penetrating injury such as a stab or gunshot
- Direct blow or stretching of the nerve during a fall or motor vehicle accident
- Surgical Hx of radical neck dissection for tumor or cervical lymph node biopsy
- Hx of a blow from a hockey stick or lacrosse stick
- Asymmetry of the neck line & drooping of the shoulder
- Inability to shrug shoulders
- Lack of scapular stabilization
- Weakness of shoulder abduction
7
Q
Axillary nerve red flags
A
- Pt’s >40 yrs with shoulder dislocation
- Hx of traction force or blunt trauma to shoulder
- Hx of brachial neuritis or quadrilateral space syndrome
- Weakness of shoulder abduction & flexion
- Lack of sensation of lateral aspect of the upper arm
8
Q
Long thoracic nerve red flags
A
- Identified in players of many sports including tennis, volleyball, archery, golf, gymnastics, bowling, weight lifting, soccer, hockey, & rifle shooting
- Serratus anterior weakness with scapular winging
- Loss of scapulohumeral rhythm
9
Q
Suprascapular nerve red flags
A
- Deep, poorly localized pain
- Hx of Fx of the scapula with involvement of the notch & blade of the scapula
- Traction injury mechanism
- Direct compression of the supra scapular nerve at the level of the scapular notch or at the spinoglenoid notch bc of a ganglion cyst or a hypertrophied transverse scapular or spinoglenoid ligament
- Presentation similar ro rotator cuff tear bc of wasting of the supraspinatus or infraspinatus muscles
- Loss of strength in abduction & external rotation of the shoulder
10
Q
Pancoat’s tumor/Superior sulcus lung tumor red flags
A
- Men>50 yrs with Hx of cigarette smoking
- Tagging type pain in the shoulder & along the vertebral border of the scapula
- Pain that has progressed from nagging to burning in nature, often extending down the arm & into the ulnar nerve distribution
11
Q
How is the shoulder unique
A
- Any adult over age 65 seen with shoulder pain/dysfunction must be screened for medical disease even if there is a known or attributed cause or injury
12
Q
Screening to evaluate shoulder & upper extremity
A
- Hx of cancer (breast and lung cancer most common to metastasize to the shoulder)
- Heart disease (those in age-specific populations)
- Cardiac related shoulder pain: HTN, diabetes, and hyperlipidemia
- Tuberculosis as possible cause of shoulder pain
13
Q
Side 9
A
14
Q
Where can shoulder pain be referred from
A
- Neck
- Chest
- Abdomen
15
Q
Key mechanisms for referred shoulder pain
A
- Multisegmental innervations & direct pressure on the diaphragm are the 2 key mechanisms for referred shoulder pain
16
Q
Describe diaphragmatic irritation
A
- Irritation of the peritoneal (outside) or pleural (inside) surface of the diaphragm refers sharp pain
- Central portion: upper traps, neck, supraclavicular fossa
- Peripheral portion: costal margins & lumbar region
- Pain is ipsilateral to area of irritation
17
Q
Associated signs and symptoms for shoulder pain + systemic symptoms
A
- Pleuritic component
- Exacerbation by recumbency
- Recent Hx of laparoscopic procedure (risk factor)
- Coincident diaphoresis (cardiac)
- Associated GI signs & symptoms
- Exacerbation by exertion unrelated to shoulder movement (cardiac)
- Associated urologic signs & symptoms
18
Q
Signs and symptoms for pulmonary causes of shoulder pain
A
- Persistent cough (dry or productive)
- Blood tinged sputum
- Chest pain
- Exacerbation by recumbency even with proper positioning of the arm
- Older adult: unknown cause, signs of confusion (pneumonia)
- Tachypnea or dyspnea, wheezing, hyperventilation
19
Q
Describe screening for pulmonary causes of shoulder pain
A
- Pleural irritation = localized sharp pain aggravated by respiratory movement
- Pain can be alleviated by lying on affected side (“auto splinting” which reduces movement of the lung(s))
- Shoulder symptoms made worse by recumbence are a concerning feature: recumbency causes a slight shift of the abdominal contents in the cephalic direction which can put pressure on the diaphragm which presses up against lower lung lobes
- Pneumonia in the older adult may appear as shoulder pain when the affected lung presses on the diaphragm
- Therapist should look for a pleuritic signs or symptom
20
Q
Describe screening for cardiovascular causes of shoulder pain
A
- Shoulder pain refers from the heart & diaphragm due to shared nerve supply (C5/C6)
- Exacerbation of the shoulder symptoms from a cardiac cause occurs with an increase in activity that does not necessarily involve the arm or shoulder
- For clients with known heart disease ask about the effect of taking nitroglycerin (male) or antacids/acid-relieving drugs (female) on their shoulder symptoms
21
Q
Describe angina or myocardial infarction (MI)
A
- Angina and/or MI can appear as arm & shoulder paint hat can be misdiagnosed as arthritis or other musculoskeletal pathologic conditions
- Look for shoulder pain that starts 3-5 min after the start of activity, including shoulder pain with isolated lower extremity motion
- If the client has known angina & takes nitroglycerin ask about the influence of the nitroglycerin on shoulder pain
- Shoulder pain associated with MII is unaffected by position, breathing, or movement
22
Q
Describe screening for renal causes of shoulder pain
A
- Upper urinary tract can refer pain to the shoulder on the same side as the involved kidney due to an irritated diaphragm
- Renal & ureteral pain is typically felt in the posterior subcostal & costovertebral regions (flank/upper quadrant & can refer to shoulder)
- Nature of pain is aching/dull but can occasionally be a severe, boring type of pain
23
Q
Differentiating questions for renal causes of shoulder pain
A
- Urinary symptoms: frequency, pain during urination, blood in urine, changes in color
- Renal past medical history, medications, family history, recent infection/illness
- Abdominal pain
24
Q
Describe screwing for GI causes of shoulder pain
A
- Upper abdominal or GII problems with diaphragmatic irritation can refer pain to the ipsilateral shoulder
- The therapist should look for a Hx of previous ulcer especially in association with the use of NSAIDs
- Shoulder pain that is worse 2-4 hrs after taking NSAID could suggest GII bleeding & is considered a concerning feature
25
Q
Differentiating questions for GI causes of shoulder pain
A
- Remember to ask about the effect of eating on shoulder pain (pattern recognition): Better/worse within 30 min = Upper GI; better/worse within 1-3 hrs after eating = Lower GI
- History of abdominal pain, bloating, nausea. vomiting, change in bowel, reflux
- Is shoulder pain relieved by belching or antacids
26
Q
Describe screening for liver/biliary causes of shoulder pain/upper quadrant symptoms
A
- Commonly refer to the mid back, scapular, & right shoulder regions: Liver = upper R abdomen, just under rib cage; Gallbladder = upper R shoulder or upper R back
- Differentiating questions: Hx of nausea/vomiting
27
Q
Associated signs and symptoms of liver/biliary causes of shoulder pain
A
- Jaundice (increased bilirubin)
- Clay colored stools (bile duct clogged)
- Dark urine (increased bilirubin)
- Fever/chills
- Itching
- Fatigue and weakness
- Asterixis “liver flap”: extension of wrists & fingers and the fingers will randomly flap
- Ascites
28
Q
Describe screening for rheumatic causes of shoulder pain
A
- RA, polymyalgia rheumatica, polymyositis, and other variants can involve the shoulder girdle
- Symmetrical joint involvement
- Morning stiffness, decreased ROM
- Rheumatoid nodules
- Swelling and warmth
- Polymyalgia rheumatica: proximal muscle pain, weight loss, elevated Erythrocyte Sedimentation Rate and C-Reactive Protein
- Frozen shoulder
29
Q
Describe screening for infectious causes of shoulder pain
A
- The most likely causes of shoulder pain in physical therapy practice include infectious (septic) arthritis, osteomyelitis, & infectious mononucleosis (mono)
- Immunosuppression for any reason puts people of all ages at risk for infection
- Septic arthritis: sudden/severe, warm with swelling & limited ROM, constitutional signs & symptoms
30
Q
Describe screening for oncologic causes of shoulder pain
A
- A past medical Hx of cancer anywhere in the body with new onset of back or shoulder pain (or impairment) is a concerning feature
- Questions about visceral function are relevant when the pattern for malignant invasion at the shoulder emerges
- Muscle wasting that is greater than expected with arthritis & follows a bizarre pattern that does not conform to any one neurologic lesion or any one muscle
31
Q
Sings & symptoms to keep an eye on for oncologic causes of shoulder pain
A
- Watch for pectoralis major muscle spasm with no known cause (clear trigger points) but full passive ROM & mobile scapula
- Shoulder flexion and abduction limited to 90º with empty end feel
- Presence of localized warmth over scapular area
32
Q
How to assess if it could be breast pathology
A
- Jarring or squeezing the breast refers pain to the shoulder
- Resisted shoulder motions do not reproduce shoulder pain but do cause breast pain or discomfort
- Obvious change in breast tissue, dimpling or peau d’orange, distended veins, nipple discharge or ulceration, erythema, change in size or shape of the breast
- Suspicious or aberrant axillary or supraclavicular lymph nodes
33
Q
Describe screening for gynecologic causes of shoulder pain
A
- Shoulder pain as a result of gynecologic conditions is uncommon but possible
- Common causes include ectopic pregnancy, ovarian cysts, pelvis inflammatory disease, endometriosis or ectopic endometrial tissue
- Ectopic pregnancy is an emergency: Kehr’s sign = blood in peritoneal cavity; common with spleen rupture as well
- Differentiating questions: changes in menstruation, pelvic pain, Hx of cysts/endometriosis, possibly pregnant, recent surgery, abdominal pain, Hx of pelvic inflammatory disease, dizzy or lightheaded, tenderness to abdomen
34
Q
Describe screening shoulder/upper extremity pain
A
- Simultaneous or alternating pain in other joints especially in the presence of associated signs & symptoms such as easy fatigue, malaise, fever
- Urologic signs & symptoms
- Presence of hepatic symptoms especially when accompanied by risk factors for jaundice
- Lack of improvement after treatment
- Shoulder pain in female of childbearing age of unknown cause associated with missed menses
- Left shoulder pain within 24 hrs of abdominal surgery, injury, or trauma (Kehr’s sign, ruptured spleen)
