Shoulder Pain Mind Map_ACUTE.webp
Shoulder Pain Mind Map_CHRONIC.jpg

This clinical mind map is organized based upon acute and chronic causes of shoulder pain. Acute and chronic causes are further subdivided based upon the exact location of pain in and around the shoulder joint, such as anterior, posterior, acromioclavicular joint, and all over. This differentiation is not always straightforward due to the following reasons:

  1. There is a great degree of variability in terms of defining what time duration correlates with acute versus chronic in cases of shoulder pain. Sources have described acute pain as lasting less than 12 to 24 weeks and chronic pain lasting more than 8 to 24 weeks.

  2. Any patient whose shoulder pain originates from a seemingly chronic cause (such as degenerative joint disease), starts with pain at some point. Typically, these pathologies do not lead to very severe pain in the beginning, which may be one of the reasons why people do not present early in the disease process. But if they seek medical advice within a few days of starting with pain instead of waiting for several weeks for various reasons, because their pain may be very severe or they may have easier than usual access to healthcare, a clinician may be misled into thinking that this pain must be arising from the differentials listed under acute causes of shoulder pain. Sometimes, if an acute cause of shoulder pain is not treated, the pain may become chronic, although the underlying pathology was acute.

To avoid this pitfall, consider the following to differentiate between acute versus chronic causes. Most differentials listed under acute causes either lead to sudden onset (severe enough to catch a patient’s attention relatively early in the disease process) or are trauma/injury related. On the other hand, differentials listed under chronic causes typically lead to somewhat subtle, gradual, nagging, and not so severe pain, at least in the beginning. One differential of particular importance is a rotator cuff tear. This can be caused by an acute injury, in which case it will present as a sudden onset of relatively severe pain. On the other hand, a rotator cuff tear can also be caused by a chronic degenerative process, in which case the pain is more subtle and gradual, and the atrophy of supra and infraspinatus muscles can be appreciated. A chronic generative process is a much more common etiology of a rotator cuff tear than an acute or traumatic process. Therefore, a rotator cuff tear is listed under chronic causes in this clinical mind map.

Another important point to remember when using this mind map is that physical exam features are of tremendous value when it comes to evaluating a patient with shoulder pain. Patients with similar histories and characteristics of pain may have two very different causes of pain based upon differentiating the physical exam findings. An example is differentiating physical exam features between adhesive capsulitis and impingement syndrome. Therefore, it is a good idea to become very familiar with the physical exam and avoid prematurely arriving at a diagnosis before completing a full physical exam. 

With the exception of cardiac ischemia, there are almost no urgent/emergent situations on the clinical mind map because shoulder injuries/pain typically do not result in or arise from life-threatening conditions. However, a clinician must be cognizant of significant morbidity and suffering which some of the conditions can cause.

A helpful tip to memorize probable diagnoses – CAB Gets Humorous ORABI.  (3Cs, 1A, 2B2, 1G, 1H in acute causes, and each letter in ORABI represents one chronic disease)