What is the diagnosis and treatment for back pain and left shoulder pain?

Diagnostic Approach to Back Pain with Left Shoulder Pain

When a patient presents with both back pain and left shoulder pain, the primary concern is to immediately rule out life-threatening emergencies—particularly aortic dissection, ruptured abdominal aortic aneurysm, or myocardial infarction—before considering musculoskeletal causes. 1

Immediate Red Flag Assessment

First, conduct a focused history and physical examination to identify red flags requiring urgent evaluation: 2, 3

• Cardiovascular emergencies to exclude:

  • Chest pain, shortness of breath, or weakness suggesting cardiovascular thrombotic events 4
  • Symptoms of aortic dissection or rupturing abdominal aortic aneurysm 2, 1
  • Left shoulder pain can be referred pain from cardiac or aortic pathology 1

• Serious spinal pathology indicators:

  • History of cancer (increases probability from 0.7% to 9%) 2
  • Unexplained weight loss, fever, or recent infection 2
  • Age >50 years, failure to improve after 1 month 2
  • Progressive neurologic deficits, urinary retention (90% sensitive for cauda equina syndrome), fecal incontinence 2
  • History of osteoporosis, steroid use, or significant trauma suggesting compression fracture 2

Diagnostic Categorization

After excluding emergencies, classify the back pain into one of three categories: 2

1. Nonspecific Low Back Pain (85% of cases)

• No specific disease or spinal abnormality identified 2
• No red flags present 3
• Do not obtain routine imaging 3

2. Back Pain with Radiculopathy or Spinal Stenosis

• Perform straight-leg-raise test (91% sensitive, 26% specific for herniated disc) 2
• Assess L4 (knee strength/reflexes), L5 (great toe/foot dorsiflexion), S1 (plantarflexion/ankle reflexes) nerve roots 2
• Crossed straight-leg-raise test is more specific (88%) but less sensitive (29%) 2

3. Back Pain with Specific Spinal Cause

• Requires prompt evaluation if red flags present 2
• Obtain urgent MRI if: severe neurologic deficits, cauda equina syndrome suspected, history of cancer, or serious underlying condition suspected 3, 5

Left Shoulder Pain Evaluation

The shoulder pain requires separate assessment to determine if it is: 6

• Referred pain from back/cervical spine: Cervical radiculopathy can cause shoulder pain 6
• Primary shoulder pathology: Rotator cuff injury, impingement syndrome, adhesive capsulitis, calcific tendinitis, biceps tendinitis, or glenohumeral osteoarthritis 6
• Referred visceral pain: Cardiac ischemia, aortic pathology, or other intra-abdominal processes 1

Perform shoulder-specific examination including active/passive range of motion and provocative tests only after excluding life-threatening causes 6

Imaging Decisions

Imaging should be obtained based on clinical suspicion, not routinely: 3

• No imaging needed: Nonspecific low back pain without red flags, even with midline tenderness 3
• Plain radiography: Risk factors for compression fracture or symptoms persisting >4-6 weeks 3
• Urgent MRI/CT: Red flags present, severe/progressive neurologic deficits, cauda equina syndrome suspected, or history of cancer 3, 5

Initial Management

For nonspecific low back pain without red flags: 3

• Maintain activity within pain limits (avoid strict bed rest) 3
• First-line medications: Acetaminophen or NSAIDs (ibuprofen 400mg every 4-6 hours) 3, 4
• Avoid systemic corticosteroids and long-term opioids 3
• Do not exceed 3200mg ibuprofen daily 4

Follow-up Timing

Reassess patients with: 3

• Persistent symptoms after 1 month 3
• Worsening symptoms at any time 3
• Older age, signs of radiculopathy/stenosis 3
• Consider imaging if symptoms persist beyond 4-6 weeks despite conservative management 3

Critical Pitfalls to Avoid

• Never dismiss combined back and left shoulder pain without excluding cardiovascular emergencies first 1
• Avoid routine imaging for uncomplicated acute low back pain 3
• Do not prescribe prolonged bed rest 3
• Avoid overreliance on opioid medications 3
• Do not fail to assess psychosocial factors predicting delayed recovery 2, 3