When “Shoulder Pain” Isn’t Orthopedic: Cardiac Red Flags APPs Should Never Miss
by: Terri Schmitt, PhD, APRN, FNP-BC, FAANP, Executive Director
February is Heart Health Month and one of the most dangerous clinical missteps we can make is anchoring onto a musculoskeletal diagnoses when the etiology is cardiac. While classic crushing substernal chest pain remains a textbook symptom, up to one-third of patients with acute coronary syndrome (ACS) present without typical chest pain (Canto et al., 2012). Instead, they may describe:
1. Isolated Arm, Shoulder, Neck, or Jaw Pain
Left arm pain is well known, but cardiac ischemia can present as isolated right arm, bilateral arm, shoulder, interscapular, neck, or jaw discomfort and these can often be described as aching, pressure, heaviness, or deep discomfort rather than reproducible tenderness. Key: Pain that is poorly localized and not clearly worsened with palpation should raise suspicion. If you can’t reproduce the pain, take a step back and re-evaluate.
2. “Muscle Strain” Without Clear Mechanism
Atraumatic shoulder or upper back pain, particularly in patients with cardiovascular risk factors, deserves pause. If ROM testing does not reliably reproduce symptoms, reconsider the differential. Key: Pain related to myocardial ischemia is typically not positional and not reproducible with movement or palpation.
3. Exertional Symptoms Misattributed to Overuse. Patients may report “my shoulder aches when I carry groceries” or “my arm hurts when I walk uphill.” This pattern suggests demand ischemia rather than tendonitis. Key: Symptoms triggered by exertion and relieved with rest are red flags.
4. Atypical Presentations in Women, Older Adults, and Patients with Diabetes
Further, we need to remember that women often present atypically. Women are more likely to present with arm, neck, jaw, or back pain without chest pain (Mehta et al., 2016). Older adults and patients with diabetes may present with vague discomfort, fatigue, dyspnea, or nausea.
Clinical Bottom Line: If pain is unexplained, exertional, poorly reproducible, or accompanied by dyspnea, diaphoresis, nausea, or unexplained fatigue then obtain an ECG and consider testing cardiac biomarkers. The cost of over-evaluation is far lower than a missed MI.
For a deeper dive into conditions that mimic musculoskeletal pain — and practical diagnostic strategies for primary care — explore the NPACE course “It’s not always ortho: medical conditions that mimic musculoskeletal pain!” With the amazing Karen Myrick DNP, APRN, FNP-BC, ANP-BC, ONP-C, FAANP, FAAN found here (INSERT LINK - https://learn.npace.org/products/its-not-always-ortho-medical-conditions-that-mimic-musculoskeletal-pain#tab-product_tab_overview )
References
Canto, J. G., Rogers, W. J., Goldberg, R. J., Peterson, E. D., Wenger, N. K., Vaccarino, V., Kiefe, C. I., Frederick, P. D., Sopko, G., & Zheng, Z.-J. (2012). Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality. JAMA, 307(8), 813–822. https://doi.org/10.1001/jama.2012.199
Mehta, L. S., Beckie, T. M., DeVon, H. A., Grines, C. L., Krumholz, H. M., Johnson, M. N., Lindley, K. J., Vaccarino, V., Wang, T. Y., Watson, K. E., & Wenger, N. K., et al. (2016). Acute myocardial infarction in women: A scientific statement from the American Heart Association. Circulation, 133(9), 916–947. https://doi.org/10.1161/CIR.0000000000000351
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