Hey guys. Welcome to PT Snacks podcast. This is Kasey, your host, and if you're tuning in for the very first time, first of all, welcome. But what you need to know is that this podcast is meant for physical therapists and physical therapist students who are looking to grow your fundamentals and bite-sized segments of time. So today we're actually gonna be covering shoulder pain that's not musculoskeletal pain. And I think that this is something that's so important to keep in the forefront of your brain, especially if you are wanting to be intentional. And I hope everybody feels this way, but intentional about screening patients and making sure that they're actually appropriate for your clinic. So the sooner that we are able to make sure that we are keeping these things in mind and capturing these patients, the sooner we can send them to the correct profession and get them the help that they actually need. So we're gonna be covering some of the most common sources of shoulder pain that are not from the shoulder. And. I would challenge you to pause this episode and just try and come up with that on, on your own. What all could refer potentially to the shoulder? Are we being all inclusive in this episode? Not necessarily. It's just a kind of a quick overview of some things to think about, but challenge yourself there and then that way. It's like our own built-in quiz. So before we do that though, if you've listened to the show at least three times and you feel like it's been really helpful, if you wouldn't mind pausing wherever you're listening to this and leaving a really brief review whether it's on YouTube or Apple Podcast, things like that, that would really mean the world to me. And if you're not following or subscribed, do so so that you don't miss out on anything. I have some exciting things in the works that I'm experimenting with. So I hope that you stay in touch and that it's helpful to you. Again. Yes, we should be good at what we treat, but we should also be good at recognizing what we shouldn't treat. So when we are talking about patterns that are related to musculoskeletal shoulder pain, our patients should probably have some sort of pain that's clearly linked to shoulder motion or loading. Maybe we can reproduce it with palpation or special tests. Maybe it improves with rest or there's positional change, or we see a difference through PT as they're being treated to where we're making a difference whether it's better or worse. We're impacting something and even if it's not in the shoulder, hopefully we've been able to figure out if it is musculoskeletal, it's coming from something else like the neck, right? So. Identifying non skeletal pain they might have constant, poorly localized pain. It might feel like deep or pressure like and it's not really altered by any shoulder movement or. Palpation or you, you can't bring it on in an exam even though you're trying to, it could be associated with systemic or autonomic symptoms. Um, maybe they have fever , diaphoresis, which is It's basically like a lot of sweating without really having a reason to sweat. Dyspnea, GI upset. Maybe they have unexplained weight loss. Or looking at their medical history. Do they have a history of cancer, cardiovascular disease? Do they smoke? Do they have significant comorbidities that might be. Putting them at a higher risk for developing other conditions that are not really physical therapy conditions. So, and as I mentioned, failure to respond or worsening symptoms despite you feeling pretty confident that you're giving them the appropriate musculoskeletal treatment is a sign that. Maybe they need more workup, they need more future steps with a different provider. So some examples of other potential sources. This is where hopefully you've quizzed yourself, but it could be from pulmonary or the thoracic region. Maybe they have pneumonia, lung cancer, maybe a pancoast tumor. If you're studying for your OCS, probably should know about that. Pleural effusion, pulmonary embolus. These are things where flags actually capture your attention. Could be cough, dyspnea, fever, weight loss, hemoptysis, pleuritic pain, smoking history, apical chest findings, so it can ask them if they have any history of a cough, shortness of breath, fever, night sweats, unintentional weight loss. Change in Sputin. And smoking history. So things that you could look at as a PT would be they're checking their temperature, their respiratory rate, auscultation or percussion of the upper lobes. Things like that. Other things I could refer, there could be cardiovascular, so hopefully they don't have some sort of acute coronary syndrome or AMI angina or aortic pathology. So they could have like jaw. Chest, epigastric, discomfort, exertional or pressure like pain, diaphoresis, nausea, dyspnea, autonomic signs and you're looking for cardiovascular or other risk factors like that. So then you can ask, does pain change with exertion versus rest? Any chest pressure, jaw, neck pain, sweating, nausea or breathlessness? Um, and any cardiac history, hypertension, diabetes, hyper lipedema, or smoking, hopefully they've already filled that out on their medical paperwork. And then you can look at their blood pressure, their heart rate rhythm observe for any distress or diaphoresis. Another one, gastrointestinal or hepatic pain. So conditions could include cholecystitis say that five times fast gallstones, pancreatitis, peptic disease hepatic tumors and things that could be associated with this would be right or upper left quadrant or epigastric pain, nausea, vomiting, jaundice, dark urine, pale stools, weight loss, or postprandial worsening. And you can ask them, do you have any upper abdominal pain, indigestion, change in appetite, nausea, jaundice, or recent weight loss and then malignancy or systemic disease. Some conditions could be primary or metastatic cancer, like lung, liver, bone, um, some sort of infection or autoimmune disease, polymyalgia rheumatica or just a few examples. But you're asking do you have a history of cancer? Unexplained weight loss, night pain, unrelieved with rest, systemic illness. And if their age is over the age of 50, that is gonna put them in a higher risk as well as failure to improve or rapid worsening despite appropriate musculoskeletal care. So you're asking any history of cancer, recent fever, chills, profound fatigue or weight loss? And is the pain constant, including at night, regardless of what position that you're in? If you're seeing this patient for the first time, you might have already. Been able to talk through some of these things. But some quick triage questions that you could integrate into your, just your normal exam or just checking up on them. You can ask them, is there anything about your, your health that you haven't mentioned? Fevers, night sweats, changes in breathing, digestion or weight, and you can say in a casual way where they're not freaked out but you still get the information that you want. Another question is, does anything about this pain worry you because it feels different than other aches that you've had? Or does shoulder or neck movement clearly make this better or worse, or does it seem pretty unrelated to movement? In addition, you can always ask about constitutional signs. So those are like fever, chills, night sweats, fatigue, unexplained weight loss. You can in your physical exam, incorporate like a red flag sweep that you just do with everybody. Where you're checking their blood pressure, heart rate, temperature, respiratory rate things like that, just observing. Do they seem distressed? Do they have diaphoresis, excessive sweating? What's their palor like? What's their skin complexion like? Do they have jaundice, any clubbing on their fingers? That sort of thing. And. We learned in PT school, like a quick chest and abdomen screen where you can palpate, um, you can do focused ascultation, see if there's any pleuritic or visceral pain provocation that you're doing. Uh, and then shoulder if full mechanical exam is normal and symptoms remain high, suspicion for a non musculoskeletal issue should be a little bit higher. So when do we refer urgently or emergently? So if we're suspecting some sort of AMI or aortic pathology, they have new chest pressure, exertional symptoms, autonomic signs. That would fit in that bucket as well as any red flag. Pulmonary signs in a high risk patient. So someone who is a smoker with progressive shoulder pain, cough, neurologic symptoms. You're suspicious of maybe a pancoast tumor that is also someone you need to send on very quickly. Um, if they are displaying any sort of progressive rapid neurologic deficit systemic sepsis signs or suspected malignancy with severe night rest pain, you also need to refer that So. In essence, if it doesn't make sense, dig deeper and make sure that you're maintaining these skills to make sure the patient that is in front of you is someone who should be in front of you. And if they shouldn't be, that you get them in front of the right provider that can care for their symptoms. Time is important. And I would, I would argue that for everyone if. PT is not where they need to be. That is the best thing that we can do, is to get them onto the next provider. So that's it for today guys. If you have any questions at all, feel free to reach out at ptsnackspodcast@gmail.com. Um, I will answer your questions to the best of my ability. 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