Shoulder

Both shoulders hurt, but the cause was the liver: liver abscess and referred shoulder pain

Hee Seung Nam, MD, Orthopedic Surgeon · September 16, 2026

A 66-year-old woman came in saying both of her shoulders had hurt for two weeks. When someone in her 60s comes with shoulder pain, I usually think first of frozen shoulder, a rotator cuff tear or calcific tendinitis. But her pain began not in the shoulder but in the liver.

The shoulder X-rays were clean

On the X-rays of both shoulders I saw nothing in the bones or joints that would explain the pain. On examination she winced when I pressed the trapezius area above the shoulder, but the pattern was a little different from typical shoulder joint disease.

When the X-ray is clean and the examination is ambiguous, it is common to move straight on to a shoulder injection or physical therapy. But wondering whether some other cause might be hiding, I ordered blood tests first.

The signal in the blood tests

All values in the table are marked as abnormal because they exceeded the normal range of the laboratory that ran the test. Normal ranges differ slightly from lab to lab.

CRP, the inflammation marker, was very high, and the liver enzymes were well beyond the normal range. It was a signal that this was not a simple joint problem but an internal medicine problem somewhere in the body that needed to be checked quickly. I immediately requested a gastroenterology consultation, and gastroenterology performed chest and abdominal CT.

The cause found on CT: liver abscess

CT confirmed a liver abscess, a pocket of pus inside the liver. The patient was transferred straight to a tertiary hospital and began inpatient treatment.

Why does a sore liver cause shoulder pain?

The reason is referred pain. Referred pain is the phenomenon of feeling pain in a different part of the body, away from where the real problem is. A well-known example is the pain in the left arm or jaw during a heart attack.

Figure. A simplified drawing of how diaphragmatic referred pain works.

For that reason, problems around the liver, gallbladder and diaphragm can show up as pain at the tip of the right shoulder or along the ridge between neck and shoulder. The trapezius area that hurt in this patient also overlaps the region served by the C4 nerve. The same thing happens on the left: when the left diaphragm is irritated, for example by a spleen injury, and the left shoulder hurts, it is called Kehr's sign.

The liver is on the right, so it usually shows up as right shoulder pain. Why this patient had pain on both sides is hard to say for certain, but we can consider the possibility that the inflammation was widespread or that a systemic inflammatory response was also at work.

Such cases are reported steadily. In a Korean case published in the Korean Journal of Pain, a 31-year-old man who improved after a bursa injection for right shoulder pain returned three weeks later with right upper abdominal pain and fever and was diagnosed with a liver abscess. An American emergency medicine journal also published a case in which multiple liver abscesses were found in a 92-year-old who came with pain in the right shoulder, flank and upper abdomen. It means that pain easing briefly after an injection does not necessarily mean the cause has been solved.

What kind of disease is a liver abscess?

A liver abscess is a disease in which bacteria enter the liver and form a pocket of pus. It can arise through bile duct disease such as gallstones, bacteria can enter from the intestine through the bloodstream, and in many cases no cause is found. It is more likely the older you are and with diabetes or weakened immunity.

In Korea, Taiwan and elsewhere in Asia, Klebsiella pneumoniae is the main causative organism. A liver abscess due to this organism can rarely cause an “invasive liver abscess syndrome” that spreads to other organs such as the eye (endophthalmitis), the meninges of the brain or the lungs, so quick diagnosis and treatment are important.

The typical symptoms are fever and abdominal pain, but because symptoms and blood test findings are not specific, it is sometimes mistaken for another disease at first. Diagnosis is by ultrasound or CT, which can confirm it in more than 90%. Treatment is usually 2–6 weeks of antibiotics, and when the abscess is large, percutaneous drainage, in which a thin tube is placed through the skin to drain the pus. Abscesses smaller than 3–5 cm are sometimes treated with antibiotics alone.

Shoulder pain: when to suspect other causes

What I want to stress first is that most shoulder pain is a problem of the shoulder joint and tendons. Internal organs are rarely the cause. But if you have features like those below, we should look at the whole body, not only the shoulder.

Items such as fever, weight loss and a history of cancer are also listed as warning signs that call for further tests in the British Medical Journal (BMJ) primary care guidance on shoulder pain.

In closing

• If the shoulder X-ray is normal but the pattern of pain is not typical, causes outside the shoulder should also be considered.
• Problems of the liver, gallbladder and diaphragm can be felt as pain at the top of the shoulder through the phrenic nerve (C3–C5).
• In this patient a simple blood test showed abnormal inflammation and liver markers, which led to a quick CT diagnosis of liver abscess and then to treatment.
• If fever, weight loss, pain that worsens with breathing, or upper abdominal pain come with it, please be sure to mention it at your visit.

I am a doctor who looks at shoulders, but I try not to look only at the shoulder. I wish the patient a speedy recovery.

This article is general medical information based on a single case. Most shoulder pain is a problem of the shoulder itself, and the exact cause should be confirmed through an examination.