Shoulder Pain
Shoulder pain is a common musculoskeletal complaint arising from disorders of the rotator cuff, glenohumeral or acromioclavicular joints, bursa, or referred sources such as cervical spine or visceral pathology.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Rotator cuff impingement / tendinopathy | Painful arc 60–120°; pain on overhead activity; passive ROM > active ROM [1][3][4] | 「舉手去到中間有冇特別痛？再舉高啲反而好啲？」(Mid-arc pain that resolves on further elevation) | ~35% |
| Adhesive capsulitis (frozen shoulder) | Global loss of BOTH active AND passive ROM; DM as risk factor; phases: pain → pain+stiffness → stiffness → resolution [3] | 「膊頭可唔可以舉到最高？我幫你郁，你覺得卡住？你有冇糖尿病？」 | ~15% | |
| ACJ osteoarthritis | Localised tenderness over ACJ; pain on cross-body adduction | 「膊頭頂痛？」+ cross-body adduction test | ~10% | |
| Serious Not To Miss | Large rotator cuff tear | Inability to initiate abduction; drop arm sign positive; loss of active ROM but preserved passive ROM [3][4] | 「舉唔舉到手？」+ drop arm test | ~5% |
| Referred cardiac pain (ACS) | Exertional left shoulder/arm pain + chest tightness, dyspnoea, risk factors | 「做嘢或者行路時膊頭痛，有冇胸口翳悶？」 | ~2% | |
| GCA / PMR (if elderly bilateral shoulder pain) | Age > 50, bilateral proximal stiffness, markedly raised ESR/CRP; temporal headache, jaw claudication, visual symptoms [5] | 「兩邊膊頭都僵硬？有冇頭痛、食嘢下巴痛、睇嘢矇？」 | ~1% | |
| Malignancy (Pancoast tumour, bone metastasis) | Constant pain, weight loss, Horner syndrome, smoker | 「有冇消瘦？你食唔食煙？有冇眼皮落、出汗少？」 | <1% | |
| Septic arthritis | Fever + hot swollen joint + restricted ROM; acutely unwell | 「有冇發燒？個關節有冇紅腫熱？」 | <1% | |
| Pitfalls | Bicipital tendinitis | Anterior shoulder pain; positive Speed's / Yergason test | 「膊頭前面痛？扭前臂會唔會加重？」 | ~10% |
| Calcific tendinitis | Acute severe pain, X-ray calcification; 4th decade [2] | 「突然好痛？之前無咩事？」+ X-ray | ~5% | |
| Cervical radiculopathy | Pain radiates below elbow to hand; paraesthesia in dermatomal pattern; Spurling test positive [6] | 「痛有冇去到手踭以下？手指有冇痺？擰頸會唔會加重？」 | ~5% | |
| Masquerades | Depression / chronic pain syndrome | Low mood, sleep disturbance, reduced motivation, widespread pain | 「心情點？有冇覺得好攰、瞓唔好？」 | ~10% |
| Cervical spondylosis / spinal disease | Neck pain + arm symptoms; UMN signs if myelopathy | 「頸有冇痛？手腳有冇痺或者無力？」 | ~5% | |
| Diabetes / thyroid disease | Known DM or hypothyroidism → frozen shoulder | 「有冇糖尿或者甲狀腺問題？」 | ~3% | |
| Trying to Tell Me Something? | Work stress / sick-leave needs | Occupational overuse, wants time off, fear of job loss | 「呢個痛影唔影響返工？有冇擔心做唔到嘢？」 | ~10% |
| Fear of cancer or serious disease | Health anxiety after family member's diagnosis | 「你最驚係咩？屋企人有冇試過類似問題？」 | ~5% |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Greeting, rapport, open question | 「你好！我係今日幫你睇症嘅醫生。請問你點稱呼？今日有咩嘢唔舒服呀？」(Hello! I'm the doctor seeing you today. How should I address you? What brought you in today?) | Warm patient-centred opening; scores interpersonal marks |
| 0:30–2:00 | HPI – symptom analysis (SOCRATES + functional impact) | 「膊頭痛咗幾耐？邊邊膊頭？痛嘅感覺係點？有冇痺或者無力？夜晚瞓覺會唔會痛醒？做咩動作最痛？有冇試過整親？」 | Covers onset, site, character, radiation, severity, timing, aggravating/relieving, night pain (red flag & frozen shoulder), trauma |
| 2:00–3:00 | Red flags + targeted systems review | 「有冇發燒、消瘦、或者手腳痺痛？個膊頭有冇紅腫熱？有冇胸口痛或者氣喘？頸有冇痛？」 | Rules out septic arthritis, malignancy, referred cardiac/cervical pain; PMR/GCA if elderly |
| 3:00–3:30 | PMHx, DHx, FHx, allergy | 「你以前有冇糖尿病、甲狀腺或者其他長期病？食緊咩藥？有冇藥物敏感？屋企人有冇類風濕或者關節問題？」 | DM → frozen shoulder link; drug Hx for NSAID safety |
| 3:30–4:00 | Social Hx, occupation, function | 「你做咩工作？平時要唔要舉高手做嘢？呢個痛對你日常生活、著衫、沖涼有咩影響？」 | Occupation (overhead work → impingement); functional impact is key biopsychosocial item |
| 4:00–4:45 | ICE + hidden agenda | 「你自己覺得係咩原因？最擔心嘅係咩嘢？（例如：「會唔會係骨癌？」）你今日嚟最希望我幫到你啲咩？」 | Unlocks ICE directly; scores heavily in Case Report Form |
| 4:45–5:30 | Signpost → brief physical exam offer | 「多謝你同我講咁多，我想幫你檢查下膊頭，可以嗎？」Then demonstrate: inspect, palpate AC/GH/greater tuberosity, active + passive ROM, painful arc, Neer's/Hawkins | Physical sign is a CRF question; doing it scores both stations |
| 5:30–6:00 | Summarise, address concern, safety-net, close | 「咁總結嚟講，你右邊膊頭痛咗兩個月，做嘢舉手時特別痛，夜晚瞓覺都會痛。我初步估計可能係肩膊夾擊綜合症。我會幫你安排檢查同埋轉介。如果突然痛好多、發燒、或者手腳無力，就要即刻返嚟睇。你仲有冇嘢想問？」 | Summarising + diagnosis + safety-net + closing question → maximum interpersonal + completeness marks |
Uncovering the hidden agenda: The patient's RFC is often NOT just "I have shoulder pain." Ask explicitly: 「你今日特別嚟睇，係唔係有啲嘢特別擔心？」Common hidden agendas: worried about cancer/tear needing surgery; unable to work/sleep; fear of losing independence (elderly); or sick-leave certificate.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Onset | When did it start? Sudden or gradual? | 「幾時開始痛？突然定慢慢嚟？」 | Acute trauma → fracture/dislocation; insidious → impingement/frozen shoulder | Trauma: fracture, RC tear. Gradual: impingement, frozen shoulder |
| Site | Where exactly? Front, side, top? | 「痛喺邊度？前面、側面定頂？指俾我睇？」 | Anterolateral and lateral margin → rotator cuff/impingement [1] | Anterolateral: RC; top of shoulder: ACJ; anterior: biceps tendinitis |
| Character | Aching? Sharp? Burning? | 「點樣痛法？酸痛、刺痛定火燒咁？」 | Sharp catching → impingement; deep ache → frozen shoulder | |
| Radiation | Does it go down the arm or to the neck? | 「有冇痛去手臂、手指或者頸？」 | Below elbow → cervical radiculopathy, not intrinsic shoulder [2] | Cervical radiculopathy, thoracic outlet, referred cardiac |
| Night pain | Does it wake you at night? Can you sleep on that side? | 「夜晚會唔會痛醒？能唔能夠瞓嗰邊？」 | Night pain, cannot sleep on affected side [1] → rotator cuff or frozen shoulder | RC tear, frozen shoulder, malignancy |
| Painful arc | Pain when lifting arm 60-120°? | 「舉手去到中間有冇特別痛？」 | Painful arc (60–120°) = subacromial impingement [3][4] | Impingement syndrome |
| Stiffness | Stiffness? Morning stiffness? How long? | 「有冇覺得膊頭好僵硬？朝早會唔會特別緊？持續幾耐？」 | Morning stiffness > 30 min → inflammatory (RA/PMR); global loss of AROM + PROM → frozen shoulder | Frozen shoulder, RA, PMR |
| Weakness | Any weakness lifting or reaching? | 「有冇覺得舉手無力？」 | Weakness [1] → RC tear; drop arm sign | Rotator cuff tear |
| Trauma | Any injury or fall? | 「有冇整親或者跌過？」 | Trauma → fracture, AC separation, acute RC tear | Fracture, dislocation, AC injury |
| Red flag: fever/swelling | Any fever, redness, swelling? | 「有冇發燒、紅腫？」 | Septic arthritis — emergency | Septic arthritis, crystal arthropathy |
| Red flag: weight loss | Any weight loss? | 「有冇消瘦？」 | Malignancy (lung apex/Pancoast, bone mets) | Malignancy |
| Red flag: bilateral shoulder + elderly | Both shoulders? Stiffness in hips too? | 「兩邊膊頭都痛？髖骨都有冇僵硬？」 | PMR (age > 50, bilateral proximal stiffness) → check for GCA symptoms | PMR/GCA |
| GCA symptoms | Headache? Jaw pain on chewing? Vision changes? | 「有冇頭痛？食嘢時下巴痛？眼矇？」 | GCA = sight-threatening emergency [5] | GCA |
| PMHx: DM | Do you have diabetes? | 「你有冇糖尿病？」 | DM is a risk factor for frozen shoulder [3] | Adhesive capsulitis |
| PMHx: thyroid | Any thyroid problems? | 「有冇甲狀腺問題？」 | Thyroid disease associated with frozen shoulder [2] | Adhesive capsulitis |
| DHx | What medications? Any steroids? | 「食緊咩藥？有冇打過針類固醇？」 | Steroid injections, fluoroquinolones → tendon pathology; NSAID contraindications | |
| Occupation | What is your job? Overhead work? | 「做咩工作？要唔要經常舉高手做嘢？」 | Repetitive overhead → impingement/RC tear; manual labour → functional impact | Impingement, RC tear |
| Functional impact | Can you dress, comb hair, reach behind? | 「自己著衫、梳頭、抹背仲做唔做到？」 | Measures severity; frozen shoulder = global restriction | Frozen shoulder |
| Psychosocial | How is this affecting your mood/work/sleep? | 「呢個痛對你心情、工作、瞓覺有咩影響？」 | Scores biopsychosocial marks; may reveal hidden agenda (anxiety, depression, sick leave) | Psychological distress, work disability |
| ICE | What do you think it is? What worries you? What do you hope for today? | 「你自己估係咩問題？最擔心啲咩？今日最想我幫到你咩？」 | Mandatory CRF field. Common expectations: pain relief, referral, X-ray, sick leave |
Case Report Form Answer Builder
High-yield points to capture:
- CC: R/L shoulder pain × duration
- HPI: onset (gradual/acute/traumatic); site (anterolateral → RC); character (aching, catching); night pain [1]; painful arc; radiation (to elbow but not below = intrinsic); aggravating (overhead activity) / relieving (rest); stiffness (morning vs all day); weakness; functional impact (dressing, combing, sleeping); previous treatment tried; red flags screened (fever, weight loss, bilateral proximal stiffness if elderly)
| Likely RFC Examples | How to Phrase |
|---|---|
| Pain affecting sleep/work | "Shoulder pain affecting sleep and work performance" |
| Concern about serious diagnosis | "Worried shoulder pain may be a tear or cancer" |
| Wants investigation or referral | "Requests X-ray/referral for persistent shoulder pain not responding to painkillers" |
| Needs sick leave | "Unable to work due to shoulder pain; requests sick leave" |
Write one sentence that integrates the patient's own reason, e.g.: "Right shoulder pain for 2 months affecting sleep and work, concerned about rotator cuff tear, wants investigation."
| Component | Example Wording |
|---|---|
| Ideas | "Patient thinks it may be frozen shoulder / 骨刺 / 筋腱撕裂" |
| Concerns | "Worried about needing surgery / losing ability to work / cancer" |
| Expectations | "Wants pain relief medication / X-ray / referral to orthopaedics / physiotherapy / sick leave" |
For a middle-aged patient with gradual-onset anterolateral shoulder pain, painful arc, positive impingement signs, night pain, no global ROM restriction:
Subacromial impingement syndrome (rotator cuff tendinopathy)
Minimum supporting evidence: painful arc 60–120° + positive Neer/Hawkins sign + pain on overhead activity + preserved passive ROM [1][3][4]
If global restriction of active AND passive ROM + DM:
Adhesive capsulitis (frozen shoulder)
| DDx | Key Discriminator |
|---|---|
| 1. Adhesive capsulitis (frozen shoulder) | Global restriction of active + passive ROM in all directions; DM risk factor |
| 2. Rotator cuff tear | Weakness, drop arm sign positive, loss of active ROM but preserved passive ROM |
| 3. Cervical radiculopathy | Pain below elbow + dermatomal paraesthesia + positive Spurling test; neck movements worsen pain |
| Domain | Problem |
|---|---|
| Biological | Shoulder pain limiting ROM and causing sleep disturbance |
| Psychological | Anxiety about serious diagnosis (e.g. rotator cuff tear needing surgery) / low mood from chronic pain |
| Social/Functional | Impaired ADLs (dressing, grooming) and inability to perform job duties (especially overhead work) |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Subacromial impingement (most likely) | Painful arc (60–120°) [1][3][4] | Ask patient to actively abduct arm from 0° to 180°; note pain between 60–120° that resolves on further elevation | Pain occurs as supraspinatus tendon is compressed under acromion in mid-arc; more specific than Neer/Hawkins [4] |
| Subacromial impingement (alternative sign) | Neer impingement sign | Stabilise scapula, internally rotate arm, passively flex to maximum; positive = pain at subacromial space [4] | 80% sensitive for subacromial impingement; greater tuberosity impinges under coracoacromial arch |
| Adhesive capsulitis | Global loss of passive external rotation | Arm at side, elbow 90° flexed; passively externally rotate forearm; compare sides | Loss of passive ROM in multiple planes = capsular restriction; external rotation lost earliest |
| Rotator cuff tear | Drop arm sign | Patient abducts arm to 90° then slowly lowers; positive = arm drops suddenly | Indicates large supraspinatus tear; inability to control eccentric lowering [3][4] |
| Cervical radiculopathy | Spurling test | Extend + laterally flex + rotate neck toward affected side; apply axial compression | Reproduces radicular arm pain/paraesthesia by narrowing neural foramen [6] |
| ACJ pathology | Cross-body adduction test | Flex shoulder 90°, adduct arm across chest | Pain localised to ACJ suggests ACJ OA or injury |
| Bicipital tendinitis | Speed's test | Shoulder flexed 60°, elbow extended, forearm supinated; resist forward flexion | Pain in bicipital groove = biceps tendon pathology |
| Septic arthritis | No specific bedside sign in FM station | Fever + hot, swollen, erythematous joint with severely restricted ROM → urgent bloods + joint aspiration | Clinical picture + raised WCC/CRP; aspirate for crystals and culture |
Top Traps That Lose Marks
- Forgetting to check PASSIVE ROM — this is the single most important discriminator. Frozen shoulder = loss of passive AND active ROM. Impingement/RC tear = reduced active but preserved passive ROM.
- Not asking about night pain — it's a GC lecture slide point and distinguishes RC pathology and frozen shoulder from simple muscle strain [1].
- Missing cervical radiculopathy — if pain radiates below the elbow, it is likely NOT an intrinsic shoulder problem [2]. Always ask about neck pain and paraesthesia.
- Ignoring DM — DM is the most testable risk factor for frozen shoulder. Ask every shoulder-pain patient [3].
- Confusing painful arc with frozen shoulder — impingement = mid-arc pain that resolves on further elevation. Frozen shoulder = pain and restriction throughout entire arc.
- Not asking ICE — this is a guaranteed CRF question. Many students forget the Expectations component.
- Elderly + bilateral shoulder stiffness → don't forget PMR/GCA — this is a serious-not-to-miss that could be sight-threatening. Ask about headache, jaw claudication, visual symptoms [5].
- Not considering referred cardiac pain — especially left shoulder pain with exertional component in a patient with cardiac risk factors.
"Must Not Miss" Red Flags → Urgent Referral:
- Fever + hot swollen joint → septic arthritis → same-day A&E referral
- Bilateral proximal shoulder/hip stiffness + temporal headache + visual symptoms (age > 50) → GCA → same-day rheumatology/ophthalmology; start prednisolone before biopsy
- Constant pain + weight loss + Horner syndrome → Pancoast tumour → urgent CXR + referral
- Trauma + deformity + neurovascular compromise → fracture/dislocation → A&E
- Acute weakness with drop arm sign in young patient after trauma → acute large RC tear → orthopaedic referral within 2 weeks
Shortest Safe Management / Safety-Net Line:
「如果你突然膊頭痛到唔郁得、發燒、或者手腳無力痺痛，要即刻去急症室。」 (If sudden severe pain with inability to move, fever, or arm weakness/numbness, go to A&E immediately.)
High Yield Summary
What to ASK: Onset, site (anterolateral?), night pain, painful arc, ROM restriction (active vs passive), weakness, DM, trauma, radiation below elbow, bilateral (PMR), red flags (fever, weight loss, headache/jaw claudication if elderly), occupation, functional impact, ICE.
What to WRITE: CC with duration → HPI (SOCRATES + red flags) → RFC in one sentence → ICE (three parts) → Most likely Dx with evidence (e.g. "Subacromial impingement: painful arc 60–120°, positive Neer's sign, preserved passive ROM") → 3 DDx with discriminators → 3 biopsychosocial problems → Physical sign: painful arc / drop arm / global passive ROM loss.
What NOT to MISS: Septic arthritis (fever + hot joint), GCA/PMR (elderly bilateral + headache), malignancy (weight loss, smoker), cervical radiculopathy (below-elbow radiation), DM-related frozen shoulder, referred cardiac pain.
Active Recall - Family Medicine Clinical Test
[1] GC 236. Common Shoulder Problems [Updated in 2025].pdf (Clinical presentations slide) [2] Taylor's Differential Diagnosis Manual 3ed.pdf (Chapter 12.9 Shoulder Pain) [3] Maksim Surgery Notes.pdf (Section 3.3–3.5: Shoulder pain, Rotator cuff syndrome, Frozen shoulder) [4] Ryan Ho Fundamentals.pdf / Ryan Ho Rheumatology.pdf (Shoulder examination: Move, Special tests) [5] Block A - Rheumatology Interactive Tutorial.pdf (Case 1: PMR and GCA) [6] Ryan Ho Neurology.pdf (Section 9.4: Cervical spondylosis, radiculopathy)
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Hand Pain
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