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. There is coarse crepitation over the shoulder on movement

Cervical spine examination is unrewarding

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 +

- The drop arm test is used to assess for rotator cuff tears, particularly of the supraspinatus, Stand
behind the seated patient and abduct patient's arm to 900, supporting the arm at the elbow. Release
the elbow support, and ask patient to slowly lower the arm to the side, It is positive if there is pain
while lowering the arm, sudden dropping of the arm or weakness in maintaining arm position during
lowering (with or without pain), suggesting injury to the supraspinatus, The test is negative if the
patient is able to control the lowering of the arm slowly and without pain
Neer’s empty can +

- The Empty Can Test is used to assess the supraspinatus muscle and tendon, The patient can be seated
or standing for this test. The patient's arm should be elevated to 90 degrees in the scapular plane,
with the elbow extended, full internal rotation, and pronation of the forearm. This results in a
thumbs-down position, as if the patient were pouring liquid out of a can. The therapist should
stabilize the shoulder while applying a downwardly directed force to the arm, the patient tries to
resist this motion. This test is considered positive if the patient experiences pain or weakness with
resistance.

Hornblower’s sign +

- To test for teres minor tear. The patient is seated or standing. The examiner places the patient's arm
to 90oin the scapular plane and flexes the elbow to 90o. The patient is then asked to externally rotate
against resistance. The test is positive if the patient is unable to perform external rotation.

What is your working diagnosis?

- Rotator Cuff tears

a. increasing shoulder stiffness and weakness
b. as when the patient attempts abduction there is a shrug of the shoulder,
c. muscle wasting over the scapula on the right compared to left,
d. There’s localized tenderness over the greater tuberosity and the AC joint,
e. Drop arm +

- Supraspinatus tear/rupture
a. increasing shoulder stiffness and weakness
b. as pain between 60 o -120 o,
c. There’s localized tenderness over the greater tuberosity and the AC joint)
 d. There is coarse crepitation over the shoulder on movement
e. muscle wasting over the scapula on the right compared to left
f. Drop arm +
g. Neer’s empty can +

- polymyalgia rheumatic
a. pain is general over the shoulder and upper arm

- Subacromial-subdeltoid bursitis
a. pain is general over the shoulder and upper arm)
b. as when the patient attempts abduction there is a shrug of the shoulder

- Biceps Tendonitis
a. There is coarse crepitation over the shoulder on movement)

Give 2 differential diagnoses?

- Rotator cuff tears

- Supraspinatus tear/rupture

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:

- Right shoulder restricted movements could be due to

a. Tendinitis/tendonitis,
b. rotator cuff pathologies,
c. scapula impingement,
d. subacromial impingement (Third stage: Strong restriction in movement due to
calcifications, Loss of muscle strength)

- History of trauma
a. Supraspinatus tear/rupture,
b. Rotator cuff tear (Night pain when lying on the affected side and a history of
trauma in a patient older than 65 years both suggest a rotator cuff tear, but no
individual symptom is definitive for the diagnosis),
c. Osteolysis of distal clavicle (age<20)

- Wasting of the deltoid muscle

a. Supraspinatus tears/rapture,
b. Rotator cuff tears

- Loss of the right shoulder contour the head of the humerus is palpated anterior.
a. SLAP (superior labrum anterior posterior) lesion),

b. Tendinopathy/Biceps tendonitis (may lead to Rupture of the long head of the

biceps tendon),

c. Hill sachs lesion (are a posterolateral humeral head compression fracture,

typically secondary to recurrent anterior shoulder dislocations, as the humeral
head comes to rest against the anteroinferior part of the glenoid. It is often
associated with a Bankart lesion of the glenoid.),
 d. Scapula fracture (Avulsion of the anteroinferior aspect of the labrum by the
anterior band of the inferior glenohumeral ligament are seen in association with
anterior shoulder dislocations (subcoracoid & subglenoid),

e. Greater tuberosity/Flap fracture (Frequently fractured during anterior humeral

dislocation, displacement of more than 1 cm indicates significant rotator cuff
disruption), Anterior Glenohumeral dislocation (95%))

- Duga’s test +
a. Positive sign of Rotator cuff & glenoid labral damage

As Dug’s test is
- a shoulder examination used to indicate a dislocated or fractured shoulder,

- Patient seated; examiner instructs patient to reach across body, place hand on opposite shoulder &
pull their elbow against their chest;

- examiner may apply gentle A→P overpressure on the flexed elbow.

- Positive Inability to complete test (patient cannot bring flexed elbow to anterior chest wall) →
shoulder dislocation,
- GH joint/muscle contracture. With shoulder dislocation there is always associated rotator cuff &
glenoid labral damage.)

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:

- Swelling
a. Bursitis, subacromial-subdeltoid bursitis

- Temperatures of fever
a. Supraspinatus calcific tendinitis

- Diffuse swelling around the shoulder

early sign of mechanical irritation of the rotator cuff

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 (Supraspinatus
tendinitis/tendinopathy (Unable to reach higher than 90° abduction, Activities of
daily living can cause a lot of pain), Biceps tendonitis) and hang laundry or put
the dishes in the cupboards of the kitchen. She finds it difficult to sleep on her left
side (Rotator cuff tears/impingement, Adhesive capsulitis, calcific tendinitis,
Supraspinatus tendinitis/tendinopathy ). 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:

- No longer able to reach up

a. Supraspinatus tendinitis/tendinopathy (Unable to reach higher than 90°

abduction, Activities of daily living can cause a lot of pain),

b. Biceps tendonitis

- difficult to sleep on her left side

a. (Rotator cuff tears/impingement, Adhesive capsulitis, calcific tendinitis,
Supraspinatus tendinitis/tendinopathy )
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:

- Pain in the right side of the chest just lateral to the sternum for ten days
a. Costochondritis, common in female >40).

- Pain is aggravated by deep breathing, coughing or pressure on the sternum and thoracic cage.
a. (Costochondritis, (causes mild to moderate anterior chest wall pain and
tenderness that may radiate to the chest, back or abdomen)

- prominence over the costochondral junction adjacent to the fourth, fifth and sixth the ribs
- a. Tietze’s syndrome, young Male (Tietze syndrome is a rare, inflammatory disorder
characterized by chest pain and swelling of the cartilage of one or more of the
upper ribs (costochondral junction), specifically where the ribs attach to the
breastbone (sternum). Onset of pain may be gradual or sudden and may spread
to affect the arms and/or shoulders.)

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

Diagnosis:

- Pain in the right shoulder blade (subscapular nerve entrapment

a. subscapular nerve entrapment

- There is a 4 cm scar at the lateral aspect of his neck

a. tendinitis/tendonitis, chronic inflammation can cause scars that restrict
movement

- Scapula is more palpable on the right.

a. long thoracic nerve C5-C7, Motor only to serratus anterior, Weakness causes
‘winging of the scapula’, Weakness and pain on flexing an extended arm, Pain
with cervical rotation to opposite side, Due to sudden traction of the upper
extremity, May be due to prolonged compression (Backpacker’s palsy)