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Shoulder pain at night
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Shoulder pain at night - January 14, 2001 6:19:00 PM
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M Luethe
Posts: 1
Joined: January 13, 2001
From: Seattle, WA, USA
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Any thoughts on a 60 year old man with "severe" R shoulder pain at night (normal range/strength/stability and painfree during the day)? He has not been able to sleep well now for the past 6 weeks. He is able to minimally relieve the pain by positioning--laying on his Left side and putting his R arm up on pillows and keeping his shoulder flexed to about 45 degrees. I'm stumped.
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Re: Shoulder pain at night - January 14, 2001 8:05:00 PM
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Betty Smoot
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Joined: March 1, 2000
From: Sonoma CA
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Hopefully your careful interview and history-taking will help clarify etiology (such as serious pathology), but if there are no mechanical findings in the shoulder, neck, elbow, etc., then he needs further work up to rule out something ominous. Talk to MD about it again. X-ray, bone scan, etc. may be warranted.
What do you find in the cervical spine and with palpation around the neck and shoulder/shoulder girdle? Inability to lie on the affected side may point toward a shoulder problem...but doesn't negate the possibility of a neck problem.
Keep us posted.
Betty
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Re: Shoulder pain at night - January 15, 2001 6:28:00 AM
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mcap
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I agree with Betty!
You must see if you can reproduce his symptoms mechanically either at the shoulder or the cervical spine. If you cannot or if the presentation remains confusing, then he should return to his physician, ASAP.
mcap
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Re: Shoulder pain at night - January 15, 2001 10:39:00 AM
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bonmar
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From: Boston, MA
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Night pain is an indication of serious pathology. I learned this many years ago when I had a 12 y.o. girl referred for knee pain. Although she did exhibit problems relating to P-F abnormalities, there was no explanation for the "severe" leg pain she was getting at night (only). I sent the pt back to the MD with a note explaining the pain. The MD called me and told me that night pain is a red flag for pathology. He ordered a bone scan on the patient and it revealed a tumor in her femur which was, thankfully, benign.
As the others have posted in their replies, please have the patient see the MD with a note from you stressing the pain is only at night.
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Re: Shoulder pain at night - January 15, 2001 6:44:00 PM
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Andrew M. Ball, MS, PT
Posts: 500
Joined: October 8, 1999
From: Chapel Hill, NC, USA
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Agreed.
Working in pediatrics, I suppose that I may see more tumors than those of ya'll in ortho. In peds, night pain is a red flag for serious pathology.
Drew
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Re: Shoulder pain at night - January 16, 2001 5:04:00 AM
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gerry
Posts: 238
Joined: July 6, 1999
From: Montgomery, AL, USA
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Drew,
How do you distinguish between "growing pains", which typically occur at night, and something indicative of more serious pathology?
Thanks!
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Re: Shoulder pain at night - January 16, 2001 8:49:00 AM
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mcap
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I agree with the previous posters. Extreme night pain is obviously a red flag and, in and of itself should warrent a further work-up.
However, in my few years of ortho experience I have seen several patients with presentations of sinsister pathology that have ended up being true ortho problems. But you can't take the chance, always refer back if there is any doubt at all.
It can work the other way as well. Some patients present with what seems like mechanical pain that ends up being sinster.
mcap
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Re: Shoulder pain at night - January 16, 2001 1:27:00 PM
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Andrew M. Ball, MS, PT
Posts: 500
Joined: October 8, 1999
From: Chapel Hill, NC, USA
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Good question Gerry. The best answer is that PT's really don't have the diagnositc tools available to them to truly differentially diagnose. When in doubt, it's best to refer.
That said, the following is based on clinical experience only . . . so take it with a grain of salt . . .
I've found that most growing pains occur at the anterior aspect of the tibia (e.g. the shin). To a lesser extent, I've seen pain at the growth plate . . . though once the pain was localized, this usually turned out to be Juvenile RA (and not really at the plate at all but rather in the joint itself). I've not seen growing pains at the shoulder before, and JRA usually showes up in the knees and hand before appearing in the shoulder.
Hope that helps.
Drew
[This message has been edited by Andrew M. Ball, MS, PT (edited January 16, 2001).]
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Re: Shoulder pain at night - January 17, 2001 5:08:00 AM
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gerry
Posts: 238
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From: Montgomery, AL, USA
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Thanks Drew.
I've also not experienced any complaints of shoulder pain being attributed to growing pains. It seems to be primarily in the lower extremities. My kids complain of general pain in the upper and lower legs, as well as the knee area. growing pains also seems to be reported more at bedtime, and less likely to wake a child up in the middle of the night.
I had a client several years ago who ended up with a tumor in the upper tibia with similar complaints, so I have been particularly wary. The orthopedists I work with tend to do further tests based on severity of the pain (based on subjective complaints), or based on repeated complains over time.
Sorry to get slightly off track.
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Re: Shoulder pain at night - March 8, 2001 6:57:00 AM
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patricia
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Joined: March 7, 2001
From: quakertown, pa , usa
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My husband has had severe shoulder pain for the past 9 years. He was originally told he had a torn rotator
cuff and underwent surgery. The pain got worse as time went by. He has been to physical therapy, cortisone shots, and also has seen some of the top surgeons in Philadelphia, who cannot find out what the problem is. They all basically told him that he had never had a torn rotator cuff in the first place, but are unable to say what is causing the pain.
He is usually okay during the day, but its when evening arrives and he wants to relax, that the pain starts. He uses a heating pad and takes hydrocodone prescribed by his doctor, which gives some relief. However he is usually awakened in the night again with the pain and has to get up for a couple of hours, use the heating pad again and take more medication. He is 58 years of age and other than this problem, is in perfect health. Do you have any answers for us, we are at our wits end. Ee have considered acupuncture, but have not taken that any further as yet. HELP!!!! [QUOTE]Originally posted by M Luethe:
Any thoughts on a 60 year old man with "severe" R shoulder pain at night (normal range/strength/stability and painfree during the day)? He has not been able to sleep well now for the past 6 weeks. He is able to minimally relieve the pain by positioning--laying on his Left side and putting his R arm up on pillows and keeping his shoulder flexed to about 45 degrees. I'm stumped.[/QUOTE]
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Re: Shoulder pain at night - March 8, 2001 9:13:00 AM
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mcap
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Patricia:
Does the pain behave mechanically? Is it worse with certain movements or positions? Has he had a MRI and films (I assume yes). Give us a little more of the background.
Assuming that this is not a mechanical problem, then I would suggest you read Donatelli's shoulder book. There is a chapter devoted to visceral pathology referring pain to the shoulder.
Good luck and give us more background.
mcap
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Re: Shoulder pain at night - March 8, 2001 11:46:00 AM
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edilling
Posts: 139
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From: pullman,wa,usa
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Night pain from cancer tumor is intractable vs pain from other sources is most often changed with movement. The pain arises as our core temp lowers when we sleep and the tumor temp stays high due to high metabolic activity. Free nerve endings perceive this temperture differential as pain. The pain persists until core temp rises enough to reduce temp differential to below the nerve threshold. (I think)
As for the original question-- rule out neck/arm. If things still do not make sense, you cannot treat what you do not know so, send the patient back to the DR to find out what it is.
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Re: Shoulder pain at night - April 16, 2001 10:28:00 PM
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abrar
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Joined: April 16, 2001
From: Melbourne, Australia
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Hi, new member here, a very interesting topic here. I was wondering whether anyone here has considered using Electrical Stimulation as a treatment of shoulder pain. I work at a private practise where my boss applies TENS to the points where a patient feels the pain (whether its muscular or whatever) and by using electric stimulation, she gets very good results......
What are your thoughts on this? Should TENS only be used when indicated or should we apply it wherever pain is felt?
------------------
[This message has been edited by David Adamczyk (edited April 17, 2001).]
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Re: Shoulder pain at night - May 26, 2001 12:24:00 PM
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edvol
Posts: 8
Joined: May 24, 2001
From: Israel
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You have to rule out the tumor or heart problems before appying TENS
[QUOTE]Originally posted by abrar:
Hi, new member here, a very interesting topic here. I was wondering whether anyone here has considered using Electrical Stimulation as a treatment of shoulder pain. I work at a private practise where my boss applies TENS to the points where a patient feels the pain (whether its muscular or whatever) and by using electric stimulation, she gets very good results......
What are your thoughts on this? Should TENS only be used when indicated or should we apply it wherever pain is felt?
[/QUOTE]
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Re: Shoulder pain at night - June 5, 2001 12:08:00 PM
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abid
Posts: 4
Joined: June 3, 2001
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hi every one
i read your problum i thing you have to send your pt back to doctoer he need m.u.a and interarticuler injections and afer that physiotherapy for another 21 days that will hlp your pt.
kindly reexamined the pt for cervical pain b/c in my view 60% of shoulder pain is b/c of cervical problum esp: compression of c4/5.
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Re: Shoulder pain at night - July 25, 2001 11:04:00 AM
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JLymanM
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Joined: July 24, 2001
From: Washington, DC
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This patient's chronic pain is not pathologic -- no such cause would result in recurrent pain for nine years. Moreover, it cannot be reconciled with his having minimal pain during normal daily activity, only to surge forth when he begins to "relax" in the evening. In fact, when he ceases the normal activities of the work day, he is no longer sufficiently distracted (psychologically) and his repressed anxiety and anger begin to manifest themselves in shoulder pain. Any pathological cause of such recurrent pain would be easily discernable with imaging studies. The patient should be encouraged to engage the work of Dr. Sarno, or his disciples, Drs. Sopher, Brady or Schechter (New England, Florida, and Los Angeles).
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Re: Shoulder pain at night - July 26, 2001 4:52:00 AM
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henryryry
Posts: 100
Joined: September 6, 2000
From: Brisbane, Australia.
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JLymanM,
I agree once again partly that emotion will play a big part in chronic pain and thank you for bringing this issue up for discussion [IMG]http://www.rehabedge.com/forums/biggrin.gif[/IMG]
However, I would urge you to not just focus and blame everything on the patients psychological aspects [IMG]http://www.rehabedge.com/forums/smile.gif[/IMG] While I agree with you that it is an important aspect of the bigger clinical picture, we should not ignore the biological and social factors, but your statement of "This patient's chronic pain is not pathologic" seemed to have ignored these other factors. If chronic pain patients only had emotional and psychological problems, why do PT's bother seeing them at all?
Furthermore, do not disregard our basic clinical reasoning skills. The purpose of these forums is to discuss possible mechanisms and differentially diagnosing the problem.
A person with shoulder pain for 9 years does not necessarily mean that he/she will not have tissue problems, even though there will obviously be other factors involved (such as those you have mentioned including anger and frustration). Furthermore, radiological imaging is not without its flaws.
Henry***
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Re: Shoulder pain at night - July 26, 2001 6:27:00 AM
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Rennie Maeda
Posts: 10
Joined: December 15, 1999
From: Manhattan Beach
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I had a patient four years ago...
56 year old male two weeks s/p rotator cuff repair and acromioplasty referred by the orthopaedic surgeon for post op rehabilitation. The patient's main complaint was that there was as yet no improvement in his pre-surgical symptoms of night time right shoulder pain. The pain came on only at night. He had had physical therapy for this without any relief. Of course, bells and whistles went off in my head because of this red flag. (I have had several patients with night time pain who did have cancer.) However, he had had a good workup, and, a surgery which visualized the area. Initial interventions where aimed at the post-op impairments. (This included thoracic and rib mobility exercises and joint mobilization).
A month later, there was still no improvement in his night time pain. AROM cervical exam revealed no pain reproduction even with overpressure. Shoulder AROM was full, but shoulder strength was diminished. Thoracic mobility, though improving was still limited. We were able to reproduce his pain however by having him lie supine in the clinic without a pillow! We initially had given him instruction and demonstration on sleep position. But what he needed was to sleep in a more flexed cervical position. (Giving him a couple of pillows in the clinic slowly resolved the pain.) That night he was able to sleep through the night without pain. Stretching his thoracic spine just prior to sleeping was also helpful. As his thoracic spine mobility improved he was able to decrease his pillow height and still be comfortable.
So perhaps in today's parlance, this patient had a postural syndrome, or a cervical extension syndrome or ???
The other interesting thing was that the patient's contralateral shoulder was also starting to hurt before the surgery and he and his surgeon were contemplating surgery on that side.
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Re: Shoulder pain at night - July 26, 2001 8:02:00 AM
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mcap
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Joined: February 8, 2000
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JLyman:
Let me start by saying that I would never discount psychological or social contributions to any disorder, particularly chronic pain.
And let me say that I have read Sarno's book twice.
Here is my question. If you truly beleive what he has to say.......then this patient shouldn't be in PT. Furthermore, no patient with a chronic painful condition should be in PT. In his opinion, we medicalize the patient and have them focus on the pain too much.
So how do you reconcile his theories with your livelihood??
He has helped shift the debate on low back pain in a meaningful way. But his theories have plenty of flaws if you look carefully at the research.
Respectfully,
mcap
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Re: Shoulder pain at night - July 27, 2001 9:26:00 AM
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JLymanM
Posts: 5
Joined: July 24, 2001
From: Washington, DC
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MCAP,
I am very uncomfortable with Sarno's having no use for PT. Even if the genesis of some/a lot/most chronic pain is psychological (initiated by the central nervous system), I'm sure that PT can help break the chronic cycle in which the involved tissues are trapped. What's important to me is that PTs are open to the pschogenic causes.
From there, the treatment may, in fact, be the same; but understanding why you're doing what you're doing, somehow makes a difference for the PT and his patient. I'm surprised that Sarno has had so much success, sending his patients home with nothing more than something to think about.
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