Shoulder pain and shortness of breath. Shoulder exam is normal. Diagnosis?

April 20, 2016

A 78 year old man with no significant past medical history presents to his primary care physician with 4 days of right shoulder pain. The pain is located over the acromioclavicular joint. The pain is worse at night with lying down and associated with shortness of breath.  He states that the pain is better during the day. He is an avid ping pong player and does not have pain or shortness of breath with playing ping pong.

Except for abdominal bloating he denies any other symptoms. The shoulder exam is normal. Physical exam is significant for reduced breath sounds in the right lower lobe and mild abdominal distention. An X-ray of the shoulder shows mild osteoarthritis in the AC joint but is otherwise normal.

How can “shoulder pain” be not from the shoulder? Where is it from?

(answer below)


Hint: The patient got this chest x ray given the low breath sounds on the right lower lobe.


The X-ray shows a right elevated hemidiaphragm.


This case demonstrates referred pain.

The patient was diagnosed with polycystic liver disease with a dominant cyst pushing into the right chest. His shoulder pain was thought to be related to diaphragmatic irritation.

The figure below demonstrates many examples of referred pain from intra-abdominal causes. One common example is an inflamed gallbladder (cholecystitis) leading to pain in the mid-scapula or shoulder.

Illustration showing sites of referred pain from abdominal organs. From, adapted from Moore and Dalley’s Clinically Oriented Anatomy.

This patient presented with right shoulder pain. Shoulder pain is the third most common musculoskeletal complaint and is often caused by intrinsic shoulder pathology but can also be due to referred pain (from neurological, abdominal or thoracic sources). He underwent laparascopic resection of the dominant cyst and his shoulder pain resolved.

Same patient’s CT abdomen showing the large cyst in the liver cause referred pain in the shoulder.

What specific exam maneuvers for the shoulder would help evaluate the etiology of the pain?

There is a multitude of tests to evaluate the etiology of shoulder pain. The basic evaluation of shoulder pain includes inspection of both shoulders (make sure that the shoulders are not covered by clothes), palpation for any tenderness, passive and active range of motion and provocative maneuvers (e.g. Neers and Hawkins for impingement, Empty can test for supraspinatus muscle pathology).

If the shoulder exam does not reveal any abnormalities, think about referred pain from the neck, thorax or the abdomen.


What is the potential cause for liver cysts?

Cystic lesions of the liver can be due to many different etiologies. Most common are simple cysts but cysts caused by polycystic liver disease (PCLD), parasitic (hydatid) cysts, cystic tumors, and abscesses also need to be part of the differential diagnosis.


Which physical exam findings could you see in a patient with polycystic liver disease?

Patients with polycystic liver disease often have hepatomegaly. Patients can progress to liver fibrosis and present with the stigmata of liver disease and portal hypertension. Visit the Stanford 25 main site to learn more about the examination of the liver andliver disease from head to toe.

The enlarged liver can push into the right chest causing shortness of breath and an abnormal lung exam. Learn more about the pulmonary exam here.




Steven McGee: Evidence-based physical diagnosis, Examination of the musculoskeletal system: The shoulder

Robert E. Glasgow: Hepatic cysts

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