70 Differential Diagnosis in Physical Therapy of Upper Extremity and Lower Quadrant: Summary
Screening for Pulmonary Causes of Shoulder Pain • Pleural irritation then results in sharp, localized pain that is aggravated by any respiratory movement • Extensive disease may occur in periphery of lung without pain until process extends to the parietal pleura • Pain alleviated by lying on affected side, which diminishes the movement of that side of the chest • Shoulder symptoms made worse by recumbence are a yellow flag for pulmonary involvement • Pneumonia in the older adult may appear as shoulder pain when the affected lung presses on the diaphragm; older adults, confusion (or increased confusion) may be the only other associated sign Screening for Cardiovascular Causes of Shoulder Pain • Exacerbation of shoulder symptoms with increased activity that does not necessarily involve the arm or shoulder • Ask about the presence of nausea, unexplained sweating, jaw pain, or chest discomfort or pressure
Complex Regional Pain Syndrome (CRPS) of Shoulder Pain Develops after bone fracture or other injury (even slight or minor trauma, venipuncture, or an insect bite) or surgery to the UE/LE. CRPS is associated with CVA, MI or diseases of thoracic or abdominal viscera that can refer pain to the shoulder or arm. CRPS secondary to DVT has also been reported. • Type I: Not associated with a nerve lesion • Type II: Develops after trauma with a nerve lesion Stage I (acute, lasting several weeks) • Pain described as burning, aching, throbbing • Sensitivity to touch • Swelling • Muscle spasm • Stiffness, loss of motion and function • Skin changes • Accelerated hair growth Stage II (subacute, lasting 3 to 6 months) • Severity of pain increases • Swelling may spread; tissue goes from soft to boggy to firm • Muscle atrophy • Skin becomes cool, pale, bluish, sweaty • Nail bed changes (cracked, grooved, ridges) • Bone demineralization Stage III (chronic, lasting more than 6 months) • Pain may stay same, improve, or get worse; variable • Muscle atrophy and contractures • Skin becomes thin and shiny • Nails are brittle • Osteoporosis Carpal Tunnel Syndrome (CTS) There are many potential causes CTS, both musculoskeletal and systemic. Careful evaluation is required. The presence of bilateral CTS warrants a closer look.
LEARNING TIP! For client with known
heart disease or other cardiac conditions, ask about the effect of taking nitroglycerin on their shoulder symptoms.
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