Soft Tissue Shoulder Disorders Care Pathway

Date of last update: September, 2024

4. Differential Diagnosis Requiring Medical Attention

Red Flags: Immediate Referral to Emergency Care:

1. Shoulder Infection (septic arthritis)

Pain Location: Localized increasing shoulder pain.
Signs/Symptoms/Red Flags: Systemic (fever, chills, fatigue), localized pain, night pain, swelling, redness, limited shoulder range of motion, immunosuppression, recent infection or surgery, TB (tuberculosis) history, IV drug use, poor living conditions.
Physical and Neurological Examination: Redness and warmth, a sense of fluid collection, swollen lymph nodes in the armpit.
Action: Immediate referral to emergency care.

2. Traumatic Shoulder Fracture

Pain Location: Localized pain in the shoulder area.
Signs/Symptoms/Red Flags: Sudden onset of severe pain or deformity following severe trauma, inability to perform any movements of the shoulder, significant shoulder weakness.
Physical and Neurological Examination: Point tenderness, possible deformity.
Action: Immediate referral to emergency care.

3. Acute Neurological Deficit

(e.g., brachial plexus injury, acute cervical radiculopathy)

Pain Location: Shoulder pain and weakness.
Signs/Symptoms/Red Flags: Shoulder trauma, surgery, significant sensory/motor deficits in the upper extremity.
Physical and Neurological Examination: Significant sensory/motor deficits in the upper extremity.
Action: Immediate referral to emergency care.

Pain Location: Severe, progressive, localized shoulder pain.
Signs/Symptoms: History of cancer; persistent pain, worse at night, not relieved by rest, constitutional symptoms (night sweats, unexplained weight loss, fatigue, reduced appetite).
Physical and Neurological Examination: Localized tenderness, possible neurological deficits.
Action: Referral to appropriate medical provider.

2. Inflammatory Arthritides

1. Polymyalgia Rheumatica

Pain Location: Shoulder pain.
Signs/Symptoms: Pain in shoulders, neck/upper arms, morning stiffness > 1 hour or after being inactive, pain/ stiffness in hips, systemic symptoms (fatigue, weight loss, fever, loss of appetite, depression, malaise), often associated with new temporal headache.
Physical and Neurological Examination: Limited range of motion, tenderness over joints.
Action: Referral to appropriate medical provider.

2. Rheumatoid Arthritis

Pain Location: Diffuse joint pain including the shoulder.
Signs/Symptoms: Symmetrical joint pain, morning stiffness > 1 hour, systemic symptoms (fatigue, weight loss, fever).
Physical and Neurological Examination: Joint swelling, tenderness, and deformity.
Action: Referral to appropriate medical provider.

3. Systematic Lupus Erythematosus (SLE)

Pain Location: Can include shoulder and other joints.
Signs/Symptoms: Joint pain and swelling, fatigue, butterfly-shaped rash on the face, photosensitivity, systemic symptoms (fatigue, weight loss, fever).
Physical and Neurological Examination: Joint tenderness and swelling, skin rashes, signs of organ involvement such as kidney issues or pleuritis.
Action: Referral to appropriate medical provider.

3. Referred Pain (from visceral conditions)

(e.g., myocardial infarction, subphrenic abscess, aortic aneurysm, gallbladder disease)

Pain Location: Varies depending on the condition, often radiating to the shoulder.
Signs/Symptoms: Specific to the underlying condition. May include chest pain, shortness of breath, nausea (cardiac); shortness of breath, cough, pleuritic pain (pulmonary); epigastric pain, heartburn, post-meal pain (gastrointestinal); pain with deep breathing/coughing, hiccups (diaphragmatic); systemic symptoms (e.g., fever, chills, weight loss).
Physical and Neurological Examination: No change in shoulder pain when moving neck, shoulder, or arms; signs related to the condition (e.g., tenderness under the rib cage for gallbladder disease).
Action: Referral to appropriate medical provider/emergency care.

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