When is shoulder pain, not shoulder pain?

Shoulder pain is the third most common musculoskeletal pain experienced by people. However, when you examine someone’s range of movement, there is no pain provoked during testing, and they have full range of movement? What could it be if not related to the shoulder?

Gall bladder – Deep, generalised, non-specific shoulder pain on the right-hand side from irritation of the phrenic nerve (a sensory nerve) you have one on each side which run from the neck (C3-C5), through to and innervates, the diaphragm.

The gall bladder and the right phrenic nerve are in very close proximity to each other. If you have the 4 F’s, then your likelihood of having gall bladder problems is increased.

  • Fifty
  • Female
  • Fat
  • Flatulent

Symptoms include:

  • Worsening shoulder pain and bloating after ingesting high calorie meals.
  • Poo’s that float.


Spleen, diaphragm & pancreas

The spleen, diaphragm & pancreas, can refer pain to the left shoulder. Acute pain at the tip of the shoulder above the collarbone, known as Kehr’s sign, can indicate a spleen pathology or irritation of the diaphragm.  The referred pain is due to the phrenic nerve irritation in the peritoneal cavity (abdomen) plus the nerves that supply the collarbone (the supraclavicular nerves) come from the same place in the C spine as the phrenic nerve, C3-C5.  Similarly, the tail of the pancreas which is also innervated by nerves from C3-C5 will refer pain to the left shoulder when something is wrong there.


Ovarian cyst or ectopic pregnancy

An ectopic pregnancy or a ruptured ovarian cyst will refer a sharp pain to the tip of shoulder due to swelling and excess fluid in the abdominal area irritating/compressing the phrenic nerve.

Thoracic outlet syndrome (TOS).

There are three types of thoracic outlet syndrome, vascular, neural and arterial.  The condition is from compression of vessels between the clavicle (collar bone) and the first rib (the thoracic outlet) or between the middle and anterior scalene muscles and again the first rib. Referred pain to the shoulder would likely be from compression to the brachial plexus (a group of nerves in that area).

Myocardial ischemia (Heart attack)

When men experience a heart attack, in addition to chest pain, a common symptom is referred pain to the left neck, arm and shoulder, however, this isn’t because of a particular nerve being irritated, but most likely because of a ‘confusion’ of multiple sensory inputs at the spinal cord.

When women experience a heart attack the symptoms can be a little different; Nausea/vomiting, shortness of breath, and back or jaw pain can be experienced.


Cervical spondylolysis, cervical arthritis, and cervical disc disease

Age related wear and tear on the cervical discs and the cervical spine (neck). The nerve roots of C3-C8 travel through the shoulder, so compression of any of them in the cervical spine can refer pain to the shoulder and is known as cervical radiculopathy.

Other conditions that can refer pain to the shoulder include reflex sympathetic dystrophy and irritation of the diaphragm.

The above is not an exhaustive list but it’s something I’m aware of if a client’s movement and testing pattern aren’t making sense from a musculoskeletal point of view, this is when I’d be writing a referral letter to the clients GP for further investigation.

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