2 Der viszeral assoziierte Schulterschmerz - Osteopathic Research

Viscerally Associated Shoulder Pain
Subjective Perspectives and Diagnostic Procedures – the Osteopathic Point of View
it is paramount to also consider both the cervical and the dorsal spine as well as the
inner organs (cf. Diemer/Sutor 2010) since the shoulder area is one of the preferred
areas for referred pain (cf. Goodman/Snyder 2007). “Pain (“referred pain”) in the
shoulder area caused by visceral structures is a well-known fact. Unfortunately, since
there are practically no known assessment procedures, the evaluation is mainly
experience-based” (Diemer/Sutor 2010:97).
Nearly all organs close to the diaphragm refer pain – next to their organ-specific
segments – to the C4 dermatome. Therefore, complaints in this area may hide lifethreatening
diseases such as a heart attack or a Pancoast tumour (Goodman/Snyder
2007). Likewise, a myocardial infarction may produce pain radiating down the left
arm, the neck, the spine or the shoulder area, without the patient experiencing any
pain in the thorax (cf. Buckup 2009; Stevenson/Troijan 2002). Goodman/Snyder
(2007) also indicate that shoulder pain may have its origin in the abdominal or
gastrointestinal area: “Upper abdominal or gastrointestinal problems with
diaphragmatic irritation can refer pain to the ipsilateral shoulder. Peptic ulcer,
gallbladder disease and hiatal hernia are the most likely GI causes of shoulder pain
seen in the physical therapy clinic“ (p. 83). Furthermore, respiratory disorders seem
to increase the risk for shoulder problems. Petchkrua/Harris (2000) conclude from the
case description of a stroke patient that “her symptoms were possibly referred pain
from diaphragmatic irritation transmitted via right C4 sensory axons in the phrenic
nerve, which shares the same dermatome as the right acromion area. This case was
an unusual presentation of pneumonia” and consequently demand “that pneumonia
be considered in the differential diagnosis of shoulder pain“ (p. 827).
In the literature, viscerally associated shoulder pain is explained either as referred
pain or as produced by the fascial system. Regarding the mechanisms of referred
pain where pain appears in an area distant to the original pain location, three
different models try to explain the production of pain: the embryological development,
the convergence of somatic and visceral afferents and direct pressure.
The embryological development shows that already at a very early stage, at around
the third foetal week, the body starts to be organized in layers. From the outside to
the inside, the layers differentiate into dermatome, myotome, sclerotome and
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