CHIR12007

Clinical Assessment and Diagnosis

Portfolio Exercises Week 7
Exercise 1
52 year old male presents with right shoulder pain and inability to lift his arm for
about 5 months. He has a history of recurrent shoulder injury and has noted
increasing shoulder stiffness and weakness. He has worked as a logging truck
driver for the last 20 years. Lately he is unable to throw the chains because his
shoulder is too sore so his GP has put him off work for 3 weeks. He explains the
pain is general over the shoulder and upper arm. There no pain further down the
arm and no pins, needles, tingling or numbness. He enjoys his job and is missing
the camaraderie. He is otherwise fit and healthy. No history of red flags
Vital signs are normal. His arm is held by his side, elbow in extension, forearm
midprone. You noted there is muscle wasting over the scapula on the right
compared to left. No scars or masses are seen. There’s localized tenderness over
the greater tuberosity and the AC joint, no evidence of altered contour at the AC
joint {not an AC jt origin}. There is coarse crepitation over the shoulder on
movement
Cervical spine examination is unrewarding – not likely to be a brachial plexus
injury which generally has some form of neck pain. Ie. Suprascapular (C5-C6) –
motor to supraspinatus and infraspinatus presents with increased pain with
cervical rotation to the opposite side)
Shoulder ROM
Flexion A 180° P 180°
Extension A 50° P 50°
Abduction A 0° P 140°
Adduction A 45° P 45°
Internal rotation A 30° P45°
External rotation A 90° P 90°
You note that when the patient attempts abduction there is a shrug of the
shoulder as he attempts and is unable to. When you passively abduct the arm to
40°, the patient is able to abduct further on his own but this is painful to about
120°
Neurologic exam is normal
Muscle strength – Bicep 5+, Tricep 5+, Supraspinatus 2+, Infraspinatus 4+,
Subscapularis 4+
Drop arm + - indicates supraspinatus muscle tear
Neer’s empty can + - indicates overuse injury to supraspinatus muscle
sometimes the biceps tendon
Hornblower’s sign + - may indicate infraspinatus tear (as external rotation is
normal, unlikely infraspinatus problem)
What is your working diagnosis?
Supraspinatus partial tear

- Pain when lifting the arm/ overhead activities

- Signs of wasting at the supraspinatus fossae
- Weakness when lifting or rotating the arm or on external rotation of the humerus with the
arms side
- Discrepancy of active and passive movement
- Movement on attempting arm abduction is shrugging
- Tenderness over the greater tuberosity
- Pain located on anterior shoulder
- Positive drop-arm sign
- Crepitus
- Empty can test for the rotator cuff forces impingement of the greater tuberosity on the
acromion. A positive empty can test in a 50-year-old patient almost certainly represents a
rotator cuff tear.

Give 2 differential diagnoses?

Maybe supraspinatus tendinitis/tendinopathy

- Doesn’t say resisted abduction or external rotation is painful

- Can reach higher than 90o of abduction and flexion of the upper
arm
- Pain appears to be constant- no pattern of exacerbation and
remission
- Doesn’t radiate
- Doesn’t disturb sleep
- Painful arc (at 120o)
- ADL activities can cause a lot of pain
- Positive emptying the can sign

Exercise 2
The following questions will give you a brief history. Based on this weeks
lectures, using only what is presented you will assume there are no additional
findings and formulate a diagnosis.

Short Histories

A. 55 year old male, six months right shoulder pain and inability to use
the right shoulder due to restricted movements. History of trauma
to the right shoulder during a night out and consuming a copious
 amount of alcohol, woke the next morning and could not use the
right shoulder. No previous care has been sought but he has been
using a sling. On exam you notice wasting of the deltoid muscle and
loss of the right shoulder contour the head of the humerus is
palpated anterior. All ranges of motion are diminished and painful.
Muscle testing cannot be achieved. There is no distal neurovascular
deficit. Duga’s test +

Diagnosis: Anterior shoulder dislocation of the glenohumeral joint

B. 13 year old female, 3 days pain, swelling and difficulty using the
right shoulder. No history of trauma. She is tired, feeling generally
unwell and has had a temperature of 39° fever for the past three
days. She presents with the shoulder and mild flexion and
abduction. You note diffuse swelling around the shoulder which is
erythematous and warm to the touch. No scars are noted. All limb
movement is painful and restricted.

Diagnosis: Subacromial/ sub-deltoid bursitis that can be present with

or caused by an infection

C. 48 -year-old female presents with left shoulder pain and stiffness of

three months duration but getting worse. She is no longer able to
reach up and hang laundry or put the dishes in the cupboards of the
kitchen. She finds it difficult to sleep on her left side. Past history is
remarkable for hypertension and she is diabetic. There are no red or
yellow flags. On exam there is mild wasting of the deltoid muscle
with normal integument, no masses or scars are visible. On
palpation there is no localized tenderness. No lymph discrepancy is
noted. There is no distal neurovascular deficit.

Left
Flexion A 60° P 75°
Extension A 60° P 70°
External rotation A 15° P 25°
Extension – can be achieved
Right
All ranges of motion are normal

Muscle strength is normal;

X-ray – Osteoporosis; otherwise normal; referral for MRI; patient
declined due to cost and willing to trial conservative care

Diagnosis: Adhesive Capsulitis

 insidious onset with a progressive lncrease in pain
 more prevalent in women, individuals aged 40-65
 Difficulty is performing overhead activities
  Painful and limited AROM and PROM in at least two directions
 Systemic subcategory (diabetes mellitus)

D. 30 -year-old male with pain in the right side of the chest just lateral
to the sternum for ten days. Pain is aggravated by deep breathing,
coughing or pressure on the sternum and thoracic cage. No history
of trauma. There are no constitutional symptoms, vital signs are
normal. On inspection there is prominence over the costochondral
junction adjacent to the fourth, fifth and sixth the ribs however no
warmth or tenderness over the skin. There is tenderness on
palpation over the costochondral junction. Movements are not
affected but aggravated on deep inspiration. The patient has had a
previous x-ray which was reported normal and lab studies were
normal as well

Diagnosis: Costochondritis at the 4-6th costochondral junctions–

inflammation of the costochondral junction, the cartilage connecting
the anterior ribs to the sternum
 Causes mild to moderate anterior chest wall pain and tenderness

E. 27-year-old male with pain in the right shoulder blade for four
months and difficulty lifting his right arm. He had undergone minor
surgery to remove a benign cyst at the side of his neck six months
ago. No additional significant past history, no red or yellow flags.
There is no referred pain, tingling or numbness. On evaluation the
right shoulder slopes down. There is a 4 cm scar at the lateral
aspect of his neck. As the patient pushes against a wall, the right
medial border and inferior angle of the scapula become prominent
and the scapula is more palpable on the right. All other shoulder
movements are normal. No neurologic abnormalities are noted. The
remainder of the upper limb exam is normal

Scapular Winging due to long thoracic neuropathy – possibly damaged during

surgery

- weakness of serratus anterior causes winging of the scapular

- very prominent medial border and inferior angle of the scapular.