Upper Extremity Differential Diagnosis

Question 1

Primary concerns and complaints for the shoulder and neck

Answer 1

• Central cord syndromes
• Ligamentous instability
• Brachial plexus neuropathies
• Pancoast’s tumor

Question 2

Describe shoulder and neck complaints

Answer 2

• Compared with the thorax, fewer serious disorders involve the shoulder & neck regions, and metastasis to the cervical region is unusual

Question 3

Myocardial infarction red flags

Answer 3

• 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

Question 4

Cervical ligamentous instabilities with possible cord compromise red flags

Answer 4

• 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

Question 5

Cervical and shoulder girdle peripheral entrapment neuropathies red flags

Answer 5

• 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

Question 6

Spinal accessory nerve red flags

Answer 6

• 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

Question 7

Axillary nerve red flags

Answer 7

• 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

Question 8

Long thoracic nerve red flags

Answer 8

• 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

Question 9

Suprascapular nerve red flags

Answer 9

• 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

Question 10

Pancoat’s tumor/Superior sulcus lung tumor red flags

Answer 10

• 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

Question 11

How is the shoulder unique

Answer 11

• 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

Question 12

Screening to evaluate shoulder & upper extremity

Answer 12

• 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

Question 13

Side 9

Question 14

Where can shoulder pain be referred from

Answer 14

• Neck
• Chest
• Abdomen

Question 15

Key mechanisms for referred shoulder pain

Answer 15

• Multisegmental innervations & direct pressure on the diaphragm are the 2 key mechanisms for referred shoulder pain

Question 16

Describe diaphragmatic irritation

Answer 16

• 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

Question 17

Associated signs and symptoms for shoulder pain + systemic symptoms

Answer 17

• 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

Question 18

Signs and symptoms for pulmonary causes of shoulder pain

Answer 18

• 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

Question 19

Describe screening for pulmonary causes of shoulder pain

Answer 19

• 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

Question 20

Describe screening for cardiovascular causes of shoulder pain

Answer 20

• 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

Question 21

Describe angina or myocardial infarction (MI)

Answer 21

• 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

Question 22

Describe screening for renal causes of shoulder pain

Answer 22

• 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

Question 23

Differentiating questions for renal causes of shoulder pain

Answer 23

• Urinary symptoms: frequency, pain during urination, blood in urine, changes in color
• Renal past medical history, medications, family history, recent infection/illness
• Abdominal pain

Question 24

Describe screwing for GI causes of shoulder pain

Answer 24

• 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

Question 25

Differentiating questions for GI causes of shoulder pain

Answer 25

• 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

Question 26

Describe screening for liver/biliary causes of shoulder pain/upper quadrant symptoms

Answer 26

• 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

Question 27

Associated signs and symptoms of liver/biliary causes of shoulder pain

Answer 27

• 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

Question 28

Describe screening for rheumatic causes of shoulder pain

Answer 28

• 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

Question 29

Describe screening for infectious causes of shoulder pain

Answer 29

• 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

Question 30

Describe screening for oncologic causes of shoulder pain

Answer 30

• 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

Question 31

Sings & symptoms to keep an eye on for oncologic causes of shoulder pain

Answer 31

• 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

Question 32

How to assess if it could be breast pathology

Answer 32

• 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

Question 33

Describe screening for gynecologic causes of shoulder pain

Answer 33

• 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

Question 34

Describe screening shoulder/upper extremity pain

Answer 34

• 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)