Download Shoulder Cases

Longitudinal Orientation
Shoulder
Case 1:
A 38 year old male began having shoulder pain a few days after doing landscaping
around his home. There was no acute injury and the pain has slowly progressed to the
point of waking him at night. He states it is most painful when he reaches in his back
pocket or reaches overhead. Occasional Tylenol hasn’t helped.
Pertinent History: HTN, takes atenolol 50mg qd
Exam: FROM, pain over coracoid and bicipital tendon
Xray: is it necessary?
Questions for Discussion:
1.
2.
3.
4.
5.
6.
What is the diagnosis?
What are the key findings in the history and physical exam?
What maneuver might help with the diagnosis?
Is imaging indicated?
How should this patient be treated?
What is the expected course of this illness?
Answers:
1. bicipital Tendonitis: an inflammation of the long head of the biceps tendon as
it passes through the bicipital groove of the anterior humerus. Repetitious
lifting and overhead reaching lead to inflammation, microtearing and, if
untreated, degenerative change.
2. nighttime pain might suggest impingement; pain over bicipital tendon; recent
landscaping…likely doing repetitious lifting/overhead reaching.
3. Yergason Test: Patients with rotator cuff tendonitis frequently have
concomitant inflammation of the biceps tendon. This test evaluates the biceps
tendon. The patient’s elbow is flexed to 90 degrees with the thumb up. The
examiner grasps the wrist, resisting attempts by the patient to actively supinate
the arm and flex the elbow. Pain with this maneuver indicates biceps
tendonitis.
4. no imaging indicated; review normal shoulder film; www.meded.virginia.edu/courses/rad/ext/index.html
a. click on shoulder, click on normal anatomy
5. ice over deltoid muscle for 15 – 20 minutes each day, NSAIDS (3 – 4 weeks),
rest, injection if unresponsive to these; home exercise: weighted pendulum
(hold gallon jug in affected hand and gently swing the arm); PT: ultrasound
iontophoresis; orthopedic consultation if sx persist for greater than 3 months
despite the above mentioned treatments
6. gradual improvement over 3 – 4 weeks if above directions followed, some
require surgical consultation.
Case 2:
A 28 year old male playing football with some buddies over the weekend fell onto his
shoulder. Immediate pain developed and was diffuse. The patient was not able to play
any more. He has put ice on it for 48 hours and now sees you for evaluation.
Pertinent History: healthy male, no previous medical conditions or surgeries.
Exam: limited abduction 90 degrees; the most pain occurs with flexion, internal
rotation. There is extreme pain when palpating the AC joint.
Xray: normal
Questions for Discussion:
1.
2.
3.
4.
5.
6.
What is the diagnosis?
What are the key findings in the history and physical exam?
What maneuver might help with the diagnosis?
Is imaging indicated?
How should this patient be treated?
What is the expected course of this illness?
Answers:
1. Acromioclavicular joint sprain: a common site of injury in athletes and active
persons. The classic cause of an AC joint injury is a direct blow to the
acromion with the humerus in an adducted position.
2. pain with flexion and internal rotation, ie, the “cross arm test”: sharp pain at
the AC joint if the patient holds the arm out straight and brings it across the
chest.
3. see above explanation
4. yes, the uninjured side also should be imaged for comparison.
5. there are 6 grades of AC joint injuries (Rockwood classification). Grades I
and II are treated nonoperatively (symptomatic relief, sling, ice, NSAIDS),
grades IV through VI are treated surgically.
6. most patients are able to return to sports once pain-free. Some may have
nuisance symptoms such as clicking and pain with push-ups.
Case 3:
A 41 year old male brick layer complains of 3 week history of left shoulder pain. No
acute injury. No history of shoulder problems. No recent changes in activities. He states
he just woke up with it one morning.
Pertinent History: Pain aggravated by turning his head to the left. Aches all the
time with intermittent intense pain. Trouble sleeping because of pain.
Physical Exam: Full shoulder range of motion. Limited left lateral rotation of neck.
Tender trigger points in left paracervical muscles and left trapezius.
Xrays: are they needed?
Questions for Discussion:
1.
2.
3.
4.
5.
6.
What is the diagnosis?
What are the key findings in the history and physical exam?
What maneuver might help with the diagnosis?
Is imaging indicated?
How should this patient be treated?
What is the expected course of this illness?
Answers:
1. Cervical and trapezius muscle strain with spasm.
2. full range of motion, no injury, tender muscles on exam
3. check rotator cuff due to history of repetitive motion with employment as
brick layer. Spurling’s test to rule out cervical nerve root disorder (spine
extended with head rotated to affected shoulder while axially loaded)
4. NO
5. stretching exercises, pain medicines, muscle relaxants, consider trigger point
injections, consider PT for ultrasound
6. similar to other muscle strain/spasm…heals eventually
Case 4:
A 36 year old female presents with a 2 week history of increasing right shoulder pain.
Pain started after she painted the living room. No trauma. Pain has begun to wake her at
night.
Pertinent History: healthy, no other problems, no medications
Exam: limited range of motion in flexion and abduction. There is tenderness under the
tip of the acromion on abduction. No weakness.
Xray: are they needed?
Questions for Discussion:
1.
2.
3.
4.
5.
6.
What is the diagnosis?
What are the key findings in the history and physical exam?
What maneuver might help with the diagnosis?
Is imaging indicated?
How should this patient be treated?
What is the expected course of this illness?
Answers:
1. Bursitis, also known as impingement syndrome, may also be called rotator
cuff tendonitis. This is the gradual onset of anterior and lateral shoulder pain
exacerbated by overhead activity (patient was painting) . This is the
inflammation of the subacromial bursa and underlying rotator cuff tendons.
Occurs in middle-aged patients. Caused by repeated mechanical insult as the
tendon passes under the coracoacromial arch.
2. Night pain and difficulty sleeping on the affected side are common.
3. Hawkins’ test: forward flexion of the shoulder to 90 degrees and internal
rotation (indicating Supraspinatus tendon impingement); Neer’s sign: place
the arm in forced flexion with the arm fully pronated, scapula stabilized with
one of examiner’s hands.
4. radiographs of the shoulder are usually normal.
5. rest, NSAIDS, stretching program. Can consider steroid injection at
subacromial space.
6. pain can be persistent or recurrent. Rotator cuff tendonitis can progress to a
full-thickness tear. If there is significant weakness or the rotator cuff or
failure of 2 to 3 months rehab/conservative tx, refer.
Case 5:
A 40 year old male fell while skiing. He had mild post-fall pain in his right shoulder.
That night while reaching for a pitcher of beer with an extended arm he notices pain and
weakness when attempting to lift the pitcher. He presents 2 weeks later with increasing
pain and persistent weakness.
Pertinent History: healthy, no medications
Exam: full range of motion, very weak supraspinatous and infraspinatous
Xray: is it necessary?
Questions for Discussion:
1.
2.
3.
4.
5.
6.
What is the diagnosis?
What are the key findings in the history and physical exam?
What maneuver might help with the diagnosis?
Is imaging indicated?
How should this patient be treated?
What is the expected course of this illness?
Answers:
1. rotator cuff tear
2. a key finding is pain associated with weakness. Weakness, catching and
grating are common symptoms, especially when lifting the arm overhead.
3. supraspinatus: empty can test; Infraspintous/teres minor exam: pt externally
rotates against resistance with elbows flexed and at sides. Subscapularis: lift
off test.
4. xrays are usually normal; with a large tear, the AP radiograph may reveal a
high-riding humerus relative to the glenoid. MRI is the imaging study of
choice if the dx is equivocal or surgery is being considered.
5. NSAIDS, PT, stretching and strengthening exercises and avoid overhead
activities. Steroid injection should be used cautiously…can relieve
inflammation but also weakens an already ailing tendon. Pts with significant
symptoms and failed rehab may be referred for surgery.
6. After 6 weeks of nonoperative therapy, pt should be greatly improved.
Case 6:
A 52 year old male complains of a 3 week history of increasing pain in his right shoulder.
He also notices that his shoulder feels weak. Otherwise, the patient is healthy, in not on
any medications. He had a complete physical 3 months ago which was normal. His lab
work, including a PSA and TSH, was normal.
Pertinent History: numb and tingling in hand, thumb and first 2 fingers.
Compression test illicits similar symptoms.
Exam: full range of motion; impressive deltoid weakness.
Xray: is this necessary?
Questions for Discussion:
1.
2.
3.
4.
5.
6.
What is the diagnosis?
What are the key findings in the history and physical exam?
What maneuver might help with the diagnosis?
Is imaging indicated?
How should this patient be treated?
What is the expected course of this illness?
Answers:
1. C5 -6 disc herniation (C6 root): consider in patients who have shoulder pain
that does not respond to conservative tx.
2. compression test positive (Spurling’s test); weakness of shoulder, neuropathy
symptoms
3. Spurling’s Test: cervical spine is place in extension and the head is rotated
toward the affected shoulder. An axial load is then placed on the spine.
Reproduction of the patient’s shoulder or arm pain indicates possible cervical
nerve root compression. Patients may state that they can relieve the pain by
placing their hands on top of their head as this decreases tension on the
involved nerve root.
4. xray may show regions of spondylosis or degenerative involvement of the
disk and the facet. MRI can confirm the dx but not necessary in routine care.
EMG can help identify the location of neurologic dysfunction and help in
preoperative planning.
5. with radicular pain, a short course of steroids or NSAIDS. Cervical traction
and PT are helpful in the first 2 – 4 weeks.
6. spontaneous resolution of all or most symptoms occurs within 6 to 12 weeks
in most patients. Failure of nonoperative treatment, atrophy, motor weakness
or signs of myelopathy may require surgical evaluation.