The Nasty Side of Shoulder Pain

Not all shoulder pain is shoulder related. It is so important to stay vigilant when assessing someone with shoulder pain as there is a nasty side which on occasion rears its ugly head.

In this video Luke reveals some common shoulder pain “Red Flags”.

00:50 – 7% of all tumours occur in the shoulder
01:10 – The most common tumour to cause shoulder pain
02:00 – Why you should always X-ray an acute severe painful frozen shoulder
02:25 – Matching clinical history with appropriate investigations
03:15 – A list of Shoulder Pain Red Flags
04:30 – Tumours can mimic the signs and symptoms of rotator cuff pathology
06:25 – Ask the right questions to get the answers you need
07:10 – Be Suspicious

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My name is Luke, and I’m the Shoulder Guy.

You think you’ve got a shoulder pain problem, do you? Well, let’s be sure. It’s really important that you make sure that you actually do have a shoulder pain problem that you can fix, or that you can go to a physiotherapist and get fixed. Or you can go online to and access one of our products, so that you can actually work towards fixing your own problem at home.

The reason that I say this is because there are a lot of other diagnoses, or other potential problems, that masquerade themselves as shoulder pain. One of the most sinister ones, which we really want to make sure that we diagnose very quickly and very early, are tumours. Seven percent of all tumours within the body actually are up in the shoulder.

One of the most common tumours that refers its pain to the shoulder is the pancoast tumour, which actually starts in the apical section of the upper lung. Then refers pain directly out to the shoulder. So that can be a reason for acute shoulder pain. So 7% of tumours are found in the shoulder, and of all the tumours that are in the upper limbs, 70% are up in this proximal humerus. They end up high in the shoulder. Sometimes they are the primary cause, and other times they are metastases of a primary tumour elsewhere in the body.

The heart and the diaphragm can refer pain out to the shoulder. We’ve got to be careful of these visceral referrals of shoulder pain out there.

Another reason why you need to double check your shoulder pain is because some people have a diagnosis of frozen shoulder. They may actually have a tumour. Or they might have what they call avascular necrosis, which means the head of the humerus, the ball part, is actually dying off. It’s necrotic. That’s what is giving them the shoulder pain and the stiffness, which mimic the symptoms of a frozen shoulder.

Tumours are the most important things. It’s really important that we get a very good clinical diagnosis. Also we match that with really good investigations, so plain x-rays, CT and MRI. It really doesn’t take the place of a good clinical examination and some healthy suspicion. It’s really important that you’re suspicious about things when you’re examining someone with shoulder pain. Or for you at home, that you’re also suspicious about why you could have shoulder pain. It’s not always because you actually do have shoulder pain.

The other area which could refer pain into the shoulder is the neck, obviously. The nerves that come out from the neck into the brachial plexus, they can refer pain into the shoulder, too. We’ve got to be careful about neck movements, and also pain that might be starting in the neck and then referring out to the shoulder.

What I wanted to give you right now is some common things to look out for. We call these red flags. These are the big red flags that we need to identify, which could lead us to a diagnosis of something that’s more sinister in terms of a reason for your shoulder pain. Let’s go through those now, because they’re really important.

Night pain. Night pain is common when we’re looking at a shoulder problem with bursitis particularly, but night pain without a loss of active range of motion or passive range of motion. If we’ve just got this night pain, which is severe, but we see no loss or no real effect on the shoulder, then this is something that we need to pay attention to.

Constant pain is something that we need to pay attention to. We don’t mind severe pain as long as it is variable and it might be mechanically related. If we have constant pain that’s independent of activity, it doesn’t matter what we do, we’ve got this constant pain that’s in the shoulder, then this, potentially, could be a red flag. We need to pay attention to that.

Obviously, if things just don’t fit, this is where we’re putting everything together. If something just doesn’t fit with the pattern of what normally is shoulder pain, then we need to pay attention to it. The trouble with tumours and the like, they can mimic rotator cuff disease. You can get positive impingement signs. You could, on an MRI, see that there actually is a rotator cuff tear, and we go directly for that. It’s the easiest diagnosis. There is a tear, there must be shoulder pain related to that tear. If we discount these other things, then potentially we’re going to make the diagnosis of a rotator cuff tear, which is now contributing to shoulder pain. In the background, we haven’t investigated fully enough. We haven’t asked the right questions. We might have a tumour that’s mimicking the signs and symptoms of a rotator cuff problem. This is really important.

Let’s continue…

Fever, or feeling generally unwell. This is also something we want to make sure that we pay attention to, if we’re just not feeling that well.

Also unexplained weight loss. It’s doesn’t have to be massive weight loss, but it could be something that’s unexplained. If we put some weight loss together with a fever, with constant pain, there we’re starting to build up a picture that things just don’t fit.

Weakness, muscle wasting or motor and sensory loss. This is where neurological problems begin, when we have motor and sensory loss. If we’re noticing global weakness or muscle wasting in and around the shoulder or the body, then this is potentially a red flag.

If we notice masses. Some people actually have a palpable mass up in the upper chest area. This might be an indication that something just isn’t right.

Cough. If we’re noticing something on the chest, that might be the primary tumour, or the primary location for the malignancy. A cough could go along with some of these other symptoms and signs, as well. An unexplained cough is something that we would, okay, that doesn’t sound right, let’s pay attention to that.

Obviously, I’ve mentioned that before, cardiac symptoms, too.

Some of these things, they all have to come together. You don’t want to just pick one out, but we could have a few here. If we ask the right questions that are going to paint the picture of a shoulder pain problem that is outside of what we would expect normally. The trouble is that some tumours can mimic the exact shoulder pain or the exact rotator cuff lesions that we’re trying to treat. We’re trying to be helpful, so we say hey, this must be a rotator cuff problem. Let’s treat that. And all the while, we’re delaying the actual diagnosis of a tumour.

This is really important. If you think you’ve got a shoulder pain problem, make sure that you do have. Consult your physiotherapist. Consult your doctor and if you are at all concerned, you’ve got to bring some of these symptoms up. Be forward. Get on the front foot and let your doctor know that you have constant pain, potentially. You’ve got a cough, you’ve got weakness or unexplained weight loss. Things just don’t seem to fit. That could help them make the diagnosis that could potentially solve your problem fast and potentially save your life, as well.

My name’s Luke. I’m The Shoulder Guy. I hope this has helped you. I look forward to seeing you again soon on another episode of Shoulder Guy TV. Bye for now.

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