Mononucleosis is a viral infection of the respiratory tract, liver, and spleen. Splenomegaly, which can lead to rupture, is a possible cause of left shoulder pain (Kehr’s sign). Symptoms of mononucleosis include left upper abdominal pain and palpation of an enlarged and tender spleen in the Screening for oncologic causes of shoulder pain History of a cancer diagnosis is a red flag when a patient reports new-onset shoulder pain. The most common types of cancer that metastasize to the bones include breast, lung, and prostate, followed by thyroid and kidney (UConn Health, 2017). Pain is a common symptom and will be present without activity. ● Primary bone neoplasms : Bone cancer affects young people almost exclusively. A primary bone tumor in the shaft of the humerus will often result in “pins and needles” in the hand and guarded movement of the elbow. A palpable mass may be present. The pain pattern associated with bone tumors is a deep aching that is worse at night. ● Pulmonary (Secondary) neoplasm : Pain may be referred to the shoulder from metastatic lung cancer. In such cases, the patient will be unable to lift their shoulder above 90 degrees without resultant muscle spasms. If the neoplasm affects the diaphragm, each breath may cause shoulder pain. The lungs themselves do not have sensation, but large tumors that invade the chest wall can cause pain and spasm in the pectoralis muscle. This can result in shoulder pain and limited shoulder elevation. ● Pancoast tumor : A Pancoast tumor of the lung apex that infiltrates the chest wall into the axilla will cause shoulder pain. Brachial plexus involvement occasionally occurs with resultant sharp neuropathic pain in the axilla, shoulder, and subscapular area of the affected side. Screening for gynecologic causes of shoulder pain Shoulder pain related to gynecologic conditions is uncommon but still possible. As discussed previously, breast conditions that may cause shoulder pain include tumor and infection. Breast implants, lymph disease, and trauma are other breast conditions associated with shoulder pain. The shoulder pain may be in conjunction with chest and/or breast pain.
area. Other symptoms associated with acute mononucleosis include sore throat, headache, fatigue, lymphadenopathy, fever, myalgia, and sometimes a skin rash. If the tonsils are enlarged, breathing may be noisy and difficult. The patient may report some or all these symptoms. Eventually, atrophy of the upper extremity muscles will be evident. Systemic symptoms that also may be present include sore throat, fever, hoarseness, unexplained weight loss, and productive cough with blood in the sputum. Because shoulder pain may be the only symptom of a Pancoast tumor, it is often mistaken for a musculoskeletal disorder (Al Shammari et al., 2020). ● Breast cancer : According to Heick and Lazaro (2022), breast cancer is always a consideration with upper quadrant pain of abdomen or shoulder dysfunction. Metastatic spread can occur as long as 20 years after initial diagnosis. Bone is one of the most common locations of breast cancer metastasis (Jin & Mu, 2015). Metastases to the shoulder bones might exhibit deep, localized pain with impaired use of the shoulder. This may affect occupational performance, including the ability to groom, dress, and shower. Healthcare Consideration: Any history of cancer, even from previous decades, should alert the assessing clinician that metastases might be a source of shoulder pain. This is especially relevant when a history of cancer is accompanied by a clinical picture that includes shoulder pain without activity and/or presenting shoulder symptoms do not fit the clinical pattern for a specific tab shoulder diagnosis. In this case, referral to a medical professional for further evaluation is indicated. Shoulder pain commonly occurs with an ectopic pregnancy and may be the only presenting symptom. Other symptoms of an ectopic pregnancy include a sudden, sharp pain in the lower abdomen/pelvis area and irregular bleeding or spotting. This condition is prevalent among women of childbearing age. Risk factors for ectopic pregnancy include history of endometriosis, pelvic inflammatory disease, previous ectopic pregnancy, ruptured ovarian cyst or appendix, and tubal surgery.
SPECIAL TESTS FOR SHOULDER DIFFERENTIAL DIAGNOSIS
Interpreting metrics for special tests for the shoulder is important with differential diagnosis (Hegedus et al., 2015). Table 1 provides the most used test metrics (Parikh et al., 2008).
According to Hegedus et al (2015), differential diagnosis is a combination of an analytical approach encompassing test metrics and an intuitive approach encompassing the clinical experience of the assessor.
Table 1: Metrics Metric
Abbreviation Definition
Sensitivity Specificity
SN Percentage of people who have a disease or disorder and test positive for it.
SP
Percentage of people who do not have a disease or disorder and test negative for it.
Positive predictive value Negative predictive value Positive likelihood ratio Negative likelihood ratio
Probability that subjects with a positive test truly have the disorder.
PPV
Probability that subjects with a negative test truly don’t have the disorder.
NPV
Likelihood that a patient has a disorder if the test is positive compared to the probability for someone who does not have the disorder. Likelihood that a patient does not have the disorder if the test is negative compared to the probability for a patient who has the disorder.
LR+
LR–
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