Rheuma Case: 63-year-old Woman with Increasing Right Shoulder Pain

by Stephen Holt, MD, MS

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    00:00 Alright, so let's just review one last case to review some of the stuff that we'd been talking about. So, this one is a 63-year-old woman with no significant past medical history who presents with increasing right shoulder pain over the past 2 or 3 months. She is a regular swimmer and reports increasing discomfort with her freestyle stroke when she is reaching her right arm out in front of her. Her pain is anterolateral in location and is exacerbated by reaching overhead, which creates a popping sensation. She also reports lateral arm pain at night especially when she lies on her right side. Now, gross inspection is within normal limits. Palpation of landmarks highlights some point tenderness over the acromiohumeral sulcus. Active range of motion is pain limited to about 90 degrees of abduction and external rotation. Passive range of motion is appropriate for her age, but the patient does have a positive painful arc between 60-120 degrees of abduction. Strength testing is normal and her Speed's test is negative. Alright. So let's go and take a specific look at some of these features of this case. So first up, her pain is anterolateral in location. Now that's pretty typical for rotator cuff disease. You can have rotator cuff disease, biceps tendinopathy which would also be anterolateral in location or potentially disease of the acromioclavicular joint though that tends to be more on the top of the shoulder. Importantly, if a patient complains of posterior shoulder pain you should be thinking more about neck pathology like cervical radiculopathy. Next up, she says she has a popping sensation and that's something you might also see with any instability of the glenohumeral joint either due to rotator cuff disease or a glenoid labral tear. She has lateral arm pain at night and that is one of the textbook features that you'll see for a patient who's reporting rotator cuff tendinopathy. The pain is on the lateral aspect and it's more uncomfortable in the evening. We talked about point tenderness of the acromiohumeral sulcus. That is essentially the little concavity that's formed by tugging down on the shoulder. It's basically where the humerus ends and the acromion begins and it basically indicates tenderness over the supraspinatus tendon. Lastly, the painful arc is a test that helps to suggest that there is disease of the rotator cuff and most commonly tendinopathy since she did not have a drop arm test. Alright, with all that information, let's look at our table as well. So, shoulder pain she does have, looking at our column for our patient all the way in the far right. She does not have stiffness, she does not have weakness, she does have a painful arc as I said but no drop arm test. She has normal range of motion passively and a negative Speed's test. So, trying to compare her column with another column in our table, it looks like she's got rotator cuff tendinosis. And that's it for the shoulder exam.

    About the Lecture

    The lecture Rheuma Case: 63-year-old Woman with Increasing Right Shoulder Pain by Stephen Holt, MD, MS is from the course General Approach to Arthritis and Joint Pain.

    Included Quiz Questions

    1. Drop arm test
    2. Hawkins test
    3. Jobe test
    4. Neer impingement test
    5. Speed’s test

    Author of lecture Rheuma Case: 63-year-old Woman with Increasing Right Shoulder Pain

     Stephen Holt, MD, MS

    Stephen Holt, MD, MS

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