When shoulder pain is not the shoulder: differential diagnosis in physiotherapy

Shoulder pain is one of the most common reasons why patients turn to a physiotherapist. However, the cause is not always to be found in the glenohumeral joint or in the surrounding tissues. In many cases, pain felt in the scapulohumeral area originates from distant structures, such as the cervical spine, the chest, or even from visceral or neurological disorders. Differential diagnosis in physiotherapy is essential in order to understand whether the shoulder is really the problem, or merely the place where the symptom appears.

For this reason, the physiotherapist's ability to carry out an accurate clinical and functional assessment is essential. Targeted treatment means avoiding unnecessary therapies and directing the patient towards the most effective therapeutic pathway.

Differential diagnosis in physiotherapy is the process by which the professional distinguishes between musculoskeletal conditions that can be treated with physical therapy and disorders that require another specialist. In the case of shoulder pain, the complexity is greater because the shoulder is an area where many postural, biomechanical and neurological influences converge.

Carrying out an accurate differential diagnosis of shoulder pain in physiotherapy means exploring every possible source of the symptom, starting from orthopaedic and neurological tests, observation of movement, targeted palpation and a complete functional assessment. Only in this way is it possible to pinpoint the origin of the pain and build a genuinely effective treatment.

A common mistake is to link the pain that is felt to a local problem. In physiotherapy, however, the concept of “referred pain” is well known: pain that appears far from the real origin of the disorder. This phenomenon may arise from visceral, neurological or musculoskeletal structures.

In the case of the shoulder, the areas that most often cause referred pain are the following:

• Cervical spine: herniated discs, disc protrusions, arthritis and radiculopathies can cause pain radiating to the trapezius, the upper back and the arm.
• Thoracic region: costovertebral dysfunctions can mimic scapular or subacromial pain.
• Internal organs: conditions of the liver, the lungs or the diaphragm can cause referred discomfort in the right or left shoulder.
• Peripheral nervous system: compression of the brachial plexus or of the suprascapular nerve often produces symptoms similar to tendon problems.

Knowing how to distinguish local pain from referred pain is one of the cornerstones of the physiotherapy assessment of shoulder pain.

Some elements of the initial assessment may indicate that the shoulder is not the true origin of the pain:

• The pain changes with movements of the neck or of the thoracic spine
• Muscle strength is impaired without any obvious tendon lesion
• The pain also appears at rest, without any recent exertion
• The patient reports no recent injury or overload of the shoulder
• The specific orthopaedic tests for the shoulder come back negative

In these cases, the physiotherapist carries out a broader assessment, also checking cervical mobility, thoracic function, breathing, postural balance and the behaviour of the nervous system.

Ti-Fisio takes an advanced, multidisciplinary approach to assessing shoulder pain. The first session includes a detailed history, validated clinical tests and the identification of any warning signs. The physiotherapist examines:

• The quality and the range of movement of the shoulder
• The response of the pain to cervical or postural movements
• The possible presence of sensory or strength deficits
• Breathing dynamics, which influence the thoracic and scapular area
• The myofascial chains that connect shoulder, trunk and upper limb

The aim is to identify the primary source of the pain and to establish whether the shoulder is the area to treat first, or whether treatment should be directed elsewhere.

Once the source of the pain has been identified, treatment is chosen accordingly. If the problem originates in the shoulder, the work focuses on joint mobility, scapular control and progressive strengthening; if the origin is cervical or thoracic, the work shifts to those areas, with manual therapy and targeted exercises.

In physiotherapy, differential diagnosis is not just about giving the pain a name: it avoids treating the wrong area and makes it possible to build a programme consistent with the real cause of the problem.

One of the most common situations seen in the clinic is shoulder symptoms arising from cervical disorders. This type of pain may present as:

• Radiation to the trapezius, the deltoid or the shoulder blade
• A feeling of heaviness or burning in the arm
• Pain that worsens when sitting for a long time
• Worsening with movements of the neck, not of the shoulder

In these cases, treating the shoulder alone would be ineffective. The physiotherapy assessment of shoulder pain instead makes it possible to redirect treatment to the cervical spine, often with rapid and lasting benefits.

A prompt approach makes it possible to avoid untargeted treatments, to save time and money and to reduce the patient's frustration. Modern physiotherapy does not stop at treating symptoms: it sets out to understand and resolve the causes.

Turning to a specialised centre such as Ti-Fisio means relying on a team trained to carry out complex functional assessments, even without an instrumental medical diagnosis. It is expertise in differential diagnosis that makes it possible to steer therapy correctly from the very first appointment.

The ability to distinguish the real causes of pain allows Ti-Fisio to combine physiotherapy treatment with postural, respiratory, neurological and motor elements. This approach ensures a more complete recovery and greater independence for the patient in the long term.

Physiotherapy for shoulder pain with differential diagnosis is therefore not a simple technique, but a clinical process that requires observation, expertise and experience.
Contact Ti-Fisio for a complete physiotherapy assessment. Identifying the real origin of the problem is the first step towards building an effective and lasting treatment.

+41 91 940 10 20

info@ti-fisio.ch

Via Ceresio 42, Pregassona.

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