Rheuma Case: 54-year-old Woman with Acute Right Shoulder Pain

00:00 Alright, so let's do another case. So this is a 58-year-old morbidly obese woman who presents with acute right shoulder pain, which has persisted over the past 4 or 5 days. She now states that she can't even lift a gallon jug of milk without considerable pain. Now the acute injury occurred while trying to lift too many shopping bags out of the back of her car. On gross inspection, we don't detect any gross deformities though of note the exam is limited by morbid obesity and that's commonly a limitation when doing an exam. Palpation of landmarks is within normal limits range of motion testing. So, active range of motion is pain limited to about 110 degrees of abduction. She has full passive range of motion, however. Rotator cuff testing, there's no obvious pain or weakness with internal or external range of motion and importantly she has no painful arc. When we performed additional maneuvers, we find that she has a positive Speed's test with pain in approximately 80% elbow flexion power compared with the other arm.

01:01 So, just looking at our common variables that we always go through, this time course sounds subacute, it's been the past 4 or 5 days, she has mono-articular joint involvement. We don't see evidence of joint inflammation right now and we're not given any systemic symptoms. So based on that information, what is our differential diagnoses for this case? Is it rotator cuff tendinosis or tear, adhesive capsulitis or biceps tendinopathy? Let's revisit that table that we put up a couple of slides ago. So, our patient was having shoulder pain but no stiffness, no shoulder weakness, no painful arc, no drop arm, and no decrease passive range of motion.

01:41 I think we're going to need to add a column just for our patient. And in addition, we talked about this patient having a positive Speed's test. Well, let's add that to our table and reflect on what that actually means. Okay, a little bit of an anatomy review again here. Remember we talked about how the long head of the biceps tendon inserts into the glenoid labrum which is shown here on my right. So, if the biceps' long head is strained or torn in some way, one can expect to have some deep anterolateral shoulder pain and you'd want to use some diagnostic maneuvers that specifically hone in on the action of that tendon. Meet the Speed's test. This test is performed by having the patient fully extend their elbow and then lift up the arm while you, the examiner, are actively resisting shoulder flexion. If while the patient is lifting up their arm, they're experiencing pain in that antero location where the long head of the biceps tendon is located, that would suggest that the patient has biceps tendinopathy. So, our patient not only had a positive Speed's test but there was also this comment that she only had 80% elbow flexion power, not shoulder flexion, flexion at the elbow. So, what does that mean? Now you may think that the biceps muscle must be the big mover and shaker for elbow flexion, but it turns out there are 2 factors here to keep in mind. Number 1, the biceps is broken up into 2 heads. That's why it's called biceps. There's a long head and a short head. The long head actually only contributes about 20% of the power of elbow flexion and that's the one that we're talking about being diseased here. There is also a short head of the biceps tendon which is not attached to the shoulder and there's also the brachioradialis muscle which also contributes to elbow flexion. So, a person could theoretically have a complete tear of the long head of the biceps tendon and still have 80% power at elbow flexion. With that in mind, our disease is biceps tendinopathy and possibly even a biceps rupture.