Superior Shoulder

Dull Ache / Sharp Pain

Trapezium mild strain / hypertonicity (Upper)

Signs and Symptoms:

Dull ache across top of shoulders
Painful after increasing desk / computer work
Pain can radiate up neck
May also bring on headaches
Overhead activity
Desk work
Stress
Poor posture
Diagnosed through palpation and active muscle resistance exam
Severe strains (tears) may present with increased pain, swelling, bruising, and loss of function (ultrasound / MRI)
Treatment through manual therapy and rehab exercises

Supraspinatus mild strain / hypertonicity

Signs and Symptoms:

Deep dull ache on top of shoulder
Can radiate to glenohumeral joint, across to neck or down to shoulder
Can feel like a deep knot
Painful after increasing desk / computer work
Overhead activity
Desk work
Stress
Poor posture
Diagnosed through palpation and active muscle resistance exam
Severe strains (tears) may present with increased pain, swelling, bruising, and loss of function (ultrasound / MRI)
Treatment through manual therapy and rehab exercises

C5/6 (5th Cervical vertebrae) facet sprain (Referral)

Signs and Symptoms:

Dull ache back of neck, can be sharp on rotation, side bending, extension, movements, pain can refer into shoulder area
Does NOT refer down to hand,
Does not have any associated numbness or tingling
Feels restricted on turning head movement
Can refer into top of head area (cervicogenic HA)
Repetitive movements / posture – desk work
Shoulder check in car (taxi, Uber driver)
New / poor pillow
Diagnosed by Passive / acting range of motion testing
Positive Kemps test – Sensitivity 61%, Specificity 39 % (approx)
Cervical compression, distraction test (for referred pain or relief)
Treatment through joint articulation and massage to surrounding musculature

Rib 1 costovertebral / costotransverse sprain

Signs and Symptoms:

Dull ache on top of shoulder
Deep breaths in may causes pain on top of shoulder
Can refer out to lateral shoulder
May be painful to turn head
Repetitive movements / posture – desk work
Shoulder check in car (taxi, Uber driver)
New / poor pillow
Diagnosed through palpation asking patient to take deep breaths in
Treatment through joint articulation and massage to surrounding musculature

Delayed onset muscle soreness (DOMS)

Signs and Symptoms:

Pain on shoulder / neck area felt after gym sessions, exercise, or repetitive activities
Exercise routine may have included shoulder shrugs, overhead benchpress, or lateral deltoid raises
Self resolves within a week

Foraminal / Central canal stenosis with nerve root compression at Cervical vertebra C5

Symptoms:

May present as deep dull ache on top of shoulder
Unrelenting neck pain with neurological symptoms down arm or in clavicular fossa
Radiculopathy down arm – burning, pins and needles, numbness, tingling
Painful to turn neck
Weakness in arm
Muscle atrophy in shoulder and arm muscles

A) Cervical Disc herniation (M>F 40-60)

Caused by:

trauma
poor posture,
repetitive activity
overweight

Diagnosed by:

Neck compression test (Spurling’s) Positive when peripheral pain, numbness and radiculopathy increases down the arm
Sensitivity approximately 55% Specificity approximately 87%
MRI

Tests:

Muscle testing (myotomes)
Sensory testing (dermatomes)
Observing for atrophy in muscles

Treatment:

Surgery
Cortisone injection
Conservative – medication, rest, manual therapy to surrounding musculature
Disc herniations can heal on their own in 6-9 months

B) Vertebral spurs

Caused by:

Osteoarthritis
Trauma / Injury / fractures
Diagnosed by:
X-ray

Treatment:

Medication to reduce inflammation and pain
Cortisone injection
Surgery
Manual therapy to surrounding musculature

C) Anterior longitudinal ligament ossification (Thickening)

Caused by:

Unknown
Hereditary
Diffuse idiopathic skeletal hyperostosis (DISH)
Trauma

Diagnosed by:

X-ray / MRI

Treatment:

Medication to reduce inflammation and pain
Manual therapy to surrounding musculature
Cortisone injection
Surgery indicated when airways are potentially being blocked

D) Space occupying lesion (Cyst)

Caused by:

Genetics
Chronic inflammatory conditions
Trauma / Injury to arteries, veins, lymphatics
Blockages to ducts

Diagnosed by:

MRI
Treatment:
Surgery
Drainage
Injecting cyst to reduce swelling and pain
Laser removal

E) Space occupying lesion (Tumour)

Symptoms:

May include systemic signs such as night pain, night sweats, fever, or enlarged lymph nodes

Caused by:

Genetics
Trauma / Injury
Infectious disease
Obesity
Cigarette smoking / Excessive alcohol

Diagnosed by:

Treatment:

Surgery
Radiation / Chemotherapy

SUPERIOR SHOULDER

Numbness, Tingling, Weakness, Burning or Muscle atrophy

Thoracic outlet syndrome (F>M 20–50)

Blood vessels or nerves being compressed between the collar bone and first rib causing neck and shoulder pain with neurological symptoms in the shoulder and upper limb.

Potential structures compressed: scalene strain, elevated rib 1, clavicle (arthritis, fracture), pec minor strain

Neurological (Upper trunk C5,6,7 – less common)

Painful in neck, chest, shoulder, triceps, forearm,
Numbness, tingling, pins, and needles
Caused by constant compression, traction, irritation of brachial plexus
Caused by bony / soft tissue abnormalities

Neurological (Lower trunk C7,8, T1 – more common)

Pain in medial forearm, hand
Numbness, tingling, pins, and needles
Caused by constant compression, traction, irritation of brachial plexus
Caused by bony / soft tissue abnormalities

Vascular (Emergency, Hospital)

Swelling, stiffness, heaviness, coldness in arm
Discoloured limb, decreased pulse, cramping in arm
Diffuse paraesthesia
Aggravated with arm elevation, exercise

Similar diagnoses: Cervical disc herniation, cervical arthritis causing IVF narrowing, Carpal tunnel syndrome, compression of ulnar nerve at elbow

Adson’s test: Sensitivity 50% Specificity 74 – 100%

Roo’s test: Sensitivity 82% Specificity 100%

Doppler arteriography

Prognosis: Fair to good depending on Neurological or vascular cause

Treatment: Aim is to release the structures causing symptoms. Manual therapy techniques to Scalene muscles, rib 1, clavicle, and pec minor muscle. Surgery may be performed in vascular causes

Foraminal / Central canal stenosis with nerve root compression at Cervical vertebra C5

Symptoms:

Numbness, tingling, or burning sensation radiculopathy down arm
May also present only locally on top of shoulder with similar neurological symptoms
Severe pain in neck region
Painful to turn or extend neck
Weakness in arm
Muscle atrophy in shoulder and arm muscles
Patient may at times sleep in a chair or recliner to prevent neck extension leading to symptoms

A) Cervical Disc herniation (M>F 40-60)

Caused by:

trauma
poor posture,
repetitive activity
overweight

Diagnosed by:

Neck compression test (Spurling’s) Positive when peripheral pain, numbness and radiculopathy increases down the arm
Sensitivity approximately 55% Specificity approximately 87%
MRI

Treatment:

Surgery
Cortisone injection
Conservative – medication, rest, manual therapy to surrounding musculature
Disc herniations can heal on their own in 6-9 months

B) Vertebral spurs

Caused by:

Osteoarthritis
Trauma / Injury / fractures

Diagnosed by:

X-ray

Treatment:

Medication to reduce inflammation and pain
Cortisone injection
Surgery
Manual therapy to surrounding musculature

C) Anterior longitudinal ligament ossification (Thickening)

Caused by:

Unknown
Hereditary
Diffuse idiopathic skeletal hyperostosis (DISH)
Trauma

Diagnosed by:

X-ray / MRI

Treatment:

Medication to reduce inflammation and pain
Cortisone injection
Surgery indicated when airways are potentially being blocked
Manual therapy to surrounding musculature

D) Space occupying lesion (Cyst)

Caused by:

Genetics
Chronic inflammatory conditions
Trauma / Injury to arteries, veins, lymphatics
Blockages to ducts

Diagnosed by:

Treatment:

Surgery
Drainage
Injecting cyst to reduce swelling and pain
Laser removal

E) Space occupying lesion (Tumour)

Systemic symptoms may be present:

night sweats
night pain
enlarged lymph nodes in neck, armpits and groin

Caused by:

Genetics
Trauma / Injury
Infectious disease
Obesity
Cigarette smoking / Excessive alcohol

Diagnosed by:

Treatment:

Surgery
Radiation / Chemotherapy

Multiple Sclerosis (F>M 20-40)

Peripheral neuropathies
Commonly unilateral
Blurred or loss of vision in one eye
May cause atrophy of muscles or loss of motor control
May cause tremors
Weakness in one or both legs
Clumsiness of limb
Feeling of walking on cotton wool
Diagnosed through MRI (looking for lesions on brain or spinal cord), Lumbar puncture looking for abnormalities in antibodies in cerebrospinal fluid associated with MS)
Often a diagnosis of exclusion as other conditions produce similar symptoms
Treatment: medications

Local peripheral nerve damage (Supraclavicular nerve)

Numbness and tingling
Sharp, jabbing, or throbbing pain
Sensitive to touch
Gradual onset of symptoms
Caused by local trauma, repetitive movements, crushed, or cut nerves (surgery),
Medical causes: Diabetes, Multiple sclerosis, Guillain-Barre syndrome
Electromyography (EMG test), Ultrasound, Nerve conduction test
Treatment: self-resolving in 12 months, Surgery, or may not fully resolve

SUPERIOR SHOULDER

Medical Considerations

Chronic Fatigue Syndrome

Fatigue / tiredness over a period of 6 months
Worse after activity
Rest does not improve symptoms
Unexplained muscle and joint pain
Sensitivity to pain
Sleep disturbances
Impaired memory
Commonly related to depression
No specific diagnostic tests
Diagnosed based on fatigue / tiredness for at least 6 months plus 4 of the above symptoms
Treatment: Exercise, counselling, manual therapy, medications

Fibromyalgia (F>M 30-50)

Pain disorder characterized by widespread musculoskeletal pain with localized tenderness for at least 3 months. Chronic daily body aches. Overactive nerves causing pain despite lack of any physical injury. Does NOT cause joint damages

Symptoms:

Widespread muscle pain and tenderness
Points include shoulders, low / upper back, chest, elbows, knees, and temporal region of head
Fatigue, altered sleep, mental distress
Lack of energy
Morning stiffness in joints
Cognitive difficulties
Stress can magnify symptoms

Common causes:

Unknown
Genetics
May be initiated or triggered by physical or emotional event
Chemical receptors in the brain can become sensitised and overreact to painful and non-painful stimuli
Central sensitisation. Blunting of inhibitory pathways and changes in neurotransmitters cause aberrant neuro-chemical processing of sensory signals in the CNS. This lowers the patient’s pain threshold and amplifies the normal sensory signals causing pain.

Diagnosed via:

Mild to severe pain in 3 to 7 different areas of your body
Symptoms for at least 3 months
No other reason for your symptoms

Treatment – medicines / procedures

Patient education on stress reduction strategies, good sleep hygiene, and assistance for anxiety or depression related symptoms
Exercise regimen involving cardiovascular training which improves sleep and helps decrease pain levels (recommended 30 mins of aerobic exercise 3 x a week)
Manual therapy
Hydrotherapy
Medications to help reduce pain levels (consult your medical doctor)

Prognosis: Fair to poor. Factors included are listed here.

A long duration of disease
High-stress levels
Presence of depression or anxiety that has not been adequately treated
Long-standing avoidance of work (unemployed)
Alcohol or drug dependence
Moderate to severe functional impairment

Specialist: Rheumatologist, Psychiatrist, Physical medicine and rehabilitation physician (Physiatrist)

Polymyalgia Rheumatica (F>M 70-79)

Connective tissue inflammatory disorder characterised by bilateral pain and stiffness in the muscles

Symptoms:

Shoulder, neck, and hip pain associated with restricted range of motion and stiffness. Pain often spreads to the arms and legs
Pain can develop quickly or progressively over a few weeks.
Morning stiffness that lasts more than an hour
Commonly bilateral
Symptoms may be worse in the morning and with inactivity.

Common causes:

Suspected genetic and environmental factors

Diagnosed via:

A combination of clinical symptoms and laboratory findings
ESR and C reactive protein blood tests can be used to check the levels of inflammation in the body.

Treatment

Corticosteroids are considered the treatment of choice because they often cause complete symptom resolution and reduction of the ESR to normal.

Prognosis

With early diagnosis and appropriate management, the average length of disease is 3 years. Usually lasts 1-5 years. However, exacerbations may occur if steroids are tapered too rapidly.

Gall bladder disease

Definition: Refers to any condition that affects the health of the Gall bladder.

Symptoms:

Severe pain in right upper quadrant of stomach, epigastric region
Pain can refer to shoulder and upper back region
Jaundice
Nausea and vomiting
Fever and chills
Dark urine, lighter stools, or both
Increased heartbeat
Abrupt drop in blood pressure

Caused by:

Gall stones: hard crystalline mass deposit found in the fluid of the gall bladder
Cholecystitis: Inflammation of Gall bladder
Cholestasis: Flow of bile from the liver slow or stops
Gall bladder cancer: Cancer that has developed in the gall bladder
Fatty foods: Cause the gall bladder to contract and empty. Any inflammation, gall stones, or blockage in ducts will increase the pain when fatty foods are eaten, and the gall bladder is being contracted

Diagnosed via:

Abdominal ultrasound
Endoscopic ultrasound
Endoscopic retrograde cholangio-pancreatography (ERCP) (procedure used diagnose and remove gall stones from bile duct)
Blood tests

Treatment:

Medications have been shown to thin the bile and allow the gallstones to dissolve
Endoscopic retrograde cholangio-pancreatography (ERCP)
Surgery, removal of Gall bladder