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 +
Neer’s empty can +
Hornblower’s sign +
What is your working diagnosis?

LODCTRRAPPA

L- Right shoulder pain

O- N/a

D- Inability to lift arm for 5 months

C- Increasing shoulder stiffness and weakness

T- Sore. Pain is general over shoulder and upper arm

R- No pain further down the arm and no pins, needles, tingling or numbness

R- N/a

A-Throwing the chains at work

P- History of recurrent shoulder injury

P- N/a

A-N/a

Flags:

No red flags

-Enjoys his job

-Fit and healthy otherwise

GORPOMNICS:

G- His arm is held by his side, elbow in extension, forearm midprone

O- Muscle wasting over the scapula on the right compared to left. No scars or masses are
seen
R-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°

Note should be taken 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°
P- Localized tenderness over the greater tuberosity and the AC joint, coarse crepitation over
the shoulder on movement
O- Drop arm + , Neer’s empty can +, Hornblower’s sign +
M- Muscle strength – Bicep 5+, Tricep 5+, Supraspinatus 2+, Infraspinatus 4+, Subscapularis
4+
N- Neurologic exam is normal
I- N/a

C- N/a

S- N/a

Therefore, the working diagnosis is a rotator cuff tear, more specifically a full thickness
tear of the supraspinatus muscle. This is due to the correlation of the patient’s signs and
symptoms with the common clinical manifestations of a rotator cuff tear. These include, a
painful arc, pain on abduction with a large degree of loss in active range of motion, painful
impingement signs- seen in a positive Neer and Empty Can Test. The patient is also in the
correct age bracket (being above 40) and is experiencing pain with overhead activities,
weakness of the involved muscle with noted atrophy, shoulder stiffness and an observed
movement on attempting arm abduction is ‘shrugging’ the shoulder girdle.
It has been further narrowed to a tear of the supraspinatus muscle as the patient has a
painful arc, a positive drop arm sign (unable to maintain the arm in abduction when lowering
from elevated position), a diminished supraspinatus muscle strength of 2+, localised
tenderness over the greater tuberosity and muscle wasting over the scapula
Give 2 differential diagnoses?
Two other differential diagnoses could be supraspinatus tendinitis/ tendinopathy or
infraspinatus tendinitis/ tendinopathy. This is due to the clinical examination findings of
a painful resisted abduction (painful arc), positive impingement tests (Neer’s/ Emptying the
can Tests). This condition is caused by trauma or overuse to an often degenerated tendon
producing pain and weakness which is significant with the patients type of pain and also his
occupation involving repetitive movements. The patient was unable to reach 90 degrees
abduction actively. The pain is not sudden and has gradually increased over some time.
Exercise 2
The following questions will give you a brief history. Based on this week’s 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 +
 L - right shoulder
 O – following trauma to the area
 D – six months
 C – not elicited
 T – not elicited
 R – shoulder area
 R – a sling has been used for support
 A – not elicited
 P – not elicited
 P – nil
 A – not elicited
 No red or yellow flags from given history

 G – information not supplied

 O – on exam you notice wasting of the deltoid muscle and loss of the right
shoulder contour the head of the humerus is palpated anterior.
 R – all ranges of motion are diminished and painful.
 P – the head of the humerus is palpated anterior
 O – positive Duga’s test

Diagnosis: Anterior Humeral Dislocation or fracture:

ü Continued pain and limitation of motion often misinterpreted as adhesive
capsulitis
ü Previous history of trauma to the shoulder and subsequent limitation of
motion
ü Positive Duga’s Test also confirms either a dislocated or fractured shoulder

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: Joint / Bone infection - Acute Bursitis (Potentially subacromial)

ü Signs of inflammation -swelling, erythematous and warm to touch (heat)
ü Can be present with infection- She is tired, feeling generally unwell and has
had a temperature of 39° fever for the past three days
ü Pain with motion

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: Secondary Systemic Adhesive Capsulitis

ü Systemic due to diabetes mellitus and hypertension
ü External rotation is limited (also limited abduction is characteristic however, not
mentioned)
ü Between the age of 40-65yrs old
 ü More prevalent in women
ü “Three months and getting worse” correlates with the characteristic of insidious
onset with progressive increase of pain
ü Difficulty with performing overhead activities

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:
ü pain in the right side of the chest just lateral to the sternum
ü pain is aggravated by deep breathing, coughing or pressure on the
sternum and thoracic cage.
ü Usually unilateral symptoms
ü There is tenderness on palpation over the costochondral junction.

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: Long Thoracic Nerve Impingement (form of dyskinesia) causing Serratus

Anterior Weakness (Winging of the scapula)
ü Difficulty lifting his arm
ü Surgery complications can cause this condition
ü Sloping of the shoulder
ü Prominence of medial board and inferior angle of scapula when “Push Up Test”