The Shoulder

Psychogenic Limitation

The diagnosis 'psychogenic pain' should be made on the discovery of positive inconsistencies during orthopaedic assessment and not as the result of supposition about possible psychological factors, such as anxiety, depression, stressful life situation or family dissatisfaction. A patient regarded as psychoneurotic can develop a genuine orthopaedic condition in parallel, and concentration on the psychological problem may distract the examiner from the organic cause of the pain.

The shoulder is "an honest" joint: The mechanofunctional aspects of the shoulder are well defined and easy to interpret.
When some movement is found to be painful or limited, the significance of this finding is seldom equivocal, and with regularity implies what on anatomical grounds it ought to imply.

The shoulder joint is closely connected with emotional tone. The outstretched arm is a symbol of pleasure and welcome; the arm held into the side expresses repugnance. Hence, those who feel withdrawn from the world or view it with disgust readily develop an inability to abduct the arm. This is therefore common in endogenous depression or conversion hysteria

The diagnosis 'functional' limitation of the elevation is quite simple to make:

There is is marked limitation of active and passive elevation.
However, active and passive elevation of the shouldergirdle (shrugging of the shoulders) is completely normal - full (and painless).
This implies a normal movement of the sterno-clavicular and acromio-clavicular joint, together with a normal scapular mobility.
The passive, scapulohumeral abduction is as much limited as the passive elevation of the arm.
The endfeel is that of an active, voluntary muscular contraction.

The patient does not realize that, even if the shoulder joint is ankylosed, mobility of the scapula permits 60' of abduction and that the arm must be capable of this amount of abduction unless the scapula has also become fixed. Hence, detection of psychogenesis is simple if the range of voluntary and passive elevation is contrasted with the range of passive abduction at the scapulohumeral joint.

Remark:

The marked discrepancy between the ranges of active and passive elevation, typical for a complete rupture of the supraspinatus and for neurological lesions points in the direction of a serious organic lesion and not in that of a psychological problem...