What are the possible causes and treatments for a suspected hernia in the left shoulder of an adult with no prior medical history?

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Clarification: "Hernia in Left Shoulder" Likely Refers to Diaphragmatic Hernia

You are almost certainly describing a left-sided diaphragmatic hernia, not a shoulder hernia (which does not exist anatomically). The term "left shoulder" in this context likely refers to left shoulder pain as a presenting symptom of a diaphragmatic hernia, or confusion about the anatomical location.

Understanding the Diagnosis

A diaphragmatic hernia occurs when abdominal contents herniate through a defect in the diaphragm into the thoracic cavity, and left-sided hernias are the most common type (50-80% of cases). 1

Key Diagnostic Considerations

Left shoulder pain can be a referred pain symptom from diaphragmatic pathology due to phrenic nerve irritation (C3-C5 nerve roots), though this is an unusual isolated presentation. 2 A case report documented a patient with a right-sided Morgagni hernia presenting exclusively with contralateral left shoulder pain, demonstrating this atypical presentation pattern. 2

Types of Diaphragmatic Hernias

The condition can be:

  • Congenital (CDH): Most commonly Bochdalek hernias (95% of CDH), occurring posterolaterally and predominantly on the left side (80-85%). 1, 3 These can remain asymptomatic for decades, presenting at a mean age of 40-44 years. 3

  • Traumatic (TDH): Result from blunt trauma (3-8% of cases) or penetrating trauma (65% of cases), with left-sided injuries more common due to the protective effect of the liver on the right. 1

  • Acquired non-traumatic: Including hiatal hernias and iatrogenic causes. 1

Clinical Presentation

The most common symptoms of diaphragmatic hernia are dyspnea (86%) and abdominal pain (17%), though presentations can be highly variable and nonspecific. 1

Warning Signs

  • Gastrointestinal symptoms: Intestinal obstruction, nausea, vomiting (particularly with left-sided hernias) 1
  • Respiratory symptoms: Dyspnea, chest discomfort, decreased breath sounds 1
  • Referred shoulder pain: Due to diaphragmatic irritation 2

Critical pitfall: 33-66% of traumatic diaphragmatic hernias are missed in the acute phase, and delayed diagnosis occurs in 5-45% of all cases. 1 Undetected hernias can progress to bowel strangulation, perforation, peritonitis, sepsis, and multi-organ failure with high mortality. 1

Diagnostic Approach

Initial Imaging

For patients without trauma history presenting with respiratory symptoms, obtain anteroposterior and lateral chest X-rays as the first diagnostic study. 1

  • Chest X-ray findings may include: abnormal bowel gas pattern, air-fluid levels, abnormal lucency, mediastinal deviation, or hemidiaphragm elevation 1
  • Sensitivity is only 2-60% for left-sided hernias, and normal radiographs occur in 11-62% of cases 1

Definitive Imaging

CT scan with contrast enhancement of chest and abdomen is the gold standard for diagnosis, with sensitivity of 14-82% and specificity of 87%. 1

  • CT accurately determines presence, location, size of defect, and evaluates for complications 1
  • If clinical suspicion persists despite normal chest X-ray, proceed directly to CT scan 1

Alternative Modalities

  • Ultrasonography: Useful for pregnant patients or when CT is contraindicated 1
  • MRI: Recommended for pregnant patients after ultrasonography 1
  • Diagnostic laparoscopy: Consider in stable trauma patients with lower chest penetrating wounds 1

Treatment

Surgical repair is the definitive treatment for symptomatic diaphragmatic hernias to prevent life-threatening complications including bowel strangulation, perforation, and sepsis. 1

  • Approach depends on: acuity, hernia size, associated injuries, and patient stability 1
  • Options include open repair or laparoscopic/robotic-assisted repair with or without mesh 2

Urgency Considerations

Emergency surgical intervention is mandatory if there are signs of bowel obstruction, strangulation, or perforation given the high mortality risk from sepsis and multi-organ failure. 1

Next Steps for Your Patient

  1. Obtain detailed history: Any remote trauma (even years prior), respiratory symptoms, gastrointestinal symptoms, timing and character of shoulder pain 1

  2. Order chest X-ray immediately (AP and lateral views) 1

  3. Proceed to CT chest/abdomen with contrast if X-ray is suspicious or if clinical suspicion remains high despite normal X-ray 1

  4. Refer to general/thoracic surgery once diagnosis is confirmed for surgical evaluation 2

The key is maintaining high clinical suspicion, as these hernias are frequently missed and can present with atypical symptoms like isolated shoulder pain. 1, 2

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

3
Guideline

Diaphragmatic Eventration Causes and Characteristics

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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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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