What is the appropriate management for referred shoulder pain?

Management of Referred Shoulder Pain

The primary management of referred shoulder pain requires identifying and treating the underlying source rather than the shoulder itself, as the shoulder is merely the site of pain perception, not the pathology. 1

Diagnostic Approach

Initial Clinical Evaluation

Begin by distinguishing referred pain from intrinsic shoulder pathology through targeted history and examination:

• Look for absence of shoulder-specific findings: No tenderness on palpation of shoulder structures, normal range of motion without mechanical restriction, and negative provocative shoulder maneuvers suggest referred pain 2, 3
• Identify red flag symptoms: Postprandial pain suggests gastrointestinal or diaphragmatic sources, pain with breathing suggests pulmonary/pleural pathology, and pain with neck movement suggests cervical spine origin 1, 4
• Perform cervical spine examination: Assess for radiculopathy through Spurling's test, range of motion limitations, and dermatomal sensory changes 1, 2
• Evaluate thoracic outlet: Perform Adson's test, Wright's test, and Roos test to assess for neurovascular compression 1

Common Sources of Referred Shoulder Pain

Cervical spine pathology is the most common extrinsic cause of referred shoulder pain and should be evaluated first 2:

• Obtain cervical spine radiographs if neck pain, radicular symptoms, or positive provocative maneuvers are present 1
• Consider nerve conduction studies if peripheral nerve compression is suspected 1

Thoracic and abdominal sources refer pain through phrenic nerve irritation 1:

• Pulmonary neoplasms and parenchymal disease can present as shoulder pain 1
• Pleural and subdiaphragmatic infections commonly refer to the shoulder 1
• Diaphragmatic irritation from splenic pathology (Kehr's sign) or gastric distension can cause left shoulder pain 4

Thoracic outlet syndrome causes compression-related referred pain 1:

• Diagnose primarily through history, physical examination, and provocative test maneuvers 1
• Initial treatment involves shoulder girdle strengthening exercises 1
• Surgical excision of the first rib may be required for refractory cases 1

Treatment Algorithm

Step 1: Treat the Source, Not the Shoulder

Direct all therapeutic interventions toward the identified underlying pathology:

• For cervical radiculopathy: Address cervical spine pathology with appropriate medical or surgical management 1, 2
• For thoracic outlet syndrome: Begin with shoulder girdle strengthening exercises; proceed to surgical decompression if conservative management fails after 3-6 months 1
• For visceral sources: Treat the underlying pulmonary, pleural, or abdominal pathology 1

Step 2: Avoid Inappropriate Shoulder-Directed Therapy

Standard shoulder treatments will fail because the pathology is not in the shoulder:

• Patients with persistent shoulder pain and no discernible musculoskeletal abnormalities who do not respond to standard therapeutic measures require investigation for referred pain sources 1
• Do not pursue shoulder-specific interventions (injections, physical therapy, surgery) until referred sources are excluded 1, 3

Critical Pitfalls to Avoid

The most common error is treating the shoulder when the problem lies elsewhere:

• Always perform a thorough sensorimotor examination of the upper extremity and evaluate the neck and elbow, not just the shoulder 3
• Consider psychosocial factors and obtain a complete history, as these are equally important in evaluating painful shoulders 5
• Maintain high suspicion for referred pain when shoulder examination is unremarkable despite significant pain 1, 2

Imaging should target the suspected source, not the shoulder:

• Radiography of the shoulder is not indicated when clinical examination suggests referred pain 6
• Direct imaging toward the cervical spine, chest, or abdomen based on clinical findings 1