Effectiveness of high-intensity laser therapy in the treatment of patients with frozen shoulder: a systematic review and meta-analysis.

The purpose of this study is to evaluate the effects of high-intensity laser therapy (HILT) in patients with frozen shoulder. PRISMA guidelines were adhered to, and a systematic search was conducted in the PubMed, Web of Science, Scopus, CINAHL, Science Direct, and PEDro databases (last update: September 4, 2023; search period: December 2022-September 2023). The inclusion criteria encompassed RCTs comparing HILT with other physical therapy interventions in frozen patients with frozen shoulders, with or without sham HILT, assessing pain intensity, shoulder ROM, and disability outcomes. The quality of the RCTs was assessed with the Cochrane Risk of Bias tool, and evidence was assessed using the GRADE approach. Five trials met the eligibility criteria and were included in the review and meta-analysis, which pooled results from the visual analog scale (VAS), goniometry, and the shoulder pain and disability index (SPADI). Mean differences (MDs) for pain intensity and disability show a pooled effect in favor of HILT both for VAS (MD = - 2.23 cm, 95% CI: - 3.25, - 1.22) and SPADI (MD = - 10.1% (95% CI = - 16.5, - 3.7), changes that are statistical (p < 0.01) and clinical. The MD for flexion (MD = 9.0°; 95% CI: - 2.36°, 20.3°; p = 0.12), abduction (MD = 3.4°; 95% CI: - 6.9°, 13.7°; p = 0.51), and external rotation (MD = - 0.95°; 95% CI: - 5.36°, 3.5°; p = 0.67) does not show statistical and clinical differences between groups after treatment. PI and disability changes were graded as important due to their clinical and statistical results. HILT into a physical therapy plan reduce pain and disability, but it does not outperform conventional physical therapy in improving shoulder ROM. It is suggested that future RCTs compare the effects of HILT and LLLT to assess their possible differences in their analgesic effects.

Breast cancer occurrence after low dose radiotherapy of non-malignant disorders of the shoulder.

Stochastic long-term damages at relatively low doses have the potential for cancer induction. For the first time we investigated the occurrence of breast cancer in female patients after radiotherapy of non-malignant disorders of the shoulder and made a comparison with the estimated spontaneous incidence of mammary carcinoma for this cohort. In a geographically defined district with a population of approximately 100.000 inhabitants, comprehensive data of radiological diagnostics and radiotherapy were registered nearly completely for 41 years; data included mammography and radiotherapy of breast cancer patients as well as of non-malignant disorders. Within this population a collective of 158 women with radiotherapy of the shoulder was investigated. Radiotherapy was performed with cobalt-60 photons (Gammatron) with an average cumulative-dose of 6 Gy. The average follow-up time was 21.3 years. Patients were 55 years old (median) when radiotherapy of the shoulder was performed. Seven patients (4.4%) developed breast cancer after a median of 21 years. According to the incidence statistics, 9.4 +/- 1.8 (95%CI) cases (5.9%) would be expected. In regard to the irradiated shoulder neither the ipsilateral nor the contralateral breasts showed increased rates of breast cancer. An induction of additional breast cancer caused by radiation of non-malignant disorders of the shoulder wasn't detected in the investigated cohort.

Short-term Clinical Outcomes of Hemiarthroplasty With Concentric Glenoid Reaming: The Ream and Run Procedure.

The purpose of this study was to evaluate the short-term clinical and radiographic outcomes of humeral hemiarthroplasty and concentric glenoid reaming ("ream and run" procedure) and to compare the outcomes with those of total shoulder arthroplasty (TSA) for glenohumeral arthritis. Patients with glenohumeral arthritis who underwent the ream and run procedure with a minimum follow-up of 2 years were retrospectively reviewed. The primary outcome was revision to TSA. Secondary outcome measures included functional outcome scores, range of motion, and radiographic assessment. The outcome measures were compared with those of age- and sex-matched control patients who underwent anatomic TSA during the study period. One patient in the ream and run group required revision to TSA 14 months after the surgery because of excessive shoulder pain. There were significant improvements in the postoperative outcome scores and range of motion and external rotation in the ream and run group. Postoperative radiographs showed concentric glenoids without posterior subluxation in all except 1 shoulder. The outcome measures in the ream and run group were similar to those in the TSA control group except for active forward elevation and external rotation. The ream and run procedure provides improved pain relief and shoulder function at short-term follow-up for patients with shoulder arthritis. [Orthopedics. 2018; 41(6):e854-e860.].

Radiotherapy for calcaneodynia, achillodynia, painful gonarthrosis, bursitis trochanterica, and painful shoulder syndrome - Early and late results of a prospective clinical quality assessment.

BACKGROUND: The aim of this prospective clinical quality assessment was to evaluate the short-term and long-term efficacy of low dose radiotherapy (RT) for calcaneodynia, achillodynia, painful gonarthrosis, painful bursitis trochanterica, and painful shoulder syndrome. METHODS: Between October 2011 and October 2013, patients with calcaneodynia, achillodynia, painful gonarthrosis, painful bursitis trochanterica, and painful shoulder syndrome were recruited for this prospective clinical quality assessment. Single doses of 0.5-1.0 Gy and a total dose of 6.0 Gy per series were used. Pain was measured before and directly after RT (early response) with a visual analogue scale (VAS). Additionally, pain relief was measured with the four-scale pain score according to "von Pannewitz" (VPS) immediately at the end of RT and during follow-up. Within this context we defined a good response as complete pain relief and markedly improved. The assessment of the long-term efficacy was carried out by a telephone survey. RESULTS: 703 evaluable patients (461 female, 242 male) with a mean age of 63.2 years (28-96) were recruited for this prospective clinical quality assessment. In 254 patients RT was performed with the linear accelerator, 449 patients received orthovoltage radiotherapy. After a median follow-up of 33 months (3-60) 437 patients could be reached for evaluation of follow up results. The mean VAS value before treatment was 6.63 (1.9-10) and immediately on completion of RT 4.51 (0-10) (p < 0,001). Concerning the VPS immediately on completion of RT, a good response could be achieved in 264/703 patients (37.6%), and with the follow up in 255/437 patients (58.4%) (p < 0.001). Only in patients with gonarthrosis we could not observe a significantly improved long-term success in comparison to the results immediately after RT (30.2% versus 29.9%). CONCLUSION: Low dose RT is a very effective treatment for the management of calcaneodynia, achillodynia, painful gonarthrosis, painful bursitis trochanterica, and painful shoulder syndrome. Due to the delayed onset of analgesic effects low dose RT results in a significantly improved long-term efficacy in comparison to the results immediately after RT particularly in patients with calcaneodynia, achillodynia, bursitis trochanterica, and shoulder syndrome.

Efecto del tratamiento de radioterapia en el hombro homolateral en mujeres intervenidas de cáncer de mama / Effect of radiotherapy treatment in the homolateral shoulder in breast-cancer patients

Objetivo: Conocer los efectos secundarios en el miembro superior tras el tratamiento de radioterapia en mujeres intervenidas por cáncer de mama e identificar si existen diferencias en función del servicio de radioterapia que las atiende. Sujetos, material y métodos: Estudio longitudinal prospectivo, en el que participaron 22 mujeres que iban a recibir tratamiento de radioterapia en los hospitales Gregorio Marañón y Ramón y Cajal de Madrid. Se realizó una valoración previa al tratamiento de radioterapia y otra inmediatamente después. En las exploraciones se recogió el rango de movimiento del hombro, el dolor, el grado de disfunción del miembro superior y el grado de radiodermatitis. Resultados: Todas las participantes mostraron una limitación en los movimientos del hombro homolateral a la cirugía antes de comenzar la radioterapia. Tras el tratamiento de radioterapia el rango de movimiento del hombro se vio reducido en los movimientos de rotación interna y rotación externa, además de aumentar de manera estadísticamente significativa el dolor y la discapacidad del miembro superior (p < 0,05). Las mujeres atendidas en el Hospital Ramón y Cajal vieron más reducido el movimiento de rotación externa, mientras que la lesión cutánea fue mayor en las mujeres tratadas en el Hospital Gregorio Marañón. Conclusiones: El tratamiento de radioterapia produce a corto plazo toxicidad cutánea, un aumento del dolor y la discapacidad en el miembro superior y contribuye a limitar el rango de movimiento del hombro en los movimientos de rotación interna y rotación externa. Estos resultados parecen variar en función del servicio de radioterapia que atiende a las mujeres

Objective: To identify the secondary effects in the upper limb after radiotherapy treatment in women diagnosed with breast cancer, as well as to determine if there are differences in the outcomes depending on the radiotherapy service that treated the participants. Participants, material, and methods: A longitudinal prospective study was performed on 22 women who received radiotherapy treatment in the Gregorio Marañón and Ramón y Cajal Hospitals in Madrid. The assessments were carried out before and after the radiotherapy treatment. The outcomes recorded were shoulder range of motion, pain, upper limb disability and the level of radiodermatitis. Results: All the participants showed a restriction in the shoulder movement after the surgery, and before the radiotherapy. After the radiotherapy treatment, there was a decrease in the internus and externus rotation movements of the shoulder. Furthermore, there was a statistically significant increase in pain and upper limb dysfunction. Women treated in the Ramón y Cajal Hospital showed a decrease in externus rotation movement, whereas women treated in the Gregorio Marañón Hospital suffered from greater skin toxicity. Conclusions: Radiotherapy treatment increases pain and upper limb disability, produces skin toxicity, and decreases the rotation mobility of the shoulder in the short-term. The secondary effects may vary according to hospital protocols

Comparison of photobiomodulation therapy and suprascapular nerve-pulsed radiofrequency in chronic shoulder pain: a randomized controlled, single-blind, clinical trial.

Shoulder pain can be difficult to treat due to its complex anatomic structure, and different treatment methods can be used. We aimed to examine the efficacy of photobiomodulation therapy (PBMT) and suprascapular nerve (SSN)-pulsed radiofrequency (RF) therapy. In this prospective, randomized, controlled, single-blind study, 59 patients with chronic shoulder pain due to impingement syndrome received PBMT (group H) or SSN-pulsed RF therapy (group P) in addition to exercise therapy for 14 sessions over 2 weeks. Records were taken using visual analog scale (VAS), Shoulder Pain and Disability Index (SPADI), and Nottingham Health Profile (NHP) scoring systems for pretreatment (PRT), posttreatment (PST), and PST follow-up at months 1, 3, and 6. There was no statistically significant difference in initial VAS score, SPADI, and NHP values between group H and group P (p > 0.05). Compared to the values of PRT, PST, and PST at months 1, 3, and 6, VAS, SPADI, and NHP values were statistically significantly lower in both groups (p < 0.001). There was no statistically significant difference at all measurement times in VAS, SPADI, and NHP between the two groups. We established that PBMT and SSN-pulsed RF therapy are effective methods, in addition to exercise therapy, in patients with chronic shoulder pain. PBMT seems to be advantageous compared to SSN-pulsed RF therapy, as it is a noninvasive method.

Use of X-rays to treat shoulder tendonitis/bursitis: a historical assessment.

This article assesses the therapeutic efficacy of ionizing radiation for the treatment of shoulder tendonitis/bursitis in the USA over the period of its use (human 1936-1961; veterinary 1954-1974). Results from ~3,500 human cases were reported in the clinical case studies over 30 articles, and indicated a high treatment efficacy (>90 %) for patients. Radiotherapy was effective with a single treatment. The duration of treatment effectiveness was prolonged, usually lasting until the duration of the follow-up period (i.e., 1-5 years). Therapeutic effectiveness was reduced for conditions characterized as chronic. Similar findings were reported with race horses in the veterinary literature. These historical findings are consistent with clinical studies over the past several decades in Germany, which have used more rigorous study designs and a broader range of clinical evaluation parameters. Radiotherapy treatment was widely used in the mid twentieth century in the USA, but was abandoned following the discovery of anti-inflammatory drugs and the fear of radiation-induced cancer. That X-ray treatment could be an effective means of treating shoulder tendonitis/bursitis, as a treatment option, and is essentially unknown by the current medical community. This paper is the first comprehensive synthesis of the historical use of X-rays to treat shoulder tendonitis/bursitis and its efficacy in the USA.

The Erlangen Dose Optimization Trial for radiotherapy of benign painful shoulder syndrome. Long-term results.

BACKGROUND AND PURPOSE: To evaluate the long-term efficacy of pain reduction by two dose-fractionation schedules for radiotherapy of painful shoulder syndrome. PATIENTS AND METHODS: Between February 2006 and February 2010, 312 evaluable patients were recruited for this prospective trial. All patients received low-dose orthovoltage radiotherapy. One course consisted of 6 fractions in 3 weeks. In the case of insufficient pain remission after 6 weeks, a second course was administered. Patients were randomly assigned to one of two groups to receive single doses of either 0.5 or 1.0 Gy. Endpoint was pain reduction. Pain was measured before radiotherapy, as well as immediately after (early response), 6 weeks after (delayed response) and approximately 3 years after (long-term response) completion of radiotherapy using a questionnaire-based visual analogue scale (VAS) and a comprehensive pain score (CPS). RESULTS: Median follow-up was 35 months (range 11-57). The overall early, delayed and long-term response rates for all patients were 83, 85 and 82 %, respectively. The mean VAS scores before treatment and those for early, delayed and long-term response in the 0.5- and 1.0-Gy groups were 56.8 ± 23.7 and 53.2 ± 21.8 (p = 0.16); 38.2 ± 36.1 and 34.0 ± 24.5 (p = 0.19); 33.0 ± 27.2 and 23.7 ± 22.7 (p = 0.04) and 27.9 ± 25.8 and 32.1 ± 26.9 (p = 0.25), respectively. The mean CPS values before treatment and those for early, delayed and long-term response were 9.7 ± 3.0 and 9.5 ± 2.7 (p = 0.31); 6.1 ± 3.6 and 5.4 ± 3.6 (p = 0.10); 5.3 ± 3.7 and 4.1 ± 3.7 (p = 0.05) and 4.0 ± 3.9 and 5.3 ± 4.4 (p = 0.05), respectively. No significant differences in the quality of the long-term response were found between the 0.5- and 1.0-Gy arms (p = 0.28). CONCLUSION: Radiotherapy is an effective treatment for the management of benign painful shoulder syndrome. For radiation protection reasons, the dose for a radiotherapy series should not exceed 3.0 Gy.

Tratamiento del dolor de hombro mediante vibración puntual en lesionados medulares / Shoulder pain treatment with punctual vibration in spinal cord injury patients

Objetivo: Analizar los efectos inmediatos agudos de cuatro tratamientos sobre puntos gatillo miofasciales (PGM) en pacientes con lesión medular con dolor de hombro crónico (casos) y sin dolor de hombro (controles). Material y método: 16 pacientes con lesión medular (11 varones y 5 mujeres) recibieron cuatro tratamientos, uno por semana, en orden aleatorio, siendo los tratamientos: I) presión, II) vibración [Vib], III) vibración más calor [Vib+C] y IV) vibración más frío [Vib+F]. Las variables dependientes registradas fueron: Wheelchair User's Shoulder Pain Index (WUSPI) y Performance-corrected Wheelchair User's Shoulder Pain Index (PCWUSPI), escala visual analógica (EVA), amplitud de movimiento (AMD) y los umbrales de tolerancia a la presión (TP) que fueron registrados en cinco PGM, incluyendo el infraespinoso lateral (IL), infraespinoso medial (IM), supraespinoso (S), trapecio superior (TS) y el pectoral mayor (PM). Resultados: Los valores de WUSPI, PC-WUSPI y EVA fueron mayores en los casos que en los controles (p<0,05). La AMD de rotación interna fue mayor después de los tratamientos que antes (p<0,05). La Vib+F aumentó TP para el IL. La Vib+C fue el único tratamiento que incrementó TP en los casos (p<0,05) para el S; para el TS el tratamiento de Vib+C aumentó la TP (p<0,05). Conclusión: La terapia combinada resultó más eficaz para aumentar la tolerancia a la presión de la mayoría de los PGM analizados, por lo que podría ser utilizada para tratar el dolor de hombro en lesionados medulares (AU)

Objective: To analyze the acute effects of four treatments for myofascial trigger points (PGM) in spinal cord injury patients with chronic shoulder pain (cases) and without shoulder pain (controls). Material and method: 16 SCI patients (10 men and 6 women) volunteered to participate in the study. Four treatments were applied, once a week, in random order: I) pressure, II) vibration [Vib] III) heat vibration [Vib+C], and IV) cold vibration [Vib+F]. The dependent variables recorded were: Wheelchair User's Shoulder Pain Index (WUSPI) & Performance-corrected Wheelchair User's Shoulder Pain Index (PC-WUSPI), visual analog scale (VAS), range of motion (AMD) and the tolerance thresholds pressure (TP) that were recorded in five PGM, including lateral infraspinatus (IL), infraspinatus medial (IM), supraspinatus (S), upper trapezius (TS) and pectoralis major (PM). Results: WUSPI, PC-WUSPI and EVA values were higher in cases than in controls (p <0.05). AMD internal rotation was greater after treatment than before (P <0.05). The Vib+F increased TP for the IL. The Vib+C was the only treatment that increased TP in cases (p <0.05) for the S; for the TS, the Vib+C treatment increased the TP (p <0.05). Conclusion: Combination therapy was more effective to increase the TP in the majority of the PGM analyzed. In addition, the Vib+F significantly increased the AMD of shoulder internal rotation (AU)

Benign painful shoulder syndrome: initial results of a single-center prospective randomized radiotherapy dose-optimization trial.

BACKGROUND AND PURPOSE: To compare the efficacy of two different dose-fractionation schedules for radiotherapy of patients with benign painful shoulder syndrome. PATIENTS AND METHODS: Between February 2006 and February 2010, 312 consecutive evaluable patients were recruited for this prospective randomized trial. All patients received radiotherapy with an orthovoltage technique. One radiotherapy course consisted of 6 single fractions in 3 weeks. In case of insufficient remission of pain after 6 weeks, a second radiation series was performed. Patients were randomly assigned to receive either single doses of 0.5 or 1.0 Gy. The endpoint was pain reduction. Pain was measured before, right after, and 6 weeks after radiotherapy using a visual analogue scale (VAS) and a comprehensive pain score (CPS). RESULTS: The overall response rate for all patients was 83% directly after and 85% 6 weeks after radiotherapy. The mean VAS values before, directly after, and 6 weeks after treatment for the 0.5 and 1.0 Gy groups were 56.8 ± 23.7 and 53.2 ± 21.8 (p = 0.158), 38.2 ± 26.1 and 34.0 ± 24.5 (p = 0.189), and 33.0 ± 27.2 and 23.7 ± 22.7 (p = 0.044), respectively. The mean CPS before, directly after, and 6 weeks after treatment was 9.7 ± 3.0 and 9.5 ± 2.7 (p = 0.309), 6.1 ± 3.6 and 5.4 ± 3.6 (p = 0.096), 5.3 ± 3.7 and 4.1 ± 3.7 (p = 0.052), respectively. Despite a slight advantage in the VAS analysis for the 1.0 Gy group for delayed response, the CPS analysis revealed no statistically significant differences between the two single-dose trial arms for early (p = 0.652) and delayed response quality (p = 0.380). CONCLUSION: Radiotherapy is an effective treatment option for the management of benign painful shoulder syndrome. Concerning radiation protection, the dose for a radiotherapy series is recommended not to exceed 3-6 Gy.

Calcifying tendonitis of the shoulder joint : predictive value of pretreatment sonography for the response to low-dose radiotherapy.

BACKGROUND AND PURPOSE: Calcifying tendonitis is a degenerative inflammatory joint disorder. Pain relief can be successfully achieved with low-dose radiotherapy. It is actually unknown which types of calcifying tendonitis respond to radiotherapy and which do not. The authors tried to get predictive objectives for the response to radiotherapy on the basis of different morphological patterns of calcifications evaluated by X-ray and ultrasound. PATIENTS AND METHODS: Between August 1999 and September 2002, a total of 102 patients with 115 painful shoulder joints underwent low-dose radiotherapy. At the beginning of radiotherapy, every shoulder joint was examined with a radiograph in two planes. In addition, sonography was performed before and during therapy. This examination was repeated 6 and 18 months after irradiation. Radiotherapy consisted of two series with a total dose of 6.0 Gy. 29 joints with calcifying tendonitis could be further divided using the sonographic and radiographic classification according to Farin and Gärtner, respectively. RESULTS: Pain relief was achieved in 94/115 joints (82%) at a follow-up of 18 months (median). A different response to radiotherapy was found using the sonographic classification of Farin: calcifying tendonitis type III (n = 18) responded well in contrast to a significantly worse result in type I (n = 11). The radiologic classification did not provide a predictive value. CONCLUSION: Sonographic classification of calcifying tendonitis is predictive for the outcome after radiotherapy. Especially patients with Farin type III calcification will benefit from low-dose radiotherapy.

Laser therapy of painful shoulder and shoulder-hand syndrome in treatment of patients after the stroke.

The common complication after stroke is pain and dysfunction of shoulder of paralyzed arm, as well as the swelling of the hand. The aim of this study was to determine the effects of LASER therapy and to correlate with electrotherapy (TENS, stabile galvanization) in subjects after stroke. We analyzed 70 subjects after stroke with pain in shoulder and oedema of paralyzed hand. The examinees were divided in two groups of 35, and they were treated in the Clinic for Physical Medicine and Rehabilitation in Tuzla during 2006 and 2007. Experimental group (EG) had a treatment with LASER, while the control group (CG) was treated with electrotherapy. Both groups had kinesis therapy and ice massage. All patients were examined on the admission and discharge by using the VAS, DASH, Barthel index and FIM. The pain intensity in shoulder was significantly reduced in EG (p<0,0001), swelling is lowered in EG (p=0,01). Barthel index in both groups was significant higher (p<0,01). DASH was significantly improved after LASER therapy in EG (p<0,01). EG had higher level of independency (p<0,01). LASER therapy used on EG shows significantly better results in reducing pain, swelling, disability and improvement of independency.

Low-power laser treatment for shoulder pain.

OBJECTIVE: The objective of this study is to investigate the effect of low-power gallium-arsenide laser treatment on the patients with shoulder pain. BACKGROUND DATA: Low-energy laser therapy has recently been popularized in the treatment of various rheumatologic, neurologic, and musculoskeletal disorders such as osteoarthritis, rheumatoid arthritis, fibromyalgia, carpal tunnel syndrome, rotator cuff tendinitis, and chronic back pain syndromes. METHODS: A total of 40 patients who applied to our clinic with shoulder pain and complied with the selection criteria were included in the study. The patients were randomly assigned into Group I (n = 20, laser treatment) and Group II (n = 20, control). In Group I, patients were given laser treatment and an exercise protocol for 10 sessions during a period of 2 weeks. Laser was applied over tuberculum majus and minus, bicipital groove, and anterior and posterior faces of the capsule, regardless of the existence of sensitivity, for 1 min at each location at each session with a frequency of 2000 Hz using a GaAs diode laser instrument (Roland Serie Elettronica Pagani, wavelength 904 nm, frequency range of 5-7000 Hz, and maximum peak power of 27 W, 50 W, or 27 x 4 W). In Group II, placebo laser and the same exercise protocol was given for the same period. Patients were evaluated according to the parameters of pain, palpation sensitivity, algometric sensitivity, and shoulder joint range of motion before and after treatment. RESULTS: Analysis of measurement results within each group showed a significant posttreatment improvement for some active and passive movements in both groups, and also for algometric sensitivity in Group I (p < 0.05-0.01). Posttreatment palpation sensitivity values showed improvement in 17 patients (85%) for Group I and six patients (30%) for Group II. Comparison between two groups showed superior results (p < 0.01 and p < 0.001) in Group I for the parameters of passive extension and palpation sensitivity but no significant difference for other parameters. CONCLUSIONS: The results of our study have shown better results in palpation sensitivity and passive extension, but no significant improvement in pain, active range, and algometric sensitivity in laser treatment group compared to the control group in the patients with shoulder pain.

Is chronic lymphocytic leukemia a contraindication for radon and thermotherapy?--a case report.

A growing number of patients presenting for radon-thermotherapy have a history of malignant disease. The question as to whether malignancies in general are a contraindication for radon treatment or mild hyperthermia during spa therapy is still a subject of controversy. We report a patient with osteoarthritis and a frozen shoulder who repeatedly underwent speleotherapeutic radon and hyperthermia treatment in the gallery of the Gasteiner Heilstollen, Austria, despite concomitant chronic lymphocytic leukemia (B-CLL, Rai stage 0). After nine courses of radon-thermotherapy over eight years, no apparent negative impact on CLL was noted. The purpose of this case report is to encourage discussion as to whether CLL or other past or present malignancies must be considered a contraindication for spa treatment such as radon-thermotherapy.

Relief of non-metastatic shoulder pain with mediastinal radiotherapy in patients with lung cancer.

Three patients with lung cancer and shoulder pain for which no local cause could be found are described. All three benefited from a course of palliative radiotherapy to ipsilateral mediastinal disease remote from the site of the pain. It is suggested that the pain is referred from intrathoracic involvement of the phrenic nerve by cancer, and that palliative irradiation of the mediastinum should be considered if investigations fail to reveal a local cause for ipsilateral shoulder pain.