Rheuma Case: 54-year-old Man with Shoulder Pain

by Stephen Holt, MD, MS

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    00:00 Alright, next up we're going to talk about an approach to shoulder pain. Of note, for the purposes of this section, we're really going to focus on diseases that are musculoskeletal, sports injuries, or overuse pathology rather than thinking about some of the other monoarticular or oligoarticular causes of rheumatic joint pain. So, we're not going to be looking for systemic symptoms or significant joint inflammation like you might see in gout or rheumatoid arthritis. Alright, let's jump into a case. So this is a 54-year-old man with a history of hypertension and non-insulin dependent diabetes mellitus who is presenting with progressive right anterolateral shoulder pain and stiffness over the past 1 or 2 months. He reports that he had fallen on to his outstretched arm 4 or 5 months ago when he slipped on the ice, but the acute pain from the injury has dissipated over the past 2 or 3 weeks. He further reports some difficulty with simply putting on his dress shirts for work due to shoulder stiffness. On gross inspection, we don't see much but when we palpate some landmarks we see some tenderness to palpation over the acromiohumeral sulcus.

    01:08 Active and passive range of motion are significantly reduced with abduction to 90 degrees and external rotation to 30 degrees. Strength testing finds pain and weakness with external rotation.

    01:21 He has no pain with shoulder flexion with wrist supinated and elbow extended, the so-called Speed's test. Alright, so let's go through a few salient features of our history thus far. First off, time course. You know, honestly the time course is a little tricky here. We're hearing that he had a fall about 4 or 5 months ago then we're hearing that over the past 1 or 2 months he has had pain and stiffness and we're also hearing that the pain he had previously had dissipated over the past few weeks. Either way, it sounds like a subacute kind of presentation. Pattern of joint involvement, we're only talking about 1 joint here so it's monoarticular. Evidence of joint inflammation remains unclear at this point and honestly sometimes it's tricky to detect inflammation in the shoulder joint. Systemic involvement, none of that at this time. So what is the most likely diagnosis at this time? We've got rotator cuff tendinosis, a rotator cuff tear, adhesive capsulitis, or subacromial bursitis. Now, if you're having any trouble trying to figure out what the diagnosis is, we should probably review some shoulder pathology.

    About the Lecture

    The lecture Rheuma Case: 54-year-old Man with Shoulder Pain by Stephen Holt, MD, MS is from the course General Approach to Arthritis and Joint Pain.

    Included Quiz Questions

    1. rotator cuff tendinosis, rotator cuff tear, adhesive capsulitis, and subacromial bursitis.
    2. gout, rheumatoid arthritis, reactive arthritis, and bicipital tendinitis.
    3. rheumatoid arthritis, calcium pyrophosphate dihydrate arthritis, and degenerative joint disease.
    4. transient osteoporosis, polymyalgia rheumatica, shoulder-hand syndrome, and hemarthrosis.
    5. fibromyalgia, avascular necrosis, chronic synovitis, and viral arthritis.

    Author of lecture Rheuma Case: 54-year-old Man with Shoulder Pain

     Stephen Holt, MD, MS

    Stephen Holt, MD, MS

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