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

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References

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Evaluation of the cervical spine should be part of a complete shoulder examination. It is vital to follow a systematic approach that carefully assesses the cervical region for the possibility of nerve root impingement and radicular dysfunction masquerading as a primary shoulder disorder. (TABLE 1^8,9 details pain and sensory distribution patterns, reflex involvement, and potential motor impairments associated with various spinal nerve root levels.)

TABLE 1
Assessing the cervical spine

Nerve root	Pain distribution	Sensory distribution	Reflex changes	Motor involvement
C5	Lateral neck/upper trapezius	Lateral arm	Biceps	Deltoid, biceps
C6	Base of neck/upper trapezius to superior glenohumeral joint	Radial aspect of distal forearm, thenar eminence, and index finger	Brachioradialis	Biceps, extensor carpi radialis longus and brevis (wrist extension)
C7	Base of neck, almost entire upper quadrant of the back	Third finger	Triceps	Triceps, wrist flexion, finger extension
C8	No shoulder pain	4th and 5th fingers, distal half of forearm (ulna side)	None	Finger flexion (grip strength)
Adapted from: Miller JD, et al. Am Fam Physician. 2000⁸; Eubanks JD. Am Fam Physician. 2010.⁹

Practitioners should develop their own approach to “clearing the neck.” A logical order is to note posture of the head/neck/shoulders, observe active motion, perform palpation and provocative tests, and then assess neurologic function with sensation/reflex/strength testing. Provocative tests that can help to identify cervical involvement relating to shoulder pain include Spurling’s maneuver, axial compression test, abduction relief sign, and Lhermitte’s sign.^10,11

CASE 2 The history: Mark, a 17-year-old, right-handed volleyball player, presented with right shoulder pain, which he felt whenever he spiked or served the ball. The pain started last season, Mark said, diminished during the months when he wasn’t playing, then got progressively worse as his activity level increased. The pain was in the posterior aspect of the shoulder.

The physical: Physical examination revealed a well-developed, but thin (6’4”, 170 pounds) young man who was not in distress. The general examination was benign, and a joint-specific exam showed no asymmetry or atrophy on inspection and no tenderness to palpation over the posterior and anterior soft tissues of the right shoulder. Rotator cuff testing yielded intact strength for all 4 muscles, but external rotation and supraspinatus testing elicited pain. The crank test, drawer sign, load and shift test, relocation test, and sulcus sign, detailed in TABLE 2,^12-14 were all positive for shoulder instability; the Clunk and O’Brien tests were negative, and the contralateral shoulder exam was within normal limits. General joint laxity was observed, with the ability to oppose the thumb to the volar forearm and hyperextension noted in both elbows and knees. There were no outward signs of connective tissue disease.

Because of the chronicity of Mark’s pain and the progressive nature of his symptoms, we ordered radiographs, including anterior-posterior, lateral axillary, and scapular Y views. These films showed a nearly skeletally mature male without bony abnormalities; the humeral head was well located in the glenoid.

TABLE 2
Testing for shoulder instability^12-14

Test	Procedure	Positive result/implication
Apprehension	Patient supine, arm abducted 90º, externally rotated with anteriorly directed force applied to humeral head	Pain/apprehension with force suggests anterior instability
Relocation*	Patient supine, posteriorly directed force applied to humeral head	Relief with force suggests anterior instability
Crank	Patient sitting, arm abducted 90º, elbow flexed to 90º, humerus supported with forced external rotation	Pain/apprehension with forced external rotation suggests anterior instability
Load and shift	Patient supine, arm held by examiner and abducted 90º, force applied along axis of humerus to "seat" the humerus within the glenoid, followed by anterior force directed to humeral head	Pain and appreciable translation felt with anterior force suggest anterior instability
Drawer	Patient sitting, arm at side, proximal humeral shaft grasped by examiner, seating the humeral head within the glenoid then applying anterior translational force	Pain and appreciable translation felt with anterior force suggest anterior instability
Sulcus	Patient sitting, arm at side, forearm grasped by examiner with an inferior/caudally directed force applied	Sulcus or depression seen inferior to acromion as humeral head subluxes posteriorly, pathognomonic for multidirectional instability
Clunk	Patient supine, examiner grasps at forearm and humeral shaft, with humeral head seated within the fossa, taking the arm through passive ROM from extension through forward flexion	Clunk sound or clicking sensation suggests labral tear
O’Brien	Patient sitting, arm is forward flexed to 90º and fully adducted and internally rotated; patient resists downward motion. If pain is elicited, the maneuver is repeated in external rotation	Pain elicited with resisted downward motion in internal rotation but relieved with external rotation suggests labral pathology
*Perform only if apprehension test is positive. ROM, range of motion

What’s the diagnosis?

Multidirectional instability with recurrent subluxations and probable acute rotator cuff tendinitis was our provisional diagnosis. Treatment focused on physical therapy, with a concentration on scapular stabilization and rotator cuff strengthening.

Shoulder instability is relatively common and represents a spectrum of disorders ranging from dislocation to subluxation to simple laxity.^12,13 A complete loss of humeral articulation within the glenoid fossa is evidence of dislocation, whereas subluxation includes approximation of the humeral head to the limits of the glenoid rim. Dislocation typically results from trauma, whereas subluxation can be the result of microtrauma and repetitive overuse injury. Anterior instability is the most common type and is reported in as many as 95% of all dislocations.¹³