Shoulder pain: 3 cases to test your diagnostic skills

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Applied Evidence

Shoulder pain: 3 cases to test your diagnostic skills

J Fam Pract. 2012 January;61(1):16-22

By

Nilesh Shah, MD

Tom Bartsokas, MD

Ryan Wagner, MD

Before you conclude that rotator cuff tendinitis is the cause of your patient’s pain or order a range of imaging studies, take a look at these cases—and the take-away message each provides.

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References

1. Van der Windt DA, Koes BW, De Jong BA, et al. Shoulder disorders in general practice: incidence, patient characteristics, and management. Ann Rheum Dis. 1995;54:959-964.

2. Johansson K, Adolfsson L, Foldevi M. Attitudes toward management of patients with subacromial pain in Swedish primary care. Fam Pract. 1999;16:233-237.

3. Kibler WB, McMullen J. Scapular dyskinesis and its relation to shoulder pain. J Am Acad Orthop Surg. 2003;11:142-151.

4. Kibler WB. The role of the scapula in athletic shoulder function. Am J Sports Med. 1998;26:325-337.

5. Vanermen B, Aertgeerts M, Hoogmartens M, et al. The syndrome of Parsonage and Turner. Discussion of clinical features with a review of 8 cases. Acta Orthop Belg. 1991;57:414-419.

6. Misamore GW, Lehman DE. Parsonage-Turner syndrome (acute brachial neuritis). J Bone Joint Surg. 1996;78:1405-1408.

7. Stevenson J, Trojian T. Evaluation of shoulder pain. J Fam Pract. 2002;51:605-611.

8. Miller JD, Pruitt RN, McDonald TJ. Acute brachial plexus neuritis: an uncommon cause of shoulder pain. Am Fam Physician. 2000;62:2067-2072.

9. Eubanks JD. Cervical radiculopathy: nonoperative management of neck pain and radicular symptoms. Am Fam Physician. 2010;81:33-40.

10. Malanga GA, Landes P, Nadler SF. Provocative tests in cervical spine examination: historical basis and scientific analyses. Pain Physician. 2003;6:199-205.

11. Huston M, Ellis R. eds. Textbook of Musculoskeletal Medicine. Oxford, UK: Oxford University Press; 2005.

12. Mahaffey BL, Smith PA. Shoulder instability in young athletes. Am Fam Physician. 1999;59:2773-2782, 2787.

13. Petron DJ, Khan U. The shoulder and upper extremity. In: McKeag DB, Moeller JL. ACSM’s Primary Care Sports Medicine. 2nd ed. Philadelphia, Pa: Wolters Kluwer, Lippincott Williams & Wilkins; 2007:359–373.

14. Woodward TW, Best TM. The painful shoulder: part I. clinical evaluation. Am Fam Physician. 2000;61:3079-3088.

15. Kelly BT, Kadrmas WR, Speer KP. The manual muscle examination for rotator cuff strength: an electromyographic investigation. Am J Sports Med. 1996;24:581-588.

16. Murrell GA, Walton JR. Diagnosis of rotator cuff tears. Lancet. 2001;357:769-770.

17. Richards RR, An KN, Bigliani LU, et al. A standardized method for the assessment of shoulder function. J Shoulder Elbow Surg. 1994;3:347-352.

18. Neer CS, Welsh RP. The shoulder in sports. Orthop Clin North Am. 1977;8:583-591.

19. Hawkins RJ, Kennedy JC. Impingement syndrome in athletics. Am J Sports Med. 1980;8:151-163.

20. Itoi E, Kido T, Sano A, et al. Which is more useful, the “full can test” or the “empty can test,” in detecting the torn supraspinatus tendon? Am J Sports Med. 1999;27:65-68.

21. Boettcher CE, Ginn KA, Cathers I. The ‘empty can’ and ‘full can’ tests do not selectively activate supraspinatus. J Sci Med Sport. 2009;12:435-439.

Shoulder pain is a common reason for visits to primary care physicians, who are most likely to diagnose it as rotator cuff tendinitis^1,2—often erroneously. The complexity of the joint and the overlapping pathologies that may present as shoulder pain highlight the need to take a closer look when dealing with this diagnostic challenge.

Often, a targeted medical history—including the mechanism of injury and pain-provoking and pain-relieving factors—and a problem-based physical examination (incorporating many of the maneuvers highlighted in the text and tables that follow) will lead to an accurate diagnosis without the need for imaging studies. We recommend that imaging be reserved for patients who don’t respond to conventional treatments, cases in which the diagnosis is in doubt, and instances in which surgical intervention is being considered.

The 3 cases* that follow, and the take-away message incorporated in each, will give you an opportunity to test—and to hone—your shoulder pain diagnostic skill.

CASE 1 The history: Jesse, a 17-year-old student who’s active in football and track, came in during track season complaining of severe left shoulder pain. He denied any traumatic event or previous injury to the shoulder, but reported that any motion involving the shoulder caused pain. It hurt at night, the patient said, when he lay on his left side.

The physical: No muscle atrophy, redness, or swelling was evident, nor was there any indication of asymmetry or ecchymosis in the affected area. Jesse’s neck range of motion was normal; he had a very hard time with any active motion of the shoulder, however, because of the pain.

Evaluation of scapular motion demonstrated scapular dyskinesis^3,4 without winging. Passive motion of the glenohumeral joint was much better than active motion. Strength testing appeared to be grossly intact but was limited by the pain. Shoulder impingement testing was positive. Sensation and deep tendon reflexes were intact.

Patients' names have been changed to protect their privacy

What’s the diagnosis?

Subacromial bursitis, suggested by the patient’s pain and altered scapular motion, was our working diagnosis, and we administered a subacromial injection of corticosteroid with lidocaine, for diagnostic as well as therapeutic purposes. Reexamination after the injection revealed immediate partial improvement in resting pain, range of motion, and strength. We referred Jesse to physical therapy with a focus on scapular stabilization and rotator cuff strength.

Three months later, Jesse returned to our office, complaining of weakness in his left shoulder. The pain had subsided a week after his first appointment, so he’d never gone to physical therapy. The weakness, which he had first noticed about 2 months after starting a lifting program in preparation for football season, was limited to resistance exercises, especially overhead shoulder presses and bench press. There were no other changes in his history, and he reported no reinjuries.

Physical examination revealed atrophy of the supraspinatus and infraspinatus muscles (FIGURE 1) and external rotation and shoulder abduction (in the scapular plane) resistance tests revealed weakness of these muscles. There was no scapular winging. The cervical spine exam was normal, and neurovascular status was intact in both upper extremities.

FIGURE 1
Severe shoulder pain, followed by weakness

Physical examination reveals atrophy of the patient’s supraspinatus (^) and infraspinatus (+) muscles.

New evidence points to nerve injury. Based on Jesse’s current history and physical, nerve injury was our new working diagnosis. (We considered the possibility of a rotator cuff tear, but this was not corroborated by the history.)

We ordered an electromyogram/nerve conduction velocity study to localize the lesion. The test revealed a brachial plexitis/neuritis (also known as Parsonage-Turner syndrome or brachial amyotrophy). The etiology of most atraumatic brachial plexopathies is unknown, and most are thought to be viral or autoimmune in nature.^5,6

A classic case of Parsonage-Turner syndrome. The typical presentation of Parsonage-Turner syndrome (like Jesse’s) is one of acute, intense shoulder pain for no known reason. After 1 to 3 weeks, the pain resolves and the patient is left with weakness, usually of the supraspinatus and infraspinatus muscles. The weakness typically resolves with time, but full resolution may take 6 to 9 months.^5,6 (In Jesse’s case, it took about 6 months.)

FAST TRACK

Carefully assess the cervical region for the possibility of nerve root impingement and radicular dysfunction masquerading as a primary shoulder disorder.

The take-away message: Look beyond the shoulder
As this case illustrates, not all shoulder pain originates in the shoulder. When evaluating shoulder pain, it is essential to consider other causes. The differential diagnosis for shoulder pain includes cervical spine disorders, cholecystitis (right shoulder), diaphragmatic irritation (eg, in the case of splenic rupture, usually involving the left shoulder), cardiac disease, and thoracic outlet syndrome.⁷