College of Massage Therapists of British Columbia (CMTBC) Practice Exam

Which visceral structures are known to refer pain into the shoulders?

1. Gallbladder

2. Heart

3. Lungs

4. All of the above

The correct answer is: All of the above

The correct answer encompasses all the listed visceral structures because each of them has the potential to refer pain to the shoulder region due to shared nerve pathways and anatomical connections. The gallbladder is located in the upper right quadrant of the abdomen and can refer pain to the right shoulder area, often due to irritation of the diaphragm that irritates the phrenic nerve, which is responsible for sensations in the shoulder. The heart can also refer pain to the shoulders, particularly the left shoulder, often associated with angina or myocardial infarction. This is attributed to the complex interactions between the heart's sensory nerve pathways and those supplying the shoulder region. Lung conditions, such as pneumonia or a pulmonary embolism, can lead to shoulder pain due to irritation of the pleura or diaphragm, which is closely related to the shoulder nerve pathways. Thus, each of these structures—gallbladder, heart, and lungs—can effectively refer pain to the shoulders, validating the selection of all of the above as the correct answer.