What are the key questions to ask when taking a history for a patient presenting with chronic right shoulder pain without a history of trauma?

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Key Questions for Evaluating Chronic Right Shoulder Pain Without Trauma

When evaluating a patient with chronic right shoulder pain without trauma, focus on specific questions about pain characteristics, functional limitations, and associated symptoms to narrow down the differential diagnosis.

Pain Characteristics

  • Location and radiation: Ask precisely where the pain is located (anterior, posterior, lateral, diffuse) and if it radiates to the neck, arm, or chest 1
  • Onset and duration: When did the pain begin? Was it gradual or sudden? Has it worsened over time?
  • Quality: Is the pain sharp, dull, aching, burning, or throbbing?
  • Intensity: Rate pain on a scale of 0-10 at rest and with activity
  • Aggravating factors: What specific movements or activities worsen the pain?
    • Pain with overhead activities suggests rotator cuff pathology or impingement
    • Pain during overhead pressing is classic for SLAP tears 2
  • Alleviating factors: What reduces the pain? (Rest, medications, specific positions)
  • Timing: Is the pain constant or intermittent? Is it worse at certain times of day?

Functional Assessment

  • Limitations in range of motion: Can the patient reach overhead, behind the back, or across the body?
  • Impact on daily activities: How does the pain affect work, sleep, and recreational activities?
  • Weakness: Any difficulty lifting objects or performing specific movements?
  • Prior treatments: What treatments have been tried? (Physical therapy, medications, injections)
  • Response to previous treatments: What has helped or not helped?

Red Flag Symptoms

  • Constitutional symptoms: Weight loss, fatigue, fever (could indicate infection or malignancy) 3
  • Respiratory symptoms: Cough, shortness of breath (may suggest referred pain from pulmonary pathology) 3
  • Neurological symptoms: Numbness, tingling, or weakness in the arm or hand (may indicate cervical radiculopathy)
  • History of cancer: Especially those that commonly metastasize to bone

Risk Factors and Associated Conditions

  • Occupational factors: Does the patient's job involve repetitive overhead work or heavy lifting?
  • Recreational activities: Sports or hobbies that involve repetitive shoulder movements
  • History of neck pain: Concomitant neck pain is associated with poorer outcomes in shoulder disorders 4
  • Previous shoulder problems: History of prior shoulder injuries or conditions
  • Medical conditions: History of diabetes (associated with adhesive capsulitis), rheumatological disorders, or thyroid disease

Psychosocial Factors

  • Psychological factors: Anxiety, depression, catastrophizing (these can influence pain perception and recovery) 1
  • Social support: Available support system for managing chronic pain
  • Expectations: Patient's understanding and expectations regarding recovery

Differential Diagnosis Considerations

Based on the American College of Radiology guidelines 1, common causes of chronic shoulder pain without trauma include:

  • Rotator cuff pathology (tendinopathy, partial or full-thickness tears)
  • Subacromial impingement syndrome
  • Adhesive capsulitis (frozen shoulder)
  • Acromioclavicular joint arthritis
  • Labral tears (including SLAP tears)
  • Biceps tendinopathy
  • Glenohumeral osteoarthritis
  • Referred pain (cervical spine, cardiac, pulmonary, or abdominal sources)

Remember that a thorough history focusing on these key areas will help narrow the differential diagnosis and guide appropriate physical examination and imaging decisions for your patient with chronic shoulder pain.

References

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Guideline

Shoulder Injuries: SLAP Tears

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Research

Shoulder disorders in general practice: prognostic indicators of outcome.

The British journal of general practice : the journal of the Royal College of General Practitioners, 1996

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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