Shoulder case

[1FutureDPT]

Any thoughts as to possible diagnosis guys?

• Severe L shoulder pain with any movements-more so with abduction, flexion, internal and external rotation, less with extension
• Complaints of pain that radiates all the way to wrist (at times) but no complaints of neck pain at rest or with palpation-severe amount of pain demonstrated at shoulder joint with most movements discouraged diagnosis of nerve pain--no increased amount of pain with nerve impingement tests
• Report of pain most commonly at site lateral aspect of upper third of arm that radiates in a circumferential manner
• ROM limited by pain - relatively full in extension, about 90* in flexion, limited in ER and IR (can't remember degrees)
• X-rays negative, no MRI performed
• Pain pills and morphine injection relatively ineffective
• Impingement test positive-however most movements painful so could be false
• MMT of shoulder on average 4+ but with pain (more pain with resisting ER and I think resisting flexion)

Do you guys have any thoughts/suggestions/comments?

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[1FutureDPT]

Forgot to put some other information.

• No history of trauma, or previous shoulder issues. No clear mechanism of injury noted.
• Pain: 7/10

 

[Fiveoboy11]

Not enough information. The referring diagnosis is nerve pain? Who diagnosed that? Age/sex of patient? Any abnormal reflexes in the UE? Myotome weakness? Altered sensation? Symptom changes with neck ROM? With neck traction? Are the pains down the arm to the wrist in a dermatomal or peripheral nerve pattern? Do the pains abruptly stop at the wrist or to the hand/fingers too? Is there a positive drop arm test? Sounds like this person has a lot of guarding due to pain. Does the pain subside with rest or is it super irritated? Is the end feel of PROM guarding or not? What does he/she do for work/hobby? What is AROM into abd? Is there an arc of pain with AROM abd? When did the symtomps start? Abruptly i.e. When they woke up one day or over days to weeks? What do you think it might be? Adhesive capsulitis?

I would really like to hear what Truthseeker and Jesspt think...

 

[PT2Bee]

Waddell signs lol. But if everything hurts and no structural cause can be found/no MOI, I'd be curious to see an MRI or refer out. 7/10 pain and morphine injections don't touch it?? Sounds odd to me. On a side note, at least how we were taught, you can't grade an MMT if pain is present...you can't even do one if an isometric contraction is painful. Was anyone else taught differently??

 

[1FutureDPT]

Subject is a 28 y/o female

5’5”; 230 lbs.

Occupation: sitter at hospital, student at university in a computer field
Hobbies: TV, computer, Ipad
Posture: IR shoulders


No nerve pain is not the medical diagnosis; medical diagnosis is inconclusive—just “theories” from mid-level providers

The only possible MOI to note: Developed of pain noted after lifting arms in church-but may not be correlated with present complaint, carried heavy bag for short periods of time leading up to injury, went on long drive, slept on relatively firm hotel bed


Report is that pain developed on Saturday—she could lift her arm through full ROM Saturday with mild/moderate pain—next day was in unbearable pain and taken to ER. At ER was given valium and injected with intramuscular anti-inflammatory with no significant long-term symptom improvement. She was given a sling and valium upon discharge. She returned to ER Monday secondary to being unable to schedule appointment with orthopedic clinic where she received a morphine injection.


She demonstrated a lot of guarding with attempt to move arm through ROM.

Abduction ROM: ~90*

No sensation deficits noted.

When pain radiates it stops at wrist in no particular dermatomal nature.

During painful arc test patient pain noted almost immediately as she begins to move through ROM

No symptom change with neck ROM; no symptom change with compression/distraction

Drop arm test: negative

 

[1FutureDPT]

I found the presentation to be extremely odd but I know this person very well; she is dramatic at most, but I definitely think it is a legitimate musculoskeletal issue.

 

[Fiveoboy11]

Weird, I don't know. I'd be a lot less surprised if it were after a car accident. I've seen a couple shoulder cases in younger women where I suspected their lover of abuse, does she have any tag along clingies accompanying her to the clinic? Also sounds like she has poor coping or is catastrophizing.

 

[riseboi]

Any findings re: thoracic/rib mobility?

 

[jesspt]

Any PMH that is significant? Diabetes?

You need to get her pain levels down to a more manageable state prior to trying any provocative testing. If all motions hurt, than your impingement tests, labral tests, etc. likely won't tell you much.

Gentle manual therapy, avoid positions and movements that hurt.

Also, without a histroy of trauma, and with fairly good RC strength, you could likely encourage her by telling her that her symptoms ar enot likely due to any traumatic rotator cuff tendon issues, etc. Sometimes, patients can get themselves pretty "wound up" by worrying about all of the various things that could be wrong with them. It helps (sometimes) to offer some assurance that some of these things are unlikely given the physical exam results.

 

[1FutureDPT]

Any PMH that is significant? Diabetes?

You need to get her pain levels down to a more manageable state prior to trying any provocative testing. If all motions hurt, than your impingement tests, labral tests, etc. likely won't tell you much.

Gentle manual therapy, avoid positions and movements that hurt.

Also, without a histroy of trauma, and with fairly good RC strength, you could likely encourage her by telling her that her symptoms ar enot likely due to any traumatic rotator cuff tendon issues, etc. Sometimes, patients can get themselves pretty "wound up" by worrying about all of the various things that could be wrong with them. It helps (sometimes) to offer some assurance that some of these things are unlikely given the physical exam results.

Any thoughts as to possible diagnosis guys?

• Severe L shoulder pain with any movements-more so with abduction, flexion, internal and external rotation, less with extension
• Complaints of pain that radiates all the way to wrist (at times) but no complaints of neck pain at rest or with palpation-severe amount of pain demonstrated at shoulder joint with most movements discouraged diagnosis of nerve pain--no increased amount of pain with nerve impingement tests
• Report of pain most commonly at site lateral aspect of upper third of arm that radiates in a circumferential manner
• ROM limited by pain - relatively full in extension, about 90* in flexion, limited in ER and IR (can't remember degrees)
• X-rays negative, no MRI performed
• Pain pills and morphine injection relatively ineffective
• Impingement test positive-however most movements painful so could be false
• MMT of shoulder on average 4+ but with pain (more pain with resisting ER and I think resisting flexion)

Do you guys have any thoughts/suggestions/comments?

Any PMH that is significant? Diabetes?

You need to get her pain levels down to a more manageable state prior to trying any provocative testing. If all motions hurt, than your impingement tests, labral tests, etc. likely won't tell you much.

Gentle manual therapy, avoid positions and movements that hurt.

Also, without a histroy of trauma, and with fairly good RC strength, you could likely encourage her by telling her that her symptoms ar enot likely due to any traumatic rotator cuff tendon issues, etc. Sometimes, patients can get themselves pretty "wound up" by worrying about all of the various things that could be wrong with them. It helps (sometimes) to offer some assurance that some of these things are unlikely given the physical exam results.

To update: she received a steroid injection and symptoms have improved in less than 12 hours. PA thinks it could be tendinitis. If condition does not fully improve in 2 weeks she will be scheduled for MRI or physical therapy according to the PA.

 

[jesspt]

To update: she received a steroid injection and symptoms have improved in less than 12 hours. PA thinks it could be tendinitis. If condition does not fully improve in 2 weeks she will be scheduled for MRI or physical therapy according to the PA.

Several things:

1. Intra-articular steroid injections really don't start impacting the localized inflammatory process until around 3 days. If they also injectd her with a short acting anesthetic, that may be responsible for her rapid symptom reduction.
2. Tendonitis is just an educated guess unless the PA examined her after her symtpom reduction. It could still just as easily be other conditions such as adhesive capsulitis.
3. Why no PT in the intervening 2 weeks? If she really has pain reduction, this could be your window of opportunity to really start helping her?
4. What does she want to do? If she is not wanting surgery, nothing that is found on the MRI will be overly helpful in guiding her course of conservative treatment.

 

[SwampPT]

Any thoughts as to possible diagnosis guys?

• Severe L shoulder pain with any movements-more so with abduction, flexion, internal and external rotation, less with extension
• Complaints of pain that radiates all the way to wrist (at times) but no complaints of neck pain at rest or with palpation-severe amount of pain demonstrated at shoulder joint with most movements discouraged diagnosis of nerve pain--no increased amount of pain with nerve impingement tests
• Report of pain most commonly at site lateral aspect of upper third of arm that radiates in a circumferential manner
• ROM limited by pain - relatively full in extension, about 90* in flexion, limited in ER and IR (can't remember degrees)
• X-rays negative, no MRI performed
• Pain pills and morphine injection relatively ineffective
• Impingement test positive-however most movements painful so could be false
• MMT of shoulder on average 4+ but with pain (more pain with resisting ER and I think resisting flexion)

Do you guys have any thoughts/suggestions/comments?

 

[Fiveoboy11]

I haven't started school yet, but I would say it's a torn rotator cuff. Probably either the Teras Minor or Infraspinatus or both. However, I did tear my labrum in football and I had very similar symptoms. Can you ask for an MRI? That would show you for sure.

Shut up

 

[Fiveoboy11]

Several things:

1. Intra-articular steroid injections really don't start impacting the localized inflammatory process until around 3 days. If they also injectd her with a short acting anesthetic, that may be responsible for her rapid symptom reduction.
2. Tendonitis is just an educated guess unless the PA examined her after her symtpom reduction. It could still just as easily be other conditions such as adhesive capsulitis.
3. Why no PT in the intervening 2 weeks? If she really has pain reduction, this could be your window of opportunity to really start helping her?
4. What does she want to do? If she is not wanting surgery, nothing that is found on the MRI will be overly helpful in guiding her course of conservative treatment.

I agree. I'd advocate for a physical therapy reassessment even if its a placebo effect from the injection. I.e can you now screen for instability? Is there any clicking or clunking or popping, especially that is new? If she is a person who is "wound up" as jesspt said maybe from a relatively minor problem, then getting a valid assessment asap and then treatment based on that asap makes a lot of sense to me. I.e. Movement is ok, a little pain is ok, you're not going to damage your should by moving it like this. Seems to me these type of people may need PT plus CBT or some close variant and often the sooner the better.