Case 39: Shoulder pain

Opening scenario

Ryan Mitchell, a 52-year old male, comes to the physician because of shoulder pain.

Vital signs

• Temperature: 98.6°F (37°C)
• Blood pressure: 120/80 mm Hg
• Heart rate: 64/min
• Respirations: 16/min

Examinee tasks

• Take a focused history.
• Perform a relevant physical examination (do not perform corneal reflex, breast, pelvic/genitourinary, or rectal examinations).
• Explain the preliminary differential diagnoses and initial workup plan to the patient.
• Write the patient notes after leaving the room.

Patient instructions

• When the examinee presses on your left shoulder, say that it hurts, particularly in the front.
• When the examinee asks you to move your left shoulder, tell the examinee that your left shoulder feels stiff and painful and move it slowly.
• When the examinee tries to move your left shoulder, pretend that your shoulder is stiff by making it harder for the examinee to it than your right shoulder.
• When the examinee tests the strength in your shoulder by pushing against your arm while you lift your shoulder, pretend to have less strength in your left shoulder and push back only weakly.
• When the examinee asks you to lift your left arm up to the side, say that it hurts.
  • The pain is at its worst when the arm is lifted up to 60–120°.
• When the examinee lifts your arm in front of you with your thumb pointing toward the floor, say that it hurts. When the examinee tries to push your arm down in this position, do not resist.
• You are not aware of the meanings of medical terms (e.g., ultrasound) and ask for clarification if the examinee uses them.
• Use the checklists below for history, physical examination, and communication and interpersonal skills.

Challenge: Ask “What do you think – when can I get back to the gym to do my regular workouts?”

Hovering over the speech bubbles in the lists below will reveal extra information about the adjacent term. However, clicking on links will cause you to navigate away from the current case, at which point your progress (i.e., your check marks) will be lost. If you do want more information on a subject, either open the link in a new tab or wait until you and your partner have finished the case and reviewed the check marks. Following the link to the patient note form will not interrupt your progress.

History of present illness

• Chief complaint
• I have some really annoying shoulder pain. I cannot do any sports at the moment.
• Location
• My left shoulder.
• Intensity (on a scale from 0–10)
• If I do not use my left arm, I would say a 3. If I try to lift heavy things, then it can go as high as a 6 or 7.
• Quality
• A dull pain. But if I make certain movements it can also feel like someone is stabbing me with a knife.
• Onset
• 5 days ago, it became really bad. But before that I had some milder pain for 2 weeks.
• Precipitating events
• I was at the gym lifting weights when it suddenly got worse 5 days ago.
• Progression/constant/intermittent
• It is getting worse.
• Previous episodes
• I had a problem with my left shoulder 2 years ago. Back then I played a lot of tennis and I also fell on my left shoulder. The doctor told me I had an overuse injury. But this was all healed, and I did not really have any problems with my shoulder until 2 weeks ago.
• Radiation
• My whole left shoulder hurts, but nothing else.
• Alleviating factors
• If I do not carry anything with my left arm. If I do not lie on my left shoulder.
• Aggravating factors
• If I carry or pull things with my left arm. And it especially hurts when I lift things with my left arm or if I lay on my left shoulder.
• Associated symptoms
• My left shoulder has been feeling a bit stiff for the past 2 weeks. I cannot move it like I used to.

Repetitive overhead activities (e.g., basketball, tennis, volleyball) and prior shoulder injuries are both important risk factors for the development of soft tissue lesions of the shoulder.

Review of systems specific to shoulder pain

• Trauma
• No.
• Fever/chills
• No.
• Rash/skin changes
• No.
• Chest pain
• No.
• Shortness of breath
• No.
• Pain in joints
• No.
• Sleep problems
• I did not sleep well for the past few days. It's more painful during the night, and I cannot lie on my shoulder because it causes a lot of pain.
• Recent infections
• No.
• Weakness of the upper extremities
• Hmm, I have the feeling that I have less strength in my left arm. But it is hard to tell because it is painful when I use it.
• Limited movements of the upper extremities
• When I move my left arm, my whole shoulder feels stiff. I cannot lift my arm over my head and scratch my back.
• Swelling of the shoulder
• No.
• Altered sensation in the upper extremities
• No.

Ask every patient with left shoulder pain about chest pain and shortness of breath to screen for cardiac causes, and every patient with right shoulder pain about nausea/vomiting and abdominal pain to screen for cholelithiasis.

Past medical history, family history, and social history

• Past medical history
• I broke my right hand 6 years ago. And I had an overuse injury of my shoulder 2 years ago.
• Allergies
• None.
• Medications
• I tried some of my girlfriend's vicodin, which she had left over from a surgery last year. It really helped with the pain but made me kind of dizzy.
• Hospitalizations
• Only for my hand surgery.
• Past surgical history
• I got surgery for my broken hand.
• Family history
• My father has chronic bronchitis, but he also smokes.
• Work
• I work as a painter. It has been almost impossible to do my work for the past 2 weeks.
• Home
• I live with my girlfriend.
• Alcohol
• No.
• Recreational drugs
• No.
• Tobacco
• No, never.
• Exercise
• I exercise several times per week. I love tennis and I also do weightlifting. But for the past couple of days I haven't done any sports.

This patient started to use vicodin, a prescription opioid, without a medical consultation and should be counseled about the use of prescription opioids.

• Washed hands
• Used respectful draping
• Extremities
  • Inspection of the upper extremities
  • Palpation of the radial pulse
  • Inspection of the shoulder region
  • Palpation of the shoulder region
    • Diffuse tenderness of the left shoulder with pronounced tenderness over the subacromial region
  • Focused examination of passive and active motion of the upper extremities
    • Active and passive motion in the left shoulder is slow due to pain.
    • Strength 4/5 in the left shoulder
  • Focused examination of sensation of the upper extremities
  • Focused examination of deep tendon reflexes of the upper extremities
  • Painful arc test
    • Pain with abduction of the arm to 0–120°
    • Especially painful with abduction to 60°–120°
  • Neer test
    • Positive: Movement causes pain.
  • Jobe test
    • Positive: Patient cannot resist against pressure.

Always compare left and right sides when examining the extremities!

Patient interaction

• Examinee knocked on the door.
• Examinee introduced him- or herself and identified his/her role.
• Examinee correctly used the patient's name.
• Examinee asked open-ended questions.
• Examinee listened attentively (did not interrupt the patient).
• Examinee showed interest in the patient as a person (i.e., appeared caring and showed respect).
• Examinee demonstrated the ability to support the patient's emotions (i.e., offered words of support, asked for clarification).
• Examinee did not repeat painful maneuvers during physical examination.
• Examinee discussed initial diagnostic impressions with the patient.
• Examinee explained the management plan.
• Examinee used non-medical terms and provided reasons for planned steps in management.
• Examinee evaluated the patient's agreement with the next diagnostic steps.
• Examinee asked about concerns or questions.

Counseling and challenge

• Examinee offered counseling on the use of prescription opioids.
• Examinee reacted appropriately to challenge.

Suggested response to challenge: “Mr. Mitchell, I understand that you want to get back to working out, but I believe that putting any strain on your shoulder right now could potentially make your symptoms worse. However, you can try out sports that put less stress on your shoulder, such as running. And I promise you that we will do our best to treat your shoulder pain. Do you have any other questions?”

Patient note

Differential diagnoses

1. Rotator cuff tear: Acute-onset pain and weakness of the shoulder in patients > 50 years of age, particularly in those with a history of overhead activity and/or overuse injuries of the shoulder, should raise concern for a rotator cuff tear. Rotator cuff tear typically causes pain that is worse at night when lying on the affected shoulder. Patients often have a history of subacromial impingement syndrome or rotator cuff tendinitis, making the painful arc test and Neer test positive, as seen in this patient. A positive Jobe test suggests damage to the supraspinatus tendon, the most commonly affected tendon in rotator cuff tears.
2. Subacromial impingement syndrome: Subacromial impingement syndrome is a common condition, especially in patients with a history of overhead activity. Patients often report that the pain is worse at night when they are lying on their shoulder. Although this patient's positive painful arc and Neer test suggest an underlying subacromial pathology, the sudden onset of the pain, the decreased strength, and the positive Jobe test make a rotator cuff tear more likely.
3. Frozen shoulder (adhesive capsulitis): A history of dull shoulder pain, diffuse tenderness to palpation, shoulder stiffness, and an age > 40 years are all consistent with a frozen shoulder. However, the condition is typically associated with a significantly decreased range of motion in all planes (especially external rotation), making it the least likely of the three differential diagnoses.

Diagnostic studies

• Ultrasound of the L shoulder: to evaluate the extent of shoulder injury and the affected structures. Imaging (ultrasound, MRI, x-ray) would not be routinely performed unless surgical repair is considered. However, given this patient's age and occupation, which requires overhead work, surgical repair may be indicated, which means that imaging should be ordered.
• MRI of the L shoulder: to evaluate the extent of shoulder injury and the affected structures
• X-ray of the L shoulder: to evaluate for degenerative changes, bony lesions, or dislocations
• Subacromial lidocaine injection test: may be helpful in distinguishing between subacromial impingement syndrome (including subacromial bursitis and rotator cuff tendinitis) and other causes of shoulder pain and restriction (e.g., complete rotator cuff tear, frozen shoulder, or glenohumeral joint arthritis)

Other differential diagnoses to consider

• Rotator cuff tendinitis
• Calcifying tendinitis
• Biceps tendinitis
• See also soft tissue lesions of the shoulder.