What One Patient with Shoulder Pain Taught Me About Clinical Reasoning
Follow Dr Win Huang’s Clinical Reasoning (25)
By Dr Win Huang, PhD (Chinese Medicine & Acupuncture)
This case involved a 39-year-old woman who worked as an accountant.
She had experienced left shoulder pain for approximately six months, without a clear injury. At first, she had pain but almost normal movement. Over time, the shoulder gradually became more restricted.
She now experienced pain when raising the left arm close to 170 degrees. Reaching behind her back was particularly difficult. Her left hand could reach only the buttock before the pain stopped her from moving any higher, while her right hand could reach the shoulder blade. When lying down at night, placing the left hand behind her head or near the pillow also caused considerable pain.
She enjoyed going to the gym two or three times each week and was still able to continue many of her strength exercises.
Ultrasound showed thickening of the subacromial bursa but no other significant abnormality. A specialist recommended a local injection, which she declined. She then came to my clinic after being referred by a friend.
If this patient were sitting in front of you, what would you think of first?
I believe most clinicians would initially think about the shoulder itself.
The progression from shoulder pain to gradually restricted movement certainly appeared consistent with a local shoulder problem. The ultrasound showed thickening of the subacromial bursa, and a specialist had recommended an injection. Was the problem related to the supraspinatus, infraspinatus, teres minor, teres major or subscapularis? Was it a tendon, joint capsule or bursa? These possibilities all needed to be examined.
My initial approach was the same as that of most clinicians: I began with the shoulder.
I performed a routine shoulder examination, including the empty can test, resisted internal and external rotation, resisted movement with the hand behind the back, and palpation of the relevant muscles and tendons.
The shoulder was not completely normal. Compared with the unaffected side, there was clear tenderness around the infraspinatus, teres minor, teres major and subscapularis regions.
However, pressure over these areas did not reproduce the shoulder pain she normally experienced. The resisted tests also failed to provoke her typical pain and caused, at most, only mild discomfort.
I then assessed passive shoulder movement. Passive elevation could reach approximately 170 to 180 degrees, with pain developing at the front of the shoulder only near the end of the movement. When I helped move her hand farther up behind her back, the joint did not appear mechanically blocked. She stopped because pain prevented her from continuing.
At this stage, I could have stopped and made a local shoulder diagnosis.
She had shoulder pain, restricted movement, local muscle tenderness and ultrasound evidence of subacromial bursa thickening. Even though some findings were not typical, a diagnosis of periarticular soft-tissue injury or a particular rotator cuff muscle or tendon problem might still have sounded reasonable.
But I did not stop there because I felt the evidence was incomplete.
The resisted tests did not clearly reproduce her pain. Local tenderness did not behave like the main source of her familiar symptoms, and passive movement did not suggest a true mechanical block. There were abnormalities around the shoulder, but they did not adequately explain the whole presentation.
When one level of explanation is incomplete, we need to consider whether the problem may involve something farther upstream. I therefore began examining factors outside the shoulder.
Could the cervical spine be involved? Could it be related to the suprascapular nerve, axillary nerve, scalene muscles or brachial plexus?
Cervical compression did not provoke corresponding pain or numbness. There were no clear signs of suprascapular nerve irritation around the suprascapular notch or axillary nerve irritation around the quadrilateral space.
The situation changed when I examined the anterior and middle scalene muscles and the region around the supraclavicular fossa.
Pressure in this area clearly reproduced the anterior shoulder pain that the patient recognised as her usual symptom. More interestingly, when I maintained stimulation of this area and asked her to move the shoulder, she immediately felt it release. Previously, placing her hand behind her head while lying down had been painful. She could now place it down, with substantially less pain.
At this point, I began to shift my attention towards the scalene–brachial plexus region.
I then performed superficial bloodletting around the most tender area, followed by local cupping. Approximately ten minutes later, I asked her to move the shoulder again. Pain during elevation had clearly decreased. Her hand, which had previously reached only the buttock when moving behind her back, could now reach much higher, to the lower part of the shoulder blade.
The patient described the change in her own words:
“It felt like it unlocked. The whole shoulder suddenly released.”
The response to treatment provided further support for my clinical reasoning.
I became more inclined to think that the main problem was not located within the shoulder joint itself. It appeared more closely related to neural mechanical sensitivity in the scalene region. Persistent nerve-related pain may then have produced protective tension and secondary tenderness in the muscles surrounding the shoulder, eventually presenting as shoulder pain and restricted movement.
This was still a clinical judgment based on the history, physical examination and response to treatment. It did not prove that a particular nerve or tissue had a confirmed lesion.
This case made me reflect on several aspects of clinical reasoning.
What a Condition Resembles Determines Where We Start, Not Where We Finish
Shoulder pain and restricted movement may first be described simply as shoulder pain or a periarticular shoulder problem. Resisted testing, palpation and functional assessment may then help localise the problem to a particular muscle, tendon, joint or soft tissue.
However, if those findings still do not explain the symptoms adequately, we need to ask another question: why are these tissues painful? Could a more proximal neural factor be contributing?
What a condition initially resembles can determine where we begin our examination, but it should not automatically determine the final diagnosis.
Investigations Should Inform Clinical Reasoning, Not Replace It
The thickened subacromial bursa seen on ultrasound may have been a genuine finding. However, if the pain location, provocative tests and physical findings do not correspond well with that abnormality, we should not attribute every symptom to the bursa simply because the report mentions it.
Imaging and ultrasound provide important evidence, but they cannot replace the clinical history and physical examination. They do not automatically establish which finding is the main source of the patient’s pain at that moment.
The Absence of Expected Symptoms Does Not Exclude Another Level of the Problem
This patient had no significant neck pain, headache, dizziness, scapular pain or hand numbness. Without these symptoms, it would have been easy to stop the assessment at the shoulder.
Clinical examination, however, cannot follow only the symptoms the patient has already described. If the clinician does not consider a higher level in the differential diagnosis, that area will not be examined and the relevant findings may never be discovered.
Even a Closed Diagnostic Loop May Contain Contradictions
Shoulder pain, local tenderness, restricted movement and an ultrasound abnormality appeared to form a convincing local diagnostic loop.
But why were the resisted tests not clearly positive? Why did local tenderness fail to reproduce the patient’s familiar pain? Why did movement not behave like a mechanical block? Why did stimulation of the scalene and supraclavicular region immediately make the shoulder feel easier?
These unexplained findings were the evidence that broke the original diagnostic loop.
Clinical reasoning is not only about finding evidence that supports our first diagnosis. Sometimes, the observations that move us forward are precisely the symptoms and findings that do not fit.
Following Dr Huang’s clinical reasoning is not about learning where to place a needle for shoulder pain. It is about learning how a clinician asks questions, looks for evidence, recognises contradictions and moves step by step towards the real problem.
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Disclaimer
This article is based on a clinical case and is intended to share general clinical reasoning and health information. Some non-essential details may have been adjusted to protect patient privacy. It does not replace an individual consultation, physical examination, imaging assessment or medical diagnosis.
The interpretation presented here was based on the patient’s history, physical findings and response during treatment. It does not confirm injury to a particular nerve or tissue. Improvement after one treatment cannot, by itself, prove a diagnosis or pathological mechanism. The causes of shoulder pain and responses to treatment vary between patients.
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