Chapter 2: Differential Diagnosis for Shoulder and Upper Extremity 4 Contact Hours
Expiration Date : August 28, 2028 Learning outcomes
Categorize the important findings that confirm a neuromuscular or musculoskeletal source of a patient’s shoulder and/or upper extremity problem. Predict the important objective findings and limitations in occupational performance that confirm a neuromuscular or musculoskeletal source of a patient’s shoulder and/or upper extremity problem.
After completing this course, the learner will be able to: Interpret the fundamental role of differential diagnosis for healthcare providers. Predict red flag and yellow flag conditions for shoulder and upper extremity conditions. Interpret important findings to consider when accurately diagnosing shoulder and upper extremity problems. Predict potential viscerogenic and systemic origins of shoulder and upper extremity pain. Course overview The purpose of this course is to improve the knowledge and skills of clinicians in the differential diagnosis of shoulder and upper extremity pain/conditions. Identification of red flag findings and systemic sources of upper extremity Shoulder pain is a highly prevalent condition, affecting between 7% and 26% of the adult population (Ristori et al., 2018). It is the second most frequently seen musculoskeletal complaint by primary care providers (Eubank et al., 2021). Symptoms can range from minor and short-term to severe and long-term with the potential for significant functional disability (Eubank et al., 2021). Differential diagnosis of shoulder pain can be difficult, as many clinical tests have shown unacceptable levels of reliability and validity. Radiological images are subject
symptoms is outlined, and relevant clinical findings for the differential diagnosis of upper extremity conditions are presented.
INTRODUCTION
to a high level of incidental findings (Yarznbowicz, 2020). Furthermore, shoulder pain can originate from many systemic and visceral sources. In fact, according to Goodman et al. (2017), any disease or condition affecting the neck or breast can cause shoulder pain, as can pain in any organ in the chest or abdomen. This makes differential diagnosis both more complex and more critical. An important aspect of the clinical evaluation and differential diagnosis of shoulder pain is determining whether red and/ or yellow flags are present.
RED AND YELLOW FLAGS
evaluated in the context of the whole person—their medical history, known risk factors, and medication use. The focus is looking for a pattern of systemic or viscerogenic origin of pain. Healthcare Consideration: A study by (Ladeira, 2017) assessed the ability of physical therapists to evaluate red flags (medical disease), orange flags (psychiatric disorders), and yellow flags (maladaptive coping mechanisms) in patients with low back pain. Via an electronic survey, physical therapists were given a red flag vignette (ectopic pregnancy), an orange flag vignette (depression), and a yellow flag vignette (fear- avoidance behavior). The results showed that 53% of physical therapists (PT) were able to handle the red flag appropriately, 29% handled the orange flag appropriately, and 43% handled the yellow flag appropriately. They concluded that further education for physical therapists on warnings flags is needed.
Red flag findings are features of the client’s medical history or clinical examination that should be considered warning signs for clinicians. They are indicators that a serious disorder such as cancer, inflammation, or fracture may be present. Red flags often require evaluation of the patient by a medical specialist (Goodman et al., 2017). The prevalence and incidence of red flags in shoulder disorders are unknown, thus limiting the identification of serious non- musculoskeletal pathology at the first consultation (Ristori et al., 2018). Yellow flags are cautionary and warn therapists to think about the presenting problem and to dig deeper into the screening process. Yellow flag findings are not warnings of high-risk issues but rather point to factors that should be considered when devising a care plan. The significance of red and/or yellow flags should be evaluated in the context of the patient’s entire clinical picture. Often, a single yellow or red flag is not cause for immediate medical attention. These findings should be
CLINICAL PRESENTATION AND DIFFERENTIAL DIAGNOSIS
● No improvement or relief with rehabilitation intervention. Once treatment is started, if symptoms do not improve or are not relieved by rehabilitation intervention, this warrants referral to a medical specialist.
Specific signs and symptoms present during initial physical examination can serve as a warning that a systemic cause of the problem is possible. These signs and symptoms include: ● Symptom cause is unknown, or the onset of symptoms is insidious. Knowing the mechanism of injury can help a clinician diagnose the patient’s injury. Shoulder pain of insidious onset or not associated with a specific cause may have a non-musculoskeletal origin.
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