Referred Shoulder Pain is caused by a disease of a distant organ. Like heart pain may be felt over left shoulder. The pain generator is always located at different location and another part of the body.
What Is Referred Shoulder Pain?
- Referred Shoulder Pain is a pain experienced over the shoulder joint, which is not caused by abnormality or disease of the shoulder joint or soft tissue around the shoulder joint.
- The examination of the shoulder joint is often normal even though pain is experienced over the shoulder joint.
Causes Of Referred Shoulder Pain
Pain Originates In Neck
- Cervical Disc-
- Disc Bulge or Herniation Resulting in Pinched Nerve– Pain resulting from pinch nerve at the level of C6 and C7 spinal nerve is referred to shoulder joint. The pain is felt over the side of the lesion and pain is continuous and burning in character. Pain is also known as radicular pain or radiculopathy.1
- Degenerative Disc Disease– The disc degeneration causes thinning of disc, which narrows the spinal foramina through which spinal nerve passes in to surrounding tissue. The narrowing of spinal foramina causes pinch of spinal nerve which often results in referred pain to shoulder.
- Cervical Facet Joint-
- Facet Joint Sprain– Movement of the neck occurs around the facet joint. Facet joint sprain is caused by inflammation, injury or overstretching of ligaments, which fastens the articulating surface of the facet joint. The pain generated by facet joint sprain radiates to the shoulder joint. 2
- Facet Joint Arthritis– Facet joint arthritis is an inflammation of facet joint mostly observed in elderly patient suffering with osteoarthritis. The pain caused by facet joint arthritis is referred to shoulder joint.3
- Facet Joint Injury– Facet joint injury results in partial subluxation and mostly observed following fall or automobile accident.
- Cervical Spinal Stenosis-
- Spinal stenosis when caused by hypertrophy of the ligamentum flavum mostly results in pinched nerve and observed in elderly patients.
- Pain is mostly referred to shoulder and upper arm.
- Severe spinal stenosis causes compression of spinal cord, which may follow symptoms like tingling, numbness and weakness in all 4 extremities.
- Cervical Foraminal Stenosis-
- Cervical foraminal stenosis causes selective nerve block. Foraminal stenosis resulting in pinch of C6 and C7 cervical nerve causes referred pain in shoulder.4
Pain Originates in Mid Back
- Upper Thoracic Disc Bulge and Herniation-
- Disc bulge or herniation of thoracic vertebrae T1 and T2 causes pinch of T1 and T2 nerve. The referred pain caused by pinch nerve is felt over shoulder. Pain is often severe and burning in character.
- Upper Thoracic Foraminal Stenosis-
- Spinal nerve passes through the spinal foramina to the surrounding tissue. The narrowing of the foramina causes pinch of spinal nerve. Pain is distributed over upper arm and axilla. In few cases pain is referred to shoulder.
Pain Originates in Chest
- Costo-vertebral Joint Arthritis
- Costo-vertebral joint is the link between rib and vertebra mostly located on the side of vertebral column. The inflammation or trauma of the first or second costo-vertebral joint causes pain, which is in few cases referred to shoulder.
- Cardiac Pain
- Angina or decreased blood supply to heart causes pain, which in few cases is referred to left shoulder joint. Right shoulder joint pain is not related to any cardiac malfunction.5
Symptoms Of Referred Shoulder Pain
Acute or Chronic Pain-
- Acute Pain-
- Acute pain is less than 3 to 6 months in duration.
- Pain caused by angina or heart pain is acute, excruciating, and squeezing in type.
- Referred Pain when felt over shoulder is originated from distant organ but similar pain is not felt over the joint.
- Chronic Pain-
- Pain when originates from facet joint or foraminal stenosis then pain may last more than 6 months.
- Pain is known as chronic pain.
- Chronic referred shoulder pain originates from disc bulge, disc herniation, degenerative disc disease and foraminal stenosis.
- Intensity of referred pain is mild to severe and in most cases individuals may experience a dull ache over shoulder.
Associated Symptoms in Upper Extremity-
- Joint and Muscle Stiffness- Patient may feel stiffness or muscle spasm over different location like upper, mid or lower back when pain is generated in back.
Shoulder Joint Examination-
- Patient suffering with Referred Shoulder Pain may experience reduced shoulder joint movement and there may be palpable tenderness.
- Shoulder joint examination indicates normal shoulder joint even though the individual may experience palpable tenderness in the shoulder region.
- There may be presence of muscle tightness in chronic cases of Referred Shoulder Pain.
Diagnosis of Referred Shoulder Pain
- Pain over shoulder joint
- Normal function of shoulder joint
- X-ray, CT Scan and MRI examination
- Normal shoulder joint.
- Abnormal facet joint or disc
- Abnormal foramina and spinal canal
- Ultrasound Study of Shoulder Joint- Normal Findings
Treatment For Referred Shoulder Pain
Treatment for Referred Shoulder Pain usually depends on the underlying cause of the symptoms. Hence, an accurate diagnosis is imperative to formulate a favorable treatment plan. All in all, treatment of the underlying cause should result in improvement of symptoms of Referred Shoulder Pain.
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Mamula CJ1, Erhard RE, Piva SR.
J Orthop Sports Phys Ther. 2005 Oct;35(10):659-64.
2.Cervical facet joint injections in the neck and shoulder pain.
Kim KH1, Choi SH, Kim TK, Shin SW, Kim CH, Kim JI.
J Korean Med Sci. 2005 Aug;20(4):659-62.
3.Unusual cause of painful shoulder in an elderly woman with rheumatoid arthritis.
Saha E1, Dziadzio M, Irving K, Chambers A, Higgens C.
Clin Rheumatol. 2007 Sep;26(9):1549-51.
4.Shoulder pain and dysfunction secondary to neural injury.
Brown KE, Stickler L.
Int J Sports Phys Ther. 2011 Sep;6(3):224-33.
5.Coronary artery disease in women.
Chiamvimonvat V1, Sternberg L.
Can Fam Physician. 1998 Dec;44:2709-17.