Screening the Shoulder and Upper Extremity

The therapist is well aware that many primary neuromuscular and musculoskeletal conditions in the neck, cervical spine, axilla, thorax, thoracic spine, and chest wall can refer pain to the shoulder and arm. For this reason, the physical therapist’s examination usually includes assessment above and below the involved joint for referred musculoskeletal pain (Case Example 18-1).

Case Example 18-1

Evaluation of a Professional Golfer

Referral: A 38-year-old male, professional golfer presented to physical therapy with a diagnosis of shoulder impingement syndrome, with partial thickness tears of the supraspinatus tendon.

Prior to the physical therapy intervention, x-rays taken were reported as negative for fracture or tumor. Magnetic resonance imaging (MRI) was reported as positive for bursitis and supraspinatus tendinitis with some partial tears. The shoulder specialist also provided the client with one corticosteroid injection, which gave him some relief of his shoulder pain.

Past Medical History: Past medical history and Review of Systems were negative for any systemic issues. He was on no medication at the time of evaluation.

Clinical Presentation: Functional deficits were reported as pain with the take-away phase of the golf swing and with the adduction motion of the shoulder in follow-through. He also reported a loss of distance associated with his drive by 20 to 30 yards. He had trouble sleeping and reported pain would wake him up if his head were turned into left rotation. He also had pain when turning his head to the left (e.g., when driving a car).

Special tests

Hawkins/Kennedy +

Neer +

Speed +

ER lag test −

IR lag test −

Cervical ROM
Flexion 40 degrees
Extension (ext) 20 degrees	Report of left scapular pain
Left side bend 20 degrees	Report of left scapular pain
Right side bend 25 degrees	No report of pain
Left rotation 45 degrees	Report of left scapular pain
Right rotation 70 degrees	No report of pain
Quadrant position	Right and left: Reproduced left posterior scapular pain with radicular pain to the thumb and second finger area

He did have intact sensation to light touch and proprioceptive sense. Strength testing on the Cybex weight-lifting machines showed he was able to do 10 triceps extensions on the right with four plates while on the left, he was only able to do one repetition with one plate.

Result: With the data obtained in the examination, the conclusion was made that he did have an impingement syndrome as described by Neer, with involvement of the bursa and rotator cuff tendons.⁷² Cyriax muscle testing revealed some musculotendon involvement with the strong/painful tests.⁶¹

The cervical findings required consultation with the referring physician. A provisional medical diagnosis was made of cervical radiculopathy with a C5-C6 herniated disk. The client was referred to a neurosurgeon for evaluation. An MRI confirmed the diagnosis and the client underwent an anterior cervical fusion with diskectomy.

Summary: This case example helps highlight the importance of a complete examination process, even if a physician specialist refers a client for physical therapy services. The therapist must “clear” or examine the joints above and below the region thought to be the cause of the dysfunction. The major reason for the symptoms or a secondary diagnosis may be missed if the screening step is left out because of a lack of time or assuming someone else checked out the entire client.

Voshell S: Case report presented in fulfillment of DPT 910, Institute for Physical Therapy Education, Widener University, Chester, PA, 2005. Used with permission.

In this chapter, we explore systemic and viscerogenic causes of shoulder and arm pain and take a look at each system that can refer pain or symptoms to the shoulder. This will include vascular, pulmonary, renal, gastrointestinal (GI), and gynecologic causes of shoulder and upper extremity pain and dysfunction. Primary or metastatic cancer as an underlying cause of shoulder pain also is included. The therapist must know how and what to look for to screen for cancer.

Systemic diseases and medical conditions affecting the neck, breast, and any organs in the chest or abdomen can present clinically as shoulder pain (Table 18-1).¹ Peptic ulcers, heart disease, ectopic pregnancy, and myocardial ischemia are only a few examples of systemic diseases that can cause shoulder pain and movement dysfunction. Each disorder listed can present clinically as a shoulder problem before ever demonstrating systemic signs and symptoms.

TABLE 18-1

Systemic and Medical Conditions as Causes of Shoulder and Upper Extremity Symptoms

TOS, Thoracic outlet syndrome; MI, myocardial infarction; ICU/s/p CABG, intensive care unit status post coronary artery bypass graft.

Using the Screening Model to Evaluate Shoulder and Upper Extremity

Past Medical History

As you look over the various potential systemic causes of shoulder symptomatology listed in Table 18-1, think about the most common risk factors and red flag histories you might see with each of these conditions. For example, a history of any kind of cancer is always a red flag. Breast and lung cancer are the two most common types of cancer to metastasize to the shoulder.

Heart disease can cause shoulder pain, but it usually occurs in an age specific population.2,3 Anyone over 50 years old, postmenopausal women, and anyone with a positive first generation family history is at increased risk for symptomatic heart disease. Younger individuals may be more likely to demonstrate atypical symptoms such as shoulder pain without chest pain.⁴

Alternately, although atherosclerosis has been demonstrated in the blood vessels of children, teens, and young adults, they are rarely symptomatic unless some other heart anomaly is present.5,6

Hypertension, diabetes, and hyperlipidemia are other red flag histories associated with cardiac-related shoulder pain. Of course, a history of angina,⁷ heart attack, angiography, stent or pacemaker placement, coronary artery bypass graft (CABG), or other cardiac procedure is also a yellow (caution) flag to alert the therapist of the potential need for further screening.

Knowledge of risk factors associated with pathologic conditions, illnesses, and diseases helps the therapist navigate the screening process. For example, pulmonary tuberculosis (TB) is a possible cause of shoulder pain.8–10 Who is most likely to develop TB? Risk factors include:

• Health care workers

• Homeless population

• Prison inmates

• Immunocompromised individuals (e.g., transplant recipients, long-term users of immunosuppressants, anyone treated for long-term rheumatoid arthritis [RA], anyone treated with chemotherapy for cancer)

• Older adult (over 65 years)

• Immigrants from areas where TB is endemic

• Injection drug users

• Malnourished (e.g., eating disorders, alcoholism, drug users, cachexia)

In a case like tuberculosis, there will usually be other associated signs and symptoms such as fever, sweats, and cough. When completing a screening examination for a client with shoulder pain of unknown origin or an unusual clinical presentation, the therapist might look at vital signs, auscultate the client, and see what effect increased respiratory movements have on shoulder symptoms (Case Example 18-2).

Case Example 18-2 Homeless Man with Tuberculosis

Referral: A 36-year-old man was referred to physical therapy as an inpatient for a short-term hospitalization. He was a homeless man brought to the hospital by the police and admitted with an extensive medical problem list including:

There was no past medical history of cancer. The client was a smoker when he could get cigarettes. He would like to support a one-pack/day habit.

Medical service requested an evaluation of the client’s shoulder pain. X-rays were not taken because the man had full active ROM, no history of trauma, and no insurance to cover additional testing.

Clinical Presentation: The therapist was unable to reproduce the shoulder pain with palpation, position, or provocation testing. There was no sign of rotator cuff dysfunction, adhesive capsulitis, tendinitis, or trigger points in the upper quadrant. There was a noticeable stiffening of the neck with very limited cervical ROM in all planes and directions.

Vital signs were unremarkable, but the client was perspiring heavily despite being in threadbare clothing and at rest. He reported getting the “sweats” every day around this same time.

The therapist asked the client to take a deep breath and cough. He went into a paroxysm of coughing, which he said caused his shoulder to start aching. The cough was productive, but the client swallowed the sputum. Auscultation of lung sounds revealed rales (crackles) in the right upper lung lobe. Supraclavicular lymph nodes were palpable, tender, and moveable on both sides.

The therapist contacted the charge nurse and reported the following concerns:

• Constitutional symptoms of sweats and fatigue (although fatigue could be caused by his extreme malnutrition)

• Pulmonary impairment with reproduction of symptoms with respiratory movements

• Suspicious (aberrant) lymph nodes (bilateral)

• Cervical spine involvement with no apparent cause or recognizable musculoskeletal pattern

Result: Consult with the physician on-call resulted in a medical evaluation and x-ray. Client was diagnosed with pulmonary tuberculosis, which was confirmed by a skin test. Shoulder and neck pain and dysfunction were attributed to a pulmonary source and not considered appropriate for physical therapy intervention.

The client was sent to a halfway house where he could receive adequate nutrition and medical services to treat his tuberculosis.

Clinical Presentation

Differential diagnosis of shoulder pain is sometimes especially difficult because any pain that is felt in the shoulder often affects the joint as though the pain were originating in the joint.³ Shoulder pain with any of the components listed in this chapter should be approached as a manifestation of systemic visceral illness, even if shoulder movements exacerbate the pain or if there are objective findings at the shoulder.

Many visceral diseases present as unilateral shoulder pain (Table 18-2). Esophageal, pericardial (or other myocardial diseases), aortic dissection, and diaphragmatic irritation from thoracic or abdominal diseases (e.g., upper GI, renal, hepatic/biliary) all can appear as unilateral pain.

TABLE 18-2

Location of Shoulder Pain

Adhesive capsulitis, a condition in which both active and passive glenohumeral motions are restricted, can be associated with diabetes mellitus, hyperthyroidism,11,12 ischemic heart disease, infection, and lung diseases (tuberculosis, emphysema, chronic bronchitis, Pancoast’s tumors) (Case Example 18-3).^9,10,13–15

Case Example 18-3 Cardiac Cause of Shoulder Pain

A 65-year-old retired railroad engineer has come to you with a left “frozen shoulder.” During the course of the subjective examination, he tells you he is taking two cardiac medications.

What questions would you ask that might help you relate these two problems or rule out a cardiac condition as a possible cause? (shoulder/cardiac)

Try to organize your thoughts using these categories:

• Onset/history of shoulder involvement

• Medical testing

• Clinical presentation

• Past medical history

Physical Therapy Screening Interview

Onset/History

• What do you think is the cause of your shoulder problem?

• When did it occur, or how long have you had this problem (sudden or gradual onset)?

• Can you recall any specific incident when you injured your shoulder, for example, by falling, being hit by someone or something, automobile accident?

• Did you ever have a snapping or popping sensation just before your shoulder started to hurt? (Ligamentous or cartilaginous lesion)

• Did you injure your neck in any way before your shoulder developed these problems?

• Have you had a recent heart attack? Have you had nausea, fatigue, sweating, chest pain, or pressure? Any pain in your neck, jaw, left shoulder, or down your left arm?

• Has your left hand ever been stiff or swollen? (CRPS after myocardial infarction [MI])

• Do you think your shoulder pain is related to your heart problems?

• Shortly before you first noticed difficulty with your shoulder were you involved in any kind of activities that would require repetitive movements, such as painting, gardening, playing tennis or golf?

Medical Testing

• Have you had any recent x-rays taken of the shoulder or your neck?

• Have you received medical or physical therapy treatment for shoulder problems before?

• If yes, where, when, why, who, and what (see Chapter 2 for specific questions)?

• Have you had any (extensive) medical testing during the past year?

Clinical Presentation

Pain/Symptoms

Follow the usual line of questioning regarding the pattern, frequency, intensity, and duration outlined in Fig. 3-6 to establish necessary information regarding pain.

• Is your shoulder painful?

• If yes, how long has the shoulder been painful?

Aggravating/Relieving Activities

• How does rest affect your shoulder symptoms? (True muscular lesions are relieved with prolonged rest [i.e., more than 1 hour], whereas angina is usually relieved more immediately by cessation of activity or rest [i.e., usually within 2 to 5 minutes, up to 15 minutes].)

• Does your shoulder pain occur during exercise (e.g., walking, climbing stairs, mowing the lawn or any other physical or sexual activity? (Evaluate the difference between total body exertion causing shoulder symptoms versus movements of the upper extremities only reproducing symptoms. Total body exertion causing shoulder pain may be secondary to angina or MI, whereas movements of just the upper extremities causing shoulder pain are indicative of a primary musculoskeletal lesion.)

Past Medical History

• Have you had any surgery during the past year?

• How has your general health been? (Shoulder pain is a frequent site of referred pain from other internal medical problems; see Fig. 18-2.)

• Did you have rheumatic fever when you were a child?

• What is your typical pattern of chest pain or angina?

• Has this pattern changed in any way since your shoulder started to hurt? For example, does the chest pain last longer, come on with less exertion, and feel more intense?

• What medications are you taking?

• Do your heart medications relieve your shoulder symptoms, even briefly?

• If yes, how long after you take the medications do you notice a difference?

• Does this occur every time that you take your medications?

Evaluating subacute/acute/chronic musculoskeletal lesion versus systemic pain pattern (see Chapter 3 for specific meaning to the client’s answers to these questions):

• Can you lie on that side?

• Does the shoulder pain awaken you at night?

• If yes, is this because you have rolled onto that side?

• Do you notice any chest pain, night sweats, fever, or heart palpitations when you wake up at night?

• Have you ever noticed these symptoms (e.g., chest pain, heart palpitations) with your shoulder pain during the day?

• Do these symptoms wake you up separately from your shoulder pain, or does your shoulder pain wake you up and you have these additional symptoms? (As always, when asking questions about sleep patterns, the person may be unsure of the answers to the questions. In such cases the physical therapist is advised to ask the client to pay attention to what happens related to sleep during the next few days up to 1 week and report back with more information.)

Other Clinical Tests: In addition to an orthopedic screening examination, the therapist should review potential side effects and interactions of cardiac medications, take vital signs, auscultate (including femoral bruits), and palpate for the aortic pulse (see Fig. 4-55).

Shoulder pain (unilateral or bilateral) progressing to adhesive capsulitis can occur 6 to 9 months after CABG. Similarly, anyone immobile in the intensive care unit (ICU) or coronary care unit (CCU) can experience loss of shoulder motion resulting in adhesive capsulitis (Case Example 18-4). Clients with pacemakers who have complications and revisions that result in prolonged shoulder immobilization can also develop complex regional pain syndrome (CRPS) and/or adhesive capsulitis.¹⁶

Case Example 18-4 Pleural Effusion with Fibrosis, Late Complication of Coronary Artery Bypass Graft

Referral: A 53-year-old man was referred to physical therapy by his primary care physician for left shoulder pain.

Past Medical History: The client had a recent (6 months ago) history of cardiac bypass surgery (also known as coronary artery bypass graft [CABG]) and had completed phase 1 and phase 2 cardiac rehab programs. He was continuing to follow an exercise program (phase 3 cardiac rehab) prescribed for him at the time of his physical therapy referral.

Clinical Presentation: The client looked in good health and demonstrated good posture and alignment. Shoulder range of motion (ROM) was equal and symmetric bilaterally, but the client reported pain when the left arm was raised over 90 degrees of flexion or abduction. His position of preference was left sidelying. The pain could be reduced in this position from a rated level of 6 to a 2 on a scale from 0 (no pain) to 10 (worst pain).

Scapulohumeral motion on the left was altered compared to the right. Medial and lateral rotations were within normal limits (WNL) with the upper arm against the chest. Lateral rotation reproduced painful symptoms when performed with the shoulder in 90 degrees of abduction. Physiologic motions were fully present in all directions on the left but seemed “sluggish” compared to the right.

Neurologic screen was negative.

Vital signs:
Blood pressure:	122/68 mm Hg
Resting pulse:	60 bpm
Body temperature:	98.6° F

Cardiopulmonary screening exam:

Diminished basilar (lower lobes) breath sounds on the left compared to the right

Decreased chest wall excursion on the left; increased shoulder pain with deep inspiration

Dyspnea was not observed at rest

When asked if there were any symptoms of any kind anywhere else in the body, the client reported ongoing but intermittent chest pain and shortness of breath for the last 3 months. The client had not reported these “new” symptoms to the physician.

What are the red flags (if any)? Is an immediate medical referral indicated?

Red Flags

• Age over 40

• Previous (recent) history of cardiac surgery

• Unequal basilar breath sounds

• Unreported symptoms of chest pain and dyspnea

• Autosplinting (lying on the affected side diminishes lung movement, reducing shoulder pain)

Medical Consultation: Shoulder problems are not uncommon following CABG, but the number and type of red flags present caught the therapist’s attention. The client was not in any apparent physiologic distress and vital signs were WNL (although he was on antihypertensive medications). Since he was referred by his primary care physician, the therapist made telephone contact with the physician’s office and faxed a summary of findings immediately.

A program of physical therapy intervention was determined, but the therapist insisted on speaking with the physician first before proceeding with the program. The physician approved the therapist’s treatment plan but requested immediate follow-up with the client who was seen the next day.

Result: The client was diagnosed with pleural effusion causing pleural fibrosis, a rare long-term complication of cardiac bypass surgery. The physician noted that the left lower lobe was adhered to the chest wall.

Pleural effusion is a common complication of cardiac surgery and is associated with other postoperative complications. It occurs more often in women and individuals with associated cardiac or vascular comorbidities and medications used to treat those conditions.73–76

The client was treated medically but also continued in physical therapy to restore full and normal motion of the shoulder complex. The physician also asked the therapist to review the client’s cardiac rehab program and modify it accordingly due to the pulmonary complications.

The Shoulder Is Unique

It has been stressed throughout this text that the basic clues and approach to screening are similar, if not the same, from system to system and anatomic part to anatomic part.

So, for example, much of what was said about screening the neck and back (Chapter 14) applied to the sacrum, sacroiliac (SI), and pelvis (Chapter 15); buttock, hip, and groin (Chapter 16); and chest, breast, and rib (Chapter 17). Presenting the shoulder last in this text is by design. These principles do apply to the shoulder but beyond that:

Shoulder pain is difficult to diagnose because any pain felt in the shoulder will affect the joint as though the pain was originating in the joint.

John Mennell¹⁷

… even when there is a known cause, especially in the older adult.

Catherine Goodman

It is not uncommon for the older adult to attribute “overdoing” it to the appearance of physical pain or neuromusculoskeletal (NMS) dysfunction. Any adult over age 65 presenting with shoulder pain and/or dysfunction must be screened for systemic or viscerogenic origin of symptoms, even when there is a known (or attributed) cause or injury.

In Chapter 2, it was stressed that clients who present with no known cause or insidious onset must be screened along with anyone who has a known or assumed cause of symptoms. Whether the client presents with an unknown etiology of injury or impairment or with an assigned cause, always ask yourself these questions:

Follow-Up Questions

• Is it really insidious?

• Is it really caused by such and such (whatever the client told you)?

The client may wrongly attribute onset of symptoms to an activity. The alert therapist may recognize a true causative factor.

Shoulder Pain Patterns

In Chapter 3, we presented three possible mechanisms for referred pain patterns from the viscera to the soma (embryologic development, multisegmental innervations, and direct pressure on the diaphragm). Multisegmental innervations (see Fig. 3-3) and direct pressure on the diaphragm (see Figs. 3-4 and 3-5) are two key mechanisms for referred shoulder pain.

Multisegmental Innervations: Because the shoulder is innervated by the same spinal nerves that innervate the diaphragm (C3 to C5), any messages to the spinal cord from the diaphragm can result in referred shoulder pain. The nervous system can only tell what nerves delivered the message. It does not have any way to tell if the message sent along via spinal nerves C3 to C5 came from the shoulder or the diaphragm. So it takes a guess and sends a message back to one or the other.

This means that any organ in contact with the diaphragm that gets obstructed, inflamed, or infected can refer pain to the shoulder by putting pressure on the diaphragm, stimulating afferent nerve signals, and telling the nervous system that there is a problem.

Diaphragmatic Irritation: Irritation of the peritoneal (outside) or pleural (inside) surface of the central diaphragm refers sharp pain to the ipsilateral upper trapezius, neck and/or supraclavicular fossa (Fig. 18-1). Shoulder pain from diaphragmatic irritation usually does not cause anterior shoulder pain. Pain is confined to the suprascapular, upper trapezius, and posterior portions of the shoulder.

Fig. 18-1 Irritation of the peritoneal (outside) or pleural (inside) surface of the central area of the diaphragm can refer sharp pain to the upper trapezius muscle, neck, and supraclavicular fossa. The pain pattern is ipsilateral to the area of irritation. Irritation to the peripheral portion of the diaphragm can refer sharp pain to the ipsilateral costal margins and lumbar region (not shown).

If the irritation crosses the midline of the diaphragm, then it is possible to have bilateral shoulder pain. This does not happen very often and is most common with cardiac ischemia or pulmonary pathology affecting the lower lobes of the lungs on both sides. Irritation of the peripheral portion of the diaphragm is more likely to refer pain to the costal margins and lumbar region on the same side.

As you review Fig. 3-4, note how the heart, spleen, kidneys, pancreas (both the body and the tail), and the lungs can put pressure on the diaphragm. This illustration is key to remembering which shoulder can be involved based on organ pathology. For example, the spleen is on the left side of the body so pain from spleen rupture or injury is referred to the left shoulder (called Kehr’s sign) (Case Example 18-5).¹⁸

Case Example 18-5 Rugby Injury

Kehr’s Sign

Referral: A 27-year-old male accountant who has an office in the same complex with a physical therapy practice stopped by early Monday morning complaining of left shoulder pain.

When asked about repetitive motions or recent trauma or injuries, he reported playing in a rugby tournament over the weekend. “I got banged up quite a few times, but I had so much beer in me, I didn’t feel a thing.”

Clinical Presentation: Pain was described as a deep, sharp aching over the upper trapezius and shoulder area on the left side. There were no visual bruises or signs of bleeding in the upper left quadrant.

Vital signs:
Pulse:	89 bpm
Respirations:	12 per minute
Blood pressure:	90/48 mm Hg (recorded sitting, left arm)
Temperature:	97° F (reported as the client’s “normal” morning temperature)
Pain:	Rated as a 5 on a scale from 0 to 10

Range of motion was full in all planes and movements. No particular movement increased or decreased the pain. Gross manual muscle test of the upper extremities was normal (5/5 for flexion, abduction, extension, rotations).

Neurologic screen was negative. All special shoulder tests (e.g., impingement, anterior and posterior instability, quadrant position) were unremarkable.

What are the red flags here? What are your next questions, steps, or screening tests?

Red Flags

• Hypotension

• Left shoulder pain within 24 hours of possible trauma or injury

• Unable to alter, provoke, or palpate painful symptoms

• Clinical presentation is not consistent with expected picture for a shoulder problem; lack of objective findings.

What are your next questions, steps, or screening tests?

Repeat blood pressure measurements, bilaterally. Perform percussive tests for the spleen (see Fig. 4-53).

Depending on the results of these clinical tests, referral might be needed immediately. In this case, the percussive test for enlarged spleen was inconclusive, but there was an observable and palpable “fullness” in the left flank compared to the right.

Result: This client was told:

“Mr. Smith, your exam does not look like what I would expect from a typical shoulder injury. Since I cannot find any way to make your pain better or worse and I cannot palpate or feel any areas of tenderness, there may be some other cause for your symptoms.

Given your history of playing rugby over the weekend, it is possible you have some internal injuries. I am not comfortable treating you until a medical doctor examines you first. Bleeding from the spleen can cause left shoulder pain. When I tapped over the area of your spleen, it did not sound quite like I expected it to, and it seems like there is some fullness along your left side that I am not seeing or feeling on the right.

I do not want to alarm you, but it may be best to go over to the emergency department of the hospital and see what they have to say. You can also call your regular doctor and see if you can get in right away. You can do that right from our clinic phone.”

Final Result: This accountant had clients already scheduled starting in 10 minutes. He did not feel he had the time to go check this out until his lunch hour. About 45 minutes later an ambulance was called to the building. Mr. Smith had collapsed, and his coworkers called 9-1-1.

He was rushed to the hospital and diagnosed with a torn and bleeding spleen, which the doctor called a “slow leak.” It eventually ruptured, leaving him unconscious from blood loss.

Either shoulder can be involved with renal colic or distention of the renal cap from any kidney disorder, but it is usually an ipsilateral referred pain pattern depending on which kidney is impaired (see Fig. 10-7; again, via pressure on the diaphragm). Bilateral shoulder pain from renal disease would only occur if and when both kidneys are compromised at the same time.

Look for history of a recent surgery as part of the past medical history and the presence of accompanying urologic symptoms.

The body of the pancreas lies along the midline of the diaphragm. When the body of the pancreas is enlarged, inflamed, obstructed, or otherwise impinging on the diaphragm, back pain is a possible referred pain pattern. Pain felt in the left shoulder may result from activation of pain fibers in the left diaphragm by an adjacent inflammatory process in the tail of the pancreas.

Postlaparoscopic shoulder pain (PLSP) frequently occurs after various laparoscopic surgical procedures. During the procedure air is introduced into the peritoneum to expand the area and move the abdominal contents out of the way. The mechanism of PLSP is commonly assumed to be overstretching of the diaphragmatic muscle fibers due to the pressure of a pneumoperitoneum (residual carbon dioxide [CO₂] gas after surgery).¹⁹ Pressure from distention causes phrenic nerve–mediated referred pain to the shoulder.²⁰

Keep in mind that shoulder pain also can occur from diaphragmatic dysfunction. For anyone with shoulder pain of an unknown origin or which does not improve with intervention, palpate the diaphragm and assess its excursion and timing during respiration. Reproduction of shoulder symptoms with direct palpation of the diaphragm and the presence of altered diaphragmatic movement with breathing offer clues to the possibility of diaphragmatic (muscular) involvement.

Fig. 18-2 reminds us that shoulder pain can be referred from the neck, back, chest, abdomen, and elbow. During orthopedic assessment, the therapist always checks “above and below” the impaired level for a possible source of referred pain. With this guideline in mind, we know to look for potential musculoskeletal or neuromuscular causes from the cervical and thoracic spine²¹ and elbow.