Regenerative ~ Reconstructive ~ Rehabilitative

The Differential Game- Shoulder Pain Edition

Perhaps it’s my love of the shows like “House, MD”, “Dr. G, Medical Examiner”and “Tales From the ER”, but I’ve noticed that most health care professionals tend to only diagnose, or asses as the case is with anyone who isn’t a medical doctor, within their specialty, and rarely look beyond their own specialty for other causative issues.

“I suppose it is tempting, if the only tool you have is a hammer,
to treat everything as if it were a nail.”

Abraham Maslow

If your left shoulder pains you, an Orthopedist will treat you for Labrum tears requiring surgery, a Cardiologist will put you on heart meds, a Physical Therapist will give you exercises muscle imbalances, a Chiropractor will adjust the cervical spine to relieve pressure on the nerve roots, an Acupuncturist will treat the blocked meridians, a Massage Therapist will begin protocols for frozen shoulder, and mom will give you a couple of ibuprofen and some chicken soup.

Yes, it’s oversimplified, but it paints the picture. Obviously there are more symptoms then simply a pained left shoulder which will lead to a more accurate assessment, and yet- when given the opportunity to refer out to the appropriate specialist, most of the above would rather adopt protocols of their profession which fit the symptoms the best. Medical Doctors are the least likely, because their licensure is at risk for misdiagnosis or medical neglect, not to mention the sizable sums which have been won in court over malpractice. And the rest? They’re not held nearly to that accountability. Their accountability rests with their ethics mostly. Yes, this does include massage therapists.

Because the standard massage therapy education does not include differential diagnosis (I used the word diagnosis. I admit it. It’s appropriate for the conversation though, therefore I will use it without any inference that we massage therapists are diagnosing anything). Why would it be necessary though? Because the difference between a cyst, tumor, and trigger point may be difficult to tell. Because Rheumatoid Arthritis in the knee may present as flexor/extensor pain and reduce ROM. Because MS can present idiopathic lower limb pain. Because dull pain in the shoulder and arm is sometimes a heart attack.

Massage therapists are very often (at least in the US) left to their own devices when trying to help a client with pain. Most of the education received post schooling either comes from seminars and workshops, or self study. And most massage therapists didn’t have an inkling what kind of a world they would be entering into when they decided to become massage therapists.

But let’s go back to the left shoulder. A while back, I wrote an article on bicepital tendonitis, and in their I touched on differentials in a list that was no where near comprehensive. A comprehensive list is nigh impossible considering the amount of specialties out there, but I will use it as a platform to expound upon the virtues, and necessity, for both differentials and the further education of massage therapists who wish to enter a more clinically divers field of practice.

So let’s get started. In the beginning there is always a list of symptoms.

The Subjective Data

The Client has been suffering from pain and weakness proximally and anteriorly in the left shoulder. The pain started during a workout- specifically during the bench press, after recently increasing the weight. The client reported sharp pain during the ascending phase and weakness and pain on the descending phase of the exercise. The client reported a drastically shortened the duration of the exercise, eventually leading to a cessation of the exercise altogether.
Pain continued well after the workout, and disrupted the client’s sleep and activities of daily living. The pain subsided, though not leaving entirely, by not doing the exercises or actions which reproduced the pain, i.e.- flexing the shoulder and extending the elbow against an opposing force or dead weight.
Client also reported taking naproxen sodium for pain when necessary, but disliked taking pills if it could be avoided.
For the purpose of this article, I’ll leave the assessment out of it, though I will make note in the differential section where appropriate, for the sake of clarification.

The Differentials

Tendonosis/Tendinitis – a syndrome of overuse and degeneration caused by use over time. Different from tendonitis in that there is tendon damage, wearing and or fraying, but no inflammation present. This is often a function of extended use and is typical of injuries found in older populations (65+)
In this case, it could very well have been tendonosis instead of tendonitis. The protocols would have been pretty much the same.

In this case, the assessment was accurate. Muscle testing showed strong deltoids, rotators of the shoulders, triceps and pectorals. Muscle testing of the bicep, specifically of the long head of the bicep, reproduced the pain the client was describing. The proper protocols were enacted, appropriate homework was given and improvement was made.

Impingement Syndrome- a syndrome caused when the tendons of the rotator cuff, which pass under the subacromial space (the space between the acromion process and the head of the humorous), become irritated. Symptoms usually include pain in shoulder movements related directly to the rotator cuff.
In this case, all the rotator cuff muscle tests reproduced no pain, which indicates it was a different muscle or group altogether that was affected.

Subacromial Bursitis- Much in the same manner as the impingement syndrome above, Subacromial Bursitis involves the supraspinatus tendon, but as an accessory or irritant to the inflammation. The bursa, which lies between the supraspinatus tendon and the coraco-acromial ligament, acromion, coracoid (the acromial arch) and from the deep surface of the deltoid muscle, is what actually is inflamed.
It is often lumped into the diagnosis of “Impingement Syndrome” and presents many of the same symptoms.
In this case there was no swelling of the bursa, and no localized inflammation what so ever.

Frozen Shoulder- Frozen shoulder is a term used to describe painful abduction of the glenohumeral joint resulting in a limited range of motion. Typically, Frozen Shoulder is when tightness in the subscapularis muscle restricts movement causing pain in both the anteriosuperior aspects of the glenohumeral joint, as well as in the proximal deltoid muscles.
In this case, the restricted movement of the shoulder did not indicate subscapularis involvement, and the pain was localized to the area of the anterior portion of the deltoid. Shoulder abduction was only mildly restricted, with a majority of the pain being reproduced with circumduction and transverse felxion.

Labrum tears- The head of the Humerus articulates with the Scapula in a depression in the bone called the Glenoid fossa. The Glenoid labrum is a ring of cartilage which acts as a gasket deepening the depression and holds the head of the Humerus securely in place. A major tears can happen though traumatic injury- falls, etc, while minor tears can happen through repetitive use and age.
Typically, pain is felt in the joint, with the location relevant to the tear, accompanied with a “clicking” feel as the shoulder articulates.

In this case the client did report a clicking feeling in the shoulder, though the clicking was palpable anteriorly, indicating a greater likelihood this was a bicepital tendon issue and not a labrum tear. The clicking in a torn labrum would not be palpable through light to medium pressure touch. Further, the pain in the joint was not felt with all actions, but specifically load bearing transverse felxion.

Spinal root impingement- The nerve roots at C4-C6 feed the arm the impulses from the brain as well as return sensory information to the brain via the same channels. An impingement at the nerve roots can send pain signals anywhere down the line (depending on which nerve root is impinged), as well as parathesia, numbness, and loss of muscular function. Impingement can happen for a variety of reasons- bulging intravertable disks, vertebral disk ossification due to Spondylitis, Ankylosing spondylitis, fusion from either disk degeneration, surgical intervention, or traumatic injury.

In this case, the client only has mild degeneration of the intravertebral disks with no movement restrictions. Further, client experiences no reproduction of the pain with the articulation of the vertebral joints and the pain does not radiate or shoot down the arm. The client reported no pain or tingling in the arm.
Brachial Compression- The Brachial Plexus is a large bundle of nerves (which ends the literal definition), blood vessels and lymph nodes (which ends the common usage definition) with multiple origins, but coalescing lateral to the thoracic outflow. It travels under the Pectoralis minor into the the armpit. There, it is framed by a variety of muscles: the subscapularis, Pectoralis major and minor, Serratus anterior, heads of both the Biceps and Triceps, and the Deltoid.

Compression of the Brachial plexus can happen at any point along that line- bulging disks at C5-T1, on rare occasion the presence of an extra rib just superior to the first rib, and at the Pectoralis minor. Further, traumatic injury to the plexus can occur during sporting events, car and work place accidents.

Symptoms of Brachial plexus compression or generally the same though. Numbness and tingling down the arm to the ring and little fingers (ulnar nerve compression), weakness in the arm, neck/upper back pain, and so forth.

In this case, nerve compression symptoms were not present, nor was their significant weakness in the arm. Nor did the arm exhibit any signs of vascular compression- unexplained swelling, especially in the lower arm or significant reduction in the pulse with abduction
Myocardial infarction- Heart attack. When the heart- for what ever reason- fails to work, the tissues of the heart begin to die. Tissue death is not immediate, and can sometimes take an hour or more before it becomes a serious matter of life and death- depending on the level of cardiac ischemia.

Symptoms include intermittent chest pains, numbness and tingling down the left arm, and nausea. It is commonly reported that it feels like the heart, itself, is being squeezed.

In this case, Myocardial infarction was a concern. The client has had a history of cardiac dysfunction- Atrial fibrillation- and the pain in question was on the left side. It was ruled out though, as the pain only happened during a specific movement of the shoulder and arm, under specific circumstances, and was constantly present during those times only. There was no nerve or vascular dysfunction or symptoms indicated and the client was currently having the A-Fib monitored.
Blood Clot- Blood clots in the arm are typically rare, though there is some evidence which shows that the incidents of a brachial thrombosis are on the rise. It is believed the cause of that rise in incidents is because of the increased use of PICC (Peripherally Inserted Central Catheter) lines which can- when used for elongated periods of time- irritate the the walls of the veins in some patients, cause clotting.

Symptoms include swelling of the arm, pain and parathesia (numbness and tingling) in the arm, vertigo, difficulties in breathing, and fever have been reported.

In this case, the client exhibited practically none of these symptoms, nor has the client had a PICC line in, surgery, or traumatic injury to the arm. The client had no family history of blood clots and was not currently on medication for a clotting disorder.

Multiple Sclerosis- MS is a systemic, autoimmune disease where the body attacks at the myaline sheaths surrounding the nerves, which in turn damages the nerves and the ability for the brain to communicate with the body. MS is a disease with a multitude of factors and symptoms- including blurred vision, peripheral (limb) pain, numbness and weakness in the limbs, coordination issues, and many others. Because MS is a multifaceted disease which can disguise it’s self as a multitude of other diseases and dysfunctions, it’s almost impossible for a massage therapist to assess accurately. Therefore, the standing rule applies for MS, as with any other dysfunction for which seem to stump massage therapists, “when in doubt, refer out”

In this case, the pain was confined to a single point, and was usually only present during a specific motion or specific stresses.

Arthritis- Arthritis is a general descriptor for a multitude of diseases- over 100, according to the Arthritis Association- that cause swelling of the joints (though, with the inclusion of diseases such as Fibromyalgia, the description my be broadened to inflammatory diseases affecting the supporting structure of the body). Some versions of arthritis- like Rheumatoid arthritis- are autoimmune diseases, while others- like Osteoarthritis- can be a result of injury or overuse.

Warning signs of arthritis pain are swollen joints, family history of arthritis, pain through all ranges of motion, consistent pain throughout the day or lessening when the joint warms up, pain with weather changes, and a multitude of others associated with specific forms of the disease.

In this case, the pain the client reported feeling wasn’t congruent with a vast majority of the symptoms of arthritis. Client has no known family history of arthritis and the client had not sustained any traumatic joint injury to the shoulder. Further, the client only experienced pain through a single action of the joint and not through every action of the joint.

Myofascitis- Myofascitis is a generic term widely utilized by chiropractors to describe inflammation of a specific muscle or muscle group and it’s related fascia. The designation doesn’t define causative factors, only describes a certain set of generalized symptoms.

Symptoms include localized pain and swelling or inflammation of the soft tissue.

In this case the client most certainly has myofascitis of the shoulder. But since the disease name doesn’t point to a causative factor, diagnosing the client (apart form it being illegal for a massage therapist to diagnose) with myofascitis would have been clinically irrelevant and only serve to cause anxiety in a client who already had a history of anxiety and heart complications.

Dislocation/subluxation of the joint- A dislocation of a joint is when the articulating faces of two bones which comprise of any given joint are severely or traumatically misaligned. Subluxation is a partial- usually less traumatically so- dislocation of articulating surfaces. Subluxations can be caused by muscle imbalances, osteo- based pathologies or traumatic injury, and are usually found in the spine, or smaller joints of the body, like the costals, carpels, or digits.

Dislocations present server pain, extremely reduce RoM, excessive swelling and bruising, and a clear causative event. Subluxations can present a much lighter version of these symptoms, and doesn’t always have bruising or swelling associated with it, nor does a clear causative event have to be present. In both cases, once a the joint has been re-aligned, the symptoms usually go away.

In this case, a Subluxation is an unlikely event in the shoulder and a dislocation would have been obvious.

Sarcoma- Sarcoma are a broad group of malignant cancerous tumors which originate either in the osseous tissues (bone) or connective tissues (nerve, muscle and fascia).

In the early stages, sarcoma may not present with any symptoms what so ever. As the tumor grows it may present with a noticeable lump and cause localized pain if the tumor is pressing on nerve or muscle tissue. Other cancer symptoms include: fatigue, weight changes, including unintended loss or gain, skin changes, such as yellowing, darkening or redness of the skin, sores that won’t heal, or changes to existing moles, changes in bowel or bladder habits, persistent cough, difficulty swallowing, hoarseness, persistent indigestion or discomfort after eating, persistent, unexplained muscle or joint pain, and persistent, unexplained fevers or night sweats.

In this case, the client had no family history of cancer, and reported none of the symptoms related to cancer- other than the pain in the shoulder.
Swollen Lymph Nodes- Lymph nodes are small been shaped sack filled with lymph fluid, and are an important part of the bodies immune system. The lymph nodes filter the lymph fluid, removing infections, bacteria, and other foreign bodies destroyed by the bodies’ immune system (white blood cells). Most of the time, they cannot be felt.

Occasionally the lymph nodes can swell due to injury, infection or tumors. Depending on the cause of the swelling, symptoms may vary. But a deep, aching pain may be present for weeks, until the swelling recedes.

In this case, the pain was located superior and superficial (on top of the shoulder) to the auxiliary nodes in the armpit.

This is still an incomplete listing of differentials, but it should serve to illustrate the much broader range of possible issues beyond just our specialties that we, as therapists, must be aware of. This does not mean we have to be an expert in diagnostics in order successfully asses and apply our training to the client. It does me, though, that familiarity with specialties outside of our own is necessary in order to ensure our clients receive the best of care. Being familiar with the different causative factors can allow the massage therapist to refer out when appropriate, to apply their skills when appropriate, and reduce both the suffering of the client and the legal pitfalls of criminal neglect.

And as a practice, the game of differentials can help improve one’s own education making them- as a therapist- much more valuable to their clientele.

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