Many patients with shoulder pain come into the clinic and say the same thing:
“My whole shoulder hurts.”
It hurts at the front, the back and the outside. Raising the arm hurts. Reaching behind the back hurts. Movement hurts. During the examination, almost every area seems tender.
With a patient like this, the difficult part is not finding pain. The difficult part is finding the place where the problem first began.
An 85-Year-Old Patient With Shoulder Pain
The patient was an 85-year-old woman.
Two months earlier, she had been doing a shoulder mobility exercise at the gym. She held a long stick with both hands and slowly moved it from above her head towards her back. During this movement, she injured her left shoulder.
Two months later, she still could not raise her left arm smoothly or place her hand behind her back. The problem was clearly affecting her daily life.
During the examination, she showed a typical painful arc. There was tenderness at the front, back and outside of the shoulder. Several rotator cuff tests also caused mild pain.
At first, it looked as though the whole shoulder had a problem.
One Detail Made Me Stop
When shoulder pain continues for some time, the surrounding muscles gradually begin to compensate. The way the shoulder moves also starts to change.
The original injury may involve only one tendon. As the pain continues, however, other muscles become tight, the tender area becomes larger, and eventually the patient feels pain throughout the shoulder.
Many painful areas do not necessarily mean that every area is a primary injury.
If I treated every place that hurt, the treatment could cover a large area but still have no clear direction.
I needed to work out:
Which problem was the original injury, and which findings developed later as secondary changes?
I Started Comparing the Possibilities
My first step was to consider whether a neurological factor was involved.
Although the patient had tenderness around several parts of the shoulder, pressure over the scalene region did not reproduce radiating pain. I also did not find clear signs supporting cervical nerve involvement.
One examination cannot completely exclude every neurological problem, but the findings suggested that nerve-related pain was not the main diagnostic direction at that time.
My second step was to compare the main structures of the rotator cuff.
Tests related to the supraspinatus, infraspinatus, teres minor and subscapularis all produced mild discomfort. However, basic strength remained present, and no individual rotator cuff test was particularly prominent.
If I focused only on the fact that these tests caused some pain, I could easily conclude that every muscle had a problem.
But I was not looking for more positive findings. I was looking for the positive finding with the greatest value for localisation.
What Changed My Thinking Was Not Tenderness Everywhere
As I continued the examination, the long head of the biceps tendon showed a different pattern.
During resisted testing, the patient developed clear pain at the front of the shoulder together with some weakness. Palpation over the bicipital groove also produced more concentrated tenderness than palpation elsewhere around the shoulder.
I then returned to the injury mechanism. She had held a stick with both hands and moved it from above her head towards her back. This excessive shoulder mobility exercise could have placed considerable traction on the long head of the biceps tendon.
The injury mechanism, painful arc, clear pain and weakness during resisted testing, and concentrated tenderness over the bicipital groove were now pointing in the same direction.
My main diagnostic focus became:
An injury involving the long head of the biceps tendon.
Why Did I Need to Separate Primary and Secondary Findings?
If every painful part of the shoulder were treated as a primary injury, it would appear that the supraspinatus, infraspinatus, teres minor, subscapularis and the muscles around the neck and shoulder were all injured.
Everything would be treated, but there would be no clear understanding of what needed to be addressed first.
These positive findings did not all have the same diagnostic value.
Some tests produced only mild pain, while another produced pain with weakness. Some tenderness covered a large area, while another finding was concentrated over an anatomically meaningful location. Some tests caused general discomfort, while others corresponded with the injury mechanism and the patient’s main functional limitation.
In this case, much of the tightness and tenderness elsewhere around the shoulder was more likely to represent secondary changes that developed after the pain had continued.
Treatment gains a clear direction only after the primary problem has been identified.
The Immediate Change Also Helped Test My Reasoning
For treatment, I used distal acupuncture with movement to improve overall shoulder mobility. I also used local pricking, bleeding and cupping over the most tender area involving the long head of the biceps tendon.
After the first treatment, the patient’s shoulder movement improved clearly. Raising the arm and reaching backwards were both easier than before treatment.
An immediate response to treatment cannot replace diagnosis. However, when focused treatment of the main suspected area is followed by improvement in the previously restricted movement, that change may provide further support for the original clinical reasoning.
Dr Huang’s Clinical Reflection
What stayed with me from this case was not one particular test or one particular treatment method.
The longer shoulder pain continues, the more secondary tightness and compensation may develop. The original injury can then become hidden beneath a large number of painful areas.
The purpose of an examination is not to discover more places that hurt or to record more positive tests. It is to compare the clinical value of the available evidence.
What movement caused the injury? Which test produced the clearest response? Where was the tenderness most concentrated? Was there genuine weakness? Could these findings explain the patient’s main functional problem?
A diagnosis does not come directly from one painful point. It develops when the history, injury mechanism and examination findings begin to point in the same direction.
The foundation of precise treatment is not treatment technique. It is precise diagnosis.
Follow Dr Huang’s Clinical Reasoning—not simply to learn the name of a condition, but to learn a way of clinical thinking.
Seven: English Appointment CTA
Has Your Shoulder Pain Continued Without a Clear Explanation?
Shoulder pain may involve a tendon, the rotator cuff, restricted joint function, cervical nerves or surrounding tissues. The place that hurts is not always the place where the problem began.
At PhD Win Acupuncture Clinic, we consider the history, injury mechanism, functional limitations and physical findings before deciding whether acupuncture is appropriate and what the next step should be.
Button:
Supporting links:
Learn About Our Clinical Assessment
Before Your First Visit
Eight: English Disclaimer
This article is based on a real clinical case. Some non-essential details have been adjusted to protect patient privacy. It is intended to share general clinical reasoning and health information and does not replace an individual consultation, physical examination, imaging assessment or medical diagnosis. Shoulder pain can have many causes. Persistent pain following an injury, significant weakness, progressively restricted movement, severe night pain, numbness or radiating symptoms in the arm should receive appropriate professional assessment.
中文微信：nzacupunctureclinic
Leave a reply