A Case of Acute Shoulder Pain

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A Case of Acute Shoulder Pain

• Allyson Howe, MD
• Primary Care Sports Medicine Fellow
• National Capital Consortium
• Washington, DC

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PATIENT INFORMATION

• 27-year-old female
• Administrative assistant at the hospital
• CC
• Right shoulder pain for 4 days
• Fell while skiing 4 days ago
• QUESTIONS??

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HISTORY OF INJURY

• Recreational skiier
• Took a wrong turn on the slopes and ended up in
  moguls
• Fell onto her right lateral side
• Arm outstretched initially, felt her shoulder
  shift and pop

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Just be thankful, THIS is not your patient
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HISTORY OF INJURYCONT

• Able to ski back to lodge, but did not use right
  arm
• Seen at ER at the bottom of the slope
• Had shoulder x-rays
• Patient reports these were normal
• Sent home with sling and vicodin

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MORE HISTORY

• PMH
• Migraine headaches
• Mild intermittent asthma
• No history of shoulder problems

• MEDICATIONS
• Vicodin prn
• Prozac 20mg qday
• Albuterol inhaler
• Hasnt used for 3 months

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EVEN MORE HISTORY

• PSH
• None
• FH
• none
• SH
• Smoked for 5 years, quit 2 years ago

• ADD SKIING PICTURE

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REVIEW OF SYSTEMS

• No fevers, chills, constitutional symptoms
• No neck pain, back pain
• No headaches, no LOC at time of fall
• No arm paresthesias
• No chest pain, shortness of breath, abdominal
  complaints

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PHYSICAL

• Inspection
• Palpation
• Range of motion
• Strength
• Special tests

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INSPECTION

• Holds her arm close to her side
• Slightly lower resting position of right shoulder
• No bruising
• No muscle atrophy
• Scapula symmetric
• Otherwise comfortable, breathing regularly,
  speaking in full sentences

Describe how you would inspect this patient
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PALPATION

• Diffusely tender over anterior shoulder
• Non-tender at Acromioclavicular joint
• Pain along trapezius with muscle spasm on right
• No tenderness at deltoid insertion but identifies
  that area as her maximum pain spot

Where do you want to palpate?
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RANGE OF MOTION

• Tough to evaluate because she has so much pain
  with movement
• Abduction
• 70 degrees active, 90 degrees passive
• External rotation
• 30 degrees active, 45 degrees passive
• Internal rotation
• T7 on left, L4 on right

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STRENGTH

• 4/5 strength empty can, external rotation
• What muscles are these testing?
• Unable to do lift off test because of pain
• What muscle are you testing here?
• Deltoid, trapezius, pectoral m. 5/5
• Neurovascularly intact

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SPECIAL TESTS

• Hawkins and Neer /-
• Scarf test negative
• Apprehension test is positive
• Relocation test is positive
• Obriens causes pain with internal rotation,
  relieved with supination

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RADIOLOGY

• Plain films
• CT scan
• MRI
• Bone scan

NEXT TOPIC
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BONE SCAN

• Not ordered in this patient
• Might be beneficial in some situations
• Constitutional symptoms
• Overhead athletes with bony pain
• Suspicion of stress injury

RETURN
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PLAIN FILMS
Return

• Name the view

AP with internal rotation
AP with external rotation
Scapular Y view
Axillary view
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CT SCAN
RETURN

• DENIED!!

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MRI

• Axial cuts, T1 image

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LABRUM
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RETURN
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DIAGNOSIS

• Shoulder dislocation with spontaneous relocation
• Bankart lesion (soft tissue)
• Anterior labral tear
• HAGL lesion (avulsion of IGHL)
• Possible Hill-Sachs lesion

What do you think??
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SHOULDER INSTABILITYClassification

• AMBRI
• Atraumatic
• Multidirectional
• Bilateral
• Rehab
• Inferior capsular shift

• TUBS
• Traumatic
• Unilateral
• Bankart
• Surgery

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TREATMENT

• Sling for 1- 2 weeks max
• Protect from sports
• Ie. NO SKIING
• Especially avoid abducted/externally rotated
  position
• Passive ROM exercises
• Physical Therapy consult
• Orthopedics consultation

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TAKE HOME POINTS

• Do your shoulder exam with shirt off (the
  patients, not yours ?)
• Shoulder instability due to traumatic reason
  often surgery
• Fall on outstretched shoulder
• Dislocation
• Fracture
• AC separation