Referred Pain in Shoulder


Common Sources of Referred Pain in the Shoulder Region


Referred Pain in Shoulder

Cervical Spine

Vertebral joints between C3 and C4 or between C4 and C5

Nerve roots C4 or C5

Referred Pain from Related Tissues

Dermatome C4 is over the trapezius to the tip of the


Dermatome C5 is over the deltoid region and lateral


Diaphragm: pain perceived in the upper trapezius


Heart: pain perceived in the axilla and left pectoral


Gallbladder irritation: pain perceived at the tip of shoulder

and posterior scapular region.


Nerve Disorders in the Shoulder Girdle Region

Brachial plexus in the thoracic outlet

 Common sites for compression are the scalene triangle, costoclavicular space and under the coracoid process, and pectoralis minor muscle.

Suprascapular nerve in the suprascapular notch

 This injury occurs from direct compression or from nerve stretch, such as when carrying a heavy book bag over the shoulder.

Radial nerve in the axilla

 Compression occurs from continual pressure, such as when leaning on axillary crutches.


To make sound clinical decisions when managing patients with shoulder disorders, it is necessary to understand the various pathologies, surgical procedures, and associated precautions and to identify presenting impairments, functional limitations, and possible disabilities.




Glenohumeral Joint

Restricted mobility of the glenohumeral joint may occur as a result of pathology such as rheumatoid arthritis or osteoarthritis, from prolonged immobilization, or from unknown causes (idiopathic frozen shoulder). Associated impairments in mobility and muscle performance also occur in the muscles and other connective tissues in the area

Traumatic arthritis

This disorder occurs in response to a fall or blow to the shoulder or to microtrauma from faulty mechanics or overuse.

Postimmobilization arthritis or stiff shoulder

 This disorder occurs as a result of lack of movement or secondary effects from conditions such as heart disease, stroke, or diabetes mellitus.

Idiopathic frozen shoulder

 This disorder, which is also called adhesive capsulitis or periarthritis, is characterized by the development of dense adhesions, capsular thickening, and capsular restrictions, especially in the dependent folds of the capsule, rather than arthritic changes in the cartilage and bone, as seen with rheumatoid arthritis or osteoarthritis. The onset is insidious and usually occurs between the ages of 40 and 60 years; there is no known cause (primary frozen shoulder), although problems already mentioned in which there is a period of pain and or restricted motion, such as with rheumatoid arthritis, osteoarthritis, trauma, or immobilization, may lead to a frozen shoulder (secondary frozen shoulder). With primary frozen shoulder, the pathogenesis may be a provoking chronic inflammation in musculotendinous or synovial tissue such as the rotator cuff, biceps tendon, or joint capsule. Consistent with this is a faulty posture and muscle imbalance predisposing the suprahumeral space to impingement and overuse syndromes.

Clinical Signs and Symptoms

Glenohumeral joint arthritis

 The following characteristics are associated with glenohumeral (GH) joint pathologies that lead to hypomobility.

Acute phase

Pain and muscle guarding limit motion, usually external rotation and abduction. Pain is frequently experienced radiating below the elbow and may disturb sleep. Joint swelling is not detected owing to the depth of the capsule, although tenderness can be elicited by palpating in the fornix immediately below the edge of the acromion process between the attachments of the anterior and middle deltoid.

Subacute phase

 Capsular tightness begins to develop. Limited motion is detected, consistent with a capsular pattern (external rotation and abduction are most limited, and internal rotation and flexion are least limited). Often, the patient feels pain as the end of the limited range is reached. Joint-play testing reveals limited joint play. If the patient can be treated as the acute condition begins to subside by gradually increasing shoulder motion and activity, the complication of joint and soft tissue contractures can usually be minimized.

Chronic phase

 Progressive restriction of the GH joint capsule magnifies the signs of limited motion in a capsular pattern and decreased joint play. There is significant loss of function with an inability to reach overhead, outward, or behind the back.


Idiopathic frozen shoulder

 This clinical entity follows a classic pattern*.

“Freezing.” Characterized by intense pain even at rest and limitation of motion by 2 to 3 weeks after onset. These acute symptoms may last 10 to 36 weeks.

“Frozen.” Characterized by pain only with movement, significant adhesions, and limited GH motions, with substitute motions in the scapula. Atrophy of the deltoid, rotator cuff, biceps, and triceps brachii muscles occurs. This stage lasts 4 to 12 months.

“Thawing.” Characterized by no pain and no synovitis but significant capsular restrictions from adhesions. This stage lasts 2 to 24 months or longer. Some patients never regain normal ROM

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