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Differential Diagnosis in Physical Therapy of Upper Extremity and Lower Quadrant: Summary
• Eight clinical identifiers clustered into two discrete domains (pain and movement) as well as an age component ○ Pain ■ Strong component of night pain ■ Pain with rapid or unguarded movement ■ Discomfort lying on the affected shoulder ■ Pain easily aggravated by movement ○ Movement ■ Global loss of active and passive ROM ■ Pain at end-range in all directions ○ Age - Onset > 35 years of age Potential Shoulder Referral Patterns Area of Pain Possible Causes Left shoulder • MI: 68.7% of patients reported shoulder
• 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
LEARNING TIP! For client with known
pain during an acute myocardial infarction
heart disease or other cardiac conditions, ask about the effect of taking nitroglycerin on their shoulder symptoms.
• Ruptured spleen • Pancoast’s tumor • Carcinoma • Cirrhosis, hepatitis • Hiatal hernia • Peptic ulcer • Pancreatitis • Pancreatic cancer
Both shoulders Right shoulder
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
• Gall bladder • Cholecystitis: Typically
accompanied by fever, or nausea/ vomiting 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
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