{"id":28996,"date":"2026-07-16T09:28:43","date_gmt":"2026-07-16T08:28:43","guid":{"rendered":"https:\/\/apps.nhslothian.scot\/refhelp\/?page_id=28996"},"modified":"2026-08-07T08:13:35","modified_gmt":"2026-08-07T07:13:35","slug":"visceral-referred-shoulder-pain","status":"publish","type":"page","link":"https:\/\/apps.nhslothian.scot\/refhelp\/visceral-referred-shoulder-pain\/","title":{"rendered":"Visceral referred shoulder pain"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\"><strong>Definition<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Visceral pain is a type of nociceptive pain, which is stimulated from within the visceral structures, such the stomach, bladder, uterus or rectum, but experienced elsewhere in the body. It occurs in somatic areas neuromerically connected (from the same neuromere) with the affected organs. The precise mechanism of this phenomenon remains unknown.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Evidence shows that gastrointestinal, biliary, renal, hepatic, heart and pulmonary disorders may refer pain to the upper quadrant of the body, including the neck region. For example:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Liver and gallbladder &#8211; can refer pain to the right shoulder, scapula or chest wall<\/li>\n\n\n\n<li>Pancreas &#8211; can refer pain to the scapular region<\/li>\n\n\n\n<li>Cardiovascular \u2013 can refer pain to the left shoulder<\/li>\n<\/ul>\n\n\n\n<h4 class=\"wp-block-heading\">Typical signs and symptoms<\/h4>\n\n\n\n<p class=\"wp-block-paragraph\">There is no clear test or sign to differentiate visceral and somatic sources of pain. Listening to the patient story and considering their PMH can help you decide whether a visceral source should be suspected.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">General characteristics of pain due to visceral pathology<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Poorly localized with referral to somatic structures<\/li>\n\n\n\n<li>Can produce strong autonomic responses (pallor, profuse sweating, nausea, GI disturbances and changes in body temperature, blood pressure and heart rate)<\/li>\n\n\n\n<li>Can lead to sensitisation of somatic tissues<\/li>\n\n\n\n<li>Can produce strong affective responses<\/li>\n<\/ul>\n\n\n\n<h4 class=\"wp-block-heading\">Other considerations<\/h4>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Visceral disorders may cause referred altered sensitivity e.g. hyperalgesia or allodynia<\/li>\n\n\n\n<li>Radiation of pain to the neck and\/or upper extremity occurs in more than 65% of cases of acute coronary syndromes<\/li>\n\n\n\n<li>88% of patients with colonoscopy-induced splenic injury complain of pain along the C3\u2013C4 dermatomes (due to irritation of the diaphragm or distention of the splenic capsule)<\/li>\n\n\n\n<li>Neck and upper extremity pain can also occur in more common, frequently long-lasting and not so life-threatening conditions, such as hiatal hernias and gastroesophageal reflux disease<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>P.A &amp; M.A &#8211; 16-7-26<\/strong><\/p>\n\n\n\n<div class=\"wp-block-getwid-tabs\" data-active-tab=\"0\"><ul class=\"wp-block-getwid-tabs__nav-links\"><\/ul>\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Referral Guidelines<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<h4 class=\"wp-block-heading\">Who can refer: <\/h4>\n\n\n\n<ul class=\"wp-block-list\">\n<li>All primary care clinicians with relevant appropriate scope of practice i.e. GPs, Primary care MSK advanced practice physiotherapists, advanced nurse practitioners <\/li>\n\n\n\n<li>Patient self referral (resident of East Lothian HSCP, Edinburgh HSCP and West Lothian HSCP <a href=\"https:\/\/services.nhslothian.scot\/musculoskeletal\/where-to-find-us\/\" target=\"_blank\" rel=\"noreferrer noopener\">Where To Find Us \u2013 Musculoskeletal Physiotherapy<\/a>)<\/li>\n\n\n\n<li>Secondary care consultants and associated teams<\/li>\n\n\n\n<li>MSK physiotherapists who identify patients with suspected serious conditions of the shoulder or elbow shoulder follow agreed pathways and processes <a href=\"http:\/\/intranet.lothian.scot.nhs.uk\/Directory\/physiotherapy\/NHSLIntegratedShoulderandElbowService\/Pages\/default.aspx\" target=\"_blank\" rel=\"noreferrer noopener\">NHS Lothian Integrated Shoulder &amp; Elbow Service<\/a><\/li>\n<\/ul>\n\n\n\n<h4 class=\"wp-block-heading\">Who and How to refer:<\/h4>\n\n\n\n<figure class=\"wp-block-table is-style-stripes\"><table><thead><tr><th>Condition<\/th><th>Referral Type<\/th><th>Referral destination and process<\/th><\/tr><\/thead><tbody><tr><td><strong>Suspected septic arthritis\/ septic bursitis<\/strong><\/td><td>Same day<\/td><td><strong>Orthopaedic registrar<\/strong> via Flow navigation centre on 03000 134000\/ on call Orthopaedic registrar via switchboard 0131 242 1000<\/td><\/tr><tr><td><strong>Suspected facture or dislocation<\/strong><\/td><td>Same day<\/td><td><strong>Orthopaedic registrar<\/strong> via Flow navigation centre on 03000 134000\/ on call Orthopaedic registrar via switchboard 0131 242 1000<\/td><\/tr><tr><td><strong>Suspected acute distal biceps rupture<\/strong><\/td><td>Same day<\/td><td><strong>Orthopaedic registrar<\/strong> via Flow navigation centre on 03000 134000\/ on call Orthopaedic registrar via switchboard 0131 242 1000<\/td><\/tr><tr><td><strong>Suspected acute traumatic rotator cuff tear in the younger patient<\/strong><\/td><td>Urgent<\/td><td><strong>Orthopaedics<\/strong> via SCI gateway &gt; Lauriston Buildings &gt; Orthopaedics- Elbow &amp; Shoulder<\/td><\/tr><tr><td><strong>Suspected malignancy\/ tumour specific to shoulder*<\/strong><\/td><td>Urgent<\/td><td><strong>Orthopaedics<\/strong> via SCI gateway &gt; Lauriston Buildings &gt; Orthopaedics- Elbow &amp; Shoulder<\/td><\/tr><tr><td><strong>Suspected inflammatory condition<\/strong><\/td><td>&nbsp;<\/td><td>Consider referral to <strong>Rheumatology<\/strong> \u2013 see <a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/rheumatology-2\/\" target=\"_blank\" rel=\"noreferrer noopener\">RefHelp Rheumatology.<\/a><\/td><\/tr><tr><td><strong>Suspected neurological condition<\/strong><\/td><td>&nbsp;<\/td><td>Consider referral to <strong>Neurology<\/strong> \u2013 see&nbsp;<a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/neurology\/\" target=\"_blank\" rel=\"noreferrer noopener\">RefHelp Neurology.<\/a><\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">* <em>Please also see <a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/orthopaedics\/sarcoma\/\" target=\"_blank\" rel=\"noreferrer noopener\">Sarcoma \u2013 RefHelp<\/a>. If clinical assessment leads to a very strong suspicion of suspected underlying malignancy, with no specific localising signs or symptoms to suggest a specific underlying primary, consider recommendations and referral options&nbsp;detailed on <a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/paediatric-radiology\/gpaccesstoctforsuspectedcancernoclinicallyobviousprimary\/\" target=\"_blank\" rel=\"noreferrer noopener\">GP Access to CT for Suspected Cancer (No Clinically Obvious Primary) \u2013 RefHelp<\/a><\/em><\/p>\n\n\n\n<h4 class=\"wp-block-heading\">Who not to refer:<\/h4>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Patients who have the presence of significant red flags\/ suspicion of serious shoulder and elbow conditions or have suspected inflammatory condition &#8211; see <a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/serious-shoulder-and-elbow-conditions-red-flags\/\" data-type=\"link\" data-id=\"https:\/\/apps.nhslothian.scot\/refhelp\/serious-shoulder-and-elbow-conditions-red-flags\/\" target=\"_blank\" rel=\"noreferrer noopener\">serious shoulder &amp; elbow conditions<\/a><\/li>\n\n\n\n<li>Age &lt;16<\/li>\n<\/ul>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Primary Care Management<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<p class=\"wp-block-paragraph\">For further information see associated sections<\/p>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Resources and Links<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<ul class=\"wp-block-list\">\n<li>Link to NHS Lothian patient internet site including patient information resources \u2013&nbsp;<a href=\"https:\/\/services.nhslothian.scot\/ises\/\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/services.nhslothian.scot\/ISES\/Pages\/default.aspx<\/a><\/li>\n\n\n\n<li>Link to NHS Inform page shoulder &nbsp;problems&nbsp;<a href=\"https:\/\/www.nhsinform.scot\/illnesses-and-conditions\/muscle-bone-and-joints\/self-management-advice\/shoulder-problems\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/www.nhsinform.scot\/illnesses-and-conditions\/muscle-bone-and-joints\/self-management-advice\/shoulder-problems<\/a><\/li>\n\n\n\n<li>Link to NHS Inform shoulder problems- Patient self help guide&nbsp;<a href=\"https:\/\/www.nhsinform.scot\/self-help-guides\/self-help-guide-shoulder-pain\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/www.nhsinform.scot\/self-help-guides\/self-help-guide-shoulder-pain<\/a><\/li>\n\n\n\n<li>Link to NHS Inform page elbow problems&nbsp;<a href=\"https:\/\/www.nhsinform.scot\/illnesses-and-conditions\/muscle-bone-and-joints\/self-management-advice\/elbow-problems\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/www.nhsinform.scot\/illnesses-and-conditions\/muscle-bone-and-joints\/self-management-advice\/elbow-problems<\/a><\/li>\n\n\n\n<li>Link to intranet site NHS Lothian Integrated Shoulder and Elbow Service&nbsp;<a href=\"http:\/\/intranet.lothian.scot.nhs.uk\/Directory\/physiotherapy\/NHSLIntegratedShoulderandElbowService\/Pages\/default.aspx\" target=\"_blank\" rel=\"noreferrer noopener\">http:\/\/intranet.lothian.scot.nhs.uk\/Directory\/physiotherapy\/NHSLIntegratedShoulderandElbowService\/Pages\/default.aspx<\/a><\/li>\n<\/ul>\n<\/div><\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Definition Visceral pain is a type of nociceptive pain, which is stimulated from within the visceral structures, such the stomach, bladder, uterus or rectum, but experienced elsewhere in the body. It occurs in somatic areas neuromerically connected (from the same neuromere) with the affected organs. The precise mechanism of this phenomenon remains unknown. Evidence shows<\/p>\n","protected":false},"author":20,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_searchwp_excluded":"","footnotes":""},"categories":[1414,1417],"class_list":["post-28996","page","type-page","status-publish","hentry","category-https-apps-nhslothian-scot-refhelp-shoulder-conditions","category-https-apps-nhslothian-scot-refhelp-visceral-referred-shoulder-pain"],"publishpress_future_workflow_manual_trigger":{"enabledWorkflows":[]},"rttpg_featured_image_url":null,"rttpg_author":{"display_name":"mariamazoysaavedra","author_link":"https:\/\/apps.nhslothian.scot\/refhelp\/author\/mariamazoysaavedra\/"},"rttpg_comment":0,"rttpg_category":" <a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/category\/musculoskeletal-physiotherapy\/shoulder-elbow\/https-apps-nhslothian-scot-refhelp-shoulder-conditions\/\" rel=\"tag\">Shoulder conditions<\/a><a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/category\/musculoskeletal-physiotherapy\/shoulder-elbow\/https-apps-nhslothian-scot-refhelp-shoulder-conditions\/https-apps-nhslothian-scot-refhelp-visceral-referred-shoulder-pain\/\" rel=\"tag\">Visceral referred shoulder pain<\/a>","rttpg_excerpt":"Definition Visceral pain is a type of nociceptive pain, which is stimulated from within the visceral structures, such the stomach, bladder, uterus or rectum, but experienced elsewhere in the body. It occurs in somatic areas neuromerically connected (from the same neuromere) with the affected organs. The precise mechanism of this phenomenon remains unknown. Evidence shows","_links":{"self":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/28996","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/users\/20"}],"replies":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/comments?post=28996"}],"version-history":[{"count":2,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/28996\/revisions"}],"predecessor-version":[{"id":28998,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/28996\/revisions\/28998"}],"wp:attachment":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/media?parent=28996"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/categories?post=28996"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}