eMedicine Specialties > Physical Medicine and Rehabilitation > Upper Limb Musculoskeletal Conditions

Shoulder and Hemiplegia: Differential Diagnoses & Workup

Author: Robert Gould, DO, Physiatrist, Interventional Pain Care, LLC
Coauthor(s): Susan S Barnes, DO, Assistant Professor, Department of Physical Medicine and Rehabilitation, Michigan State University
Contributor Information and Disclosures

Updated: Feb 5, 2009

Differential Diagnoses

Adhesive Capsulitis
Rheumatoid Arthritis
Chronic Pain Syndrome
Spasticity
Fibromyalgia
Suprascapular Neuropathy
Heterotopic Ossification
Thoracic Outlet Syndrome
Median Neuropathy
Osteoarthritis
Osteoporosis

Other Problems to Be Considered

Glenohumeral subluxation
Trauma/soft tissue injury
Fractures
Brachial plexus traction neuropathies/injury
Neglect (increased trauma risk)
Shoulder capsule stretch and tears secondary to disuse/flaccidity
Bursitis and tendonitis
Thalamic syndrome (central poststroke pain, analgesia dolorosa, Dejerine-Roussy syndrome)
Spasticity and synergy (muscle imbalance)
Complex regional pain syndrome (shoulder-hand syndrome, reflex sympathetic dystrophy, causalgia, sympathetically maintained pain, Sudeck atrophy, minor dystrophy)
Impingement syndromes
Rotator cuff inflammation/rupture
Prior musculoskeletal injury
Bicipital tendonitis/rupture
Radiculopathy
Contractures
Vascular compromise
Myofascial pain syndrome/fibromyalgia

Workup

Laboratory Studies

  • Laboratory tests are performed when they are required for a specific workup.
  • Obtain alkaline phosphatase to determine if HO exists.
  • Obtain rheumatoid factor, ANA, and sedimentation rate in patients with suspected rheumatoid arthritis.

Imaging Studies

  • Radiographs
    • The need to objectively measure shoulder subluxation, as well as determining the effectiveness of slings and other supports used in the treatment and prevention of shoulder subluxation, has led to the development of standardized radiographic techniques. Boyd and colleagues describe that basic radiographic evaluation for shoulder subluxation involves the use of qualitative and quantitative radiographic methods.37 The qualitative method involves visually inspecting the radiographs in order to classify the degree of subluxation. The quantitative method involves comparing the affected shoulder with the unaffected shoulder, or taking a single radiograph of the affected shoulder to measure the amount of subluxation.
    • Prevost and coauthors proposed a tridimensional (3-D) radiographic technique that was shown to be more precise and reliable than other clinical and radiographic techniques in locating the true spatial position of the humeral head relative to the glenoid fossa.11 However, since the 3-D technique requires the use of specialized equipment and multiple radiographic exposures, Prevost believes that using one of the more basic bidimensional (2-D) techniques is sufficient in assisting with an accurate diagnosis of shoulder subluxation.
    • Subsequently, Boyd and coauthors proposed their standardized "plane of the scapula method" for classifying subluxation.37 This method avoids assumptions about the normality or symmetry of the unaffected shoulder and minimizes the number of radiographs required. Use of this method has shown moderate measurement validity when comparing the radiograph with the 2 most reliable clinical measures, calipers and fingerbreadths. Even though this technique shows valid correlation with clinical measures and good interrater reliability, it may not be feasible to perform because of the specialized equipment that is not widely available.
  • Bone scans assist with the diagnosis of CRPS, HO, or other occult etiologies of shoulder pain.
  • Magnetic resonance imaging (MRI) is used when evaluating soft tissue injury.

Procedures

  • Electromyography (EMG) may be beneficial when evaluating the following conditions:
    • Brachial plexopathy
    • Radiculopathy
    • Median mononeuropathy
    • Suprascapular neuropathy
    • CRPS - If the EMG and nerve studies show an identifiable nerve injury in the distribution of regional symptoms, then according to the International Association for the Study of Pain (IASP) definitions, the patient may have CRPS type-2 (causalgia), but not CRPS type-1 (RSD).
  • Injections
    • Can be used for diagnostic and treatment purposes
    • May help to alleviate shoulder pain and inflammation associated with bursitis and/or tendonitis
  • Motor point blocks
  • Neurolysis

More on Shoulder and Hemiplegia

Overview: Shoulder and Hemiplegia
Differential Diagnoses & Workup: Shoulder and Hemiplegia
Treatment & Medication: Shoulder and Hemiplegia
Follow-up: Shoulder and Hemiplegia
References
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Further Reading

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Keywords

shoulder, hemiplegia, stroke, shoulder pain, shoulders, subluxation, pain in shoulder, rotator cuff injury, hemiplegic, complex regional pain syndrome, CRPS, NMES, neuromuscular electrical stimulation, shoulder pain after stroke, contractures, spastic muscle imbalance of the glenohumeral joint

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Contributor Information and Disclosures

Author

Robert Gould, DO, Physiatrist, Interventional Pain Care, LLC
Robert Gould, DO is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Osteopathic Association, American Osteopathic College of Physical Medicine and Rehabilitation, International Spine Intervention Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Coauthor(s)

Susan S Barnes, DO, Assistant Professor, Department of Physical Medicine and Rehabilitation, Michigan State University
Susan S Barnes, DO is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Osteopathic Association, and American Osteopathic College of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

Medical Editor

Robert J Kaplan, MD, James E Van Zandt VA Medical Center, Staff Physician, Department of Rehabilitation Medicine
Robert J Kaplan, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain (Tailbone Pain, Coccydynia) Service (www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Patrick M Foye, MD, FAAPMR, FAAEM is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Rene Cailliet, MD, Professor-Chairman Emeritus, Department of Rehabilitation Medicine, University of Southern California School of Medicine; Former Director, Department of Rehabilitation Medicine, Santa Monica Hospital Medical Center
Rene Cailliet, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American Pain Society, Association of American Medical Colleges, International Association for the Study of Pain, and Pan American Medical Association
Disclosure: Nothing to disclose.

 
 
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