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.