Shoulder Case

[Taylor Blattenberger]

Hey everyone!

I had an interesting shoulder case this week and wanted to share. I’ll start with the subjective. Let me know some differentials, extra questions you have, and some things you want to objectively test.

See the case attached

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[Steven Lagasse]

Differentials:
– Cervical Radic C4/5; C5/6
– Labral
– Impingement
– Rotator cuff referral (Infraspinatus)

Additional Questions:
– What position was your arm in when you were bumped?
– Is this getting better, worse or has it plateaued?
– Is the location of your symptoms specific or vague and diffuse?
– Does your arm ever feel unstable and/or do you feel apprehensive with certain shoulder positions?
– Do any shoulder movements and/or positions provide you with relief?

Objective Testing:
– Screen: cervical, shoulder, and elbow
– Radic Cluster
– RC mm testing: MMT’s: full can and ER; Lag signs
– Impingement: Hawkin’s Kennedy, painful arc, SAT, SRT
– Labral testing based on arm position when injured and feeling of instability (cocking phase vs. traction vs. compression)

[pbarrettcoleman]

Differentials:
– Shoulder Primary Impingement, RTC tendinopathy/tear, labral tear, infraspinatus referral, frozen shoulder.
– Cervical Radiculopathy C5/6
– Lateral Epicondylagia
– Radial Nerve Entrapment at spiral groove

Subjective:
– clarification on radiating from elbow up.
– symptoms with head turns while driving, reading, computer use.
– has it felt like it was about to dislocate when reaching overhead?
– previous history of shoulder problems.
– Steven’s questions on position of arm during bump.

Objective:
– Cervical Screen with Spurling’s and Back L quadrant to rule out cervical radiculopathy.
– Shoulder with the specifics of looking for painful arc, SAT, SRT, palpation to supraspinatus, ER and Full Can MMT, HK, GH IR limited/painful, Horizontal Adduction limited/painful, Hand behind back limited/painful.
– ULTT1 or 2b to rule out ND.
– Resisted wrist Extension TTP CET to rule out Lateral Epicondylagia.

[Taylor Blattenberger]

Great thoughts guys! So…

She did not have any previous shoulder history including pain or dislocations. No feeling of instability, just sharp pain.

When she spoke about the event she described her shoulder being in a resting position by her side. It didn’t seem as if she was in a “odd” or “vulnerable” position.

Symptoms seemed to change over the year, but the c/c at this point was a specific point at the deltoid tuberosity. At this point her symptoms had plateaued. It seems to have gotten better, but now that she is doing activities that aggravate the shoulder such as her exercise routine it hasn’t changed much. She is trying to modify workouts – wall push ups instead of regular push ups.

More on the workouts – she had no pain with bicep curls, overhead tricep extensions. She also did mention a pilates like move where she had to bear weight on her R hand and BLE which caused increased symptoms.

[helenrshep]

Differentials
– impingement
– cervical radic C4/5
– infraspinatus referral

Questions (post Taylor’s clarification already)
– head position affecting symptoms?
– how long did the gripping issue last? was the “difficulty” due to weakness or pain or both?
– had she been treated for this over the past year? when did she start this new workout routine?
– does she remember more about the “started at the elbow then radiated to the shoulder” situation? how long was it like that before it switched to this new pain location?
– any other variables to note? maybe something happened earlier in the day and she doesn’t realize it and instead blames the “bump” into her arm – this just seems like too insignificant of an event to cause her symptoms and pain for this long
– yellow flags? super anxious? stress levels at home/work?

Objective tests
– neuro – reflexes, dermatomes, myotomes
– cervical radic cluster – if ruled out, proceed with neck exam
– elbow clearing exam including grip strength
– shoulder exam – AROM, OP, joint mobility
– shoulder special tests for instability, labral involvement, impingement

[lacarroll]

Differentials:
– Impingement
– Musculotaneous nerve entrapment
– RC dysfunction
– C5/6 Radic
– Lateral epicondylalgia

More questions: also after Taylor’s clarification
– How much impact happened from the “bump”? And did he directly impact the elbow or shoulder?
– Has she seen anyone else for this/had imaging done?
– Any changes in activity leading up to initial injury?
– Is the sharp pain new or has it been present since initial injury?

Objective Tests:
– Cervical screen: A/PROM, Spurling’s, compression/distraction
– ULTTs
– Sensation over arm
– Strength testing: shoulder ER/IR, flexion, abduction; elbow flex/ext & sup/pronation; wrist flexors/extensors, grip strength
– Shoulder: Hawkins Kennedy, painful arc, SAT, A/P ROM
– Palpation over lateral elbow, mms of RC

[Taylor Blattenberger]

The transition of symptoms seemed to happen in the summer. She felt as if the gripping issue (weakness>pain) was short lived compared to the long standing shoulder symptoms.

As far as other factors with the “bump” – The way she described it, it seemed mid humerus, and no known report of anything else that went on that day. I didn’t explore this much more at the time.

No prior treatment nor imaging

As for recent changes in activity, the workout routine began as some point in the early fall. Change in symptoms may have been related to this, but she didn’t seem to think so.

I did ask about sustained positions, reading, driving, computer work… all these came up negative and she related all her symptoms to arm movements (shoulder movements more recently).

I’ll share the objective tomorrow afternoon.

Thanks everyone!

[awilson12]

Sorry a bit late to the game with this…

Based on everything we know so far differentials would be:
RTC referral (infra or supraspinatus)
Shoulder external impingement
Axillary or radial nerve entrapment
Humeral shaft fracture

A few other things I would like to know- what are alleviating factors for her, PMH “unremarkable” but anything in hx that would predispose to poor bone mineral density

Objectively:
Screen cervical spine and elbow
Focus more on shoulder- AROM vs PROM and resisted testing can give good information to determine RTC involvement, any patterns with movement, end feel, etc. to help differentiate
Central vs peripheral neuro assessment & neurodynamics

[Eric Magrum]

Good discussion – keep it up
Hard to not think this is a compressive tendinopathy/IMP.
Rule out cervical/neural involvement for sure; but seems low on my differential.
I would primarily want to know the irritability/strength of the RTC (all components, all positions).
Maximize scapular positioning for RTC length/tension, and other impairments regionally that force the cuff to work sub optimally; then gradually progress strengthening/load of the RTC in the context of irritability.

Or just manipulate the thoracic spine.

Thanks again Taylor – anxiously awaiting additional objective info

[Taylor Blattenberger]

Here you go guys!

Let me know what you think and what I may have missed. Spoiler alert: It was NOT what I expected to see.

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[awilson12]

That information leads more towards anterior instability and labral pathology presentation, but still seems like there is some rotator cuff irritation as well.

A few other things I would want to know- irritability/tenderness with palpation of elbow and shoulder, range of motion normal or hypermobile?

How did you decide which special tests to use?

[Eric Magrum]

I agreed – I would love to see a discussion lead toward clusters of special tests to rule out differential, and rule in primary hypothesis.

We know the metrics for other shoulder special tests are poor secondary to concomitant pathology, and inability to specifically load individual tissue.

Thanks again Taylor – please facilitate this discussion in that direction.

How do you “weight” the poor metrics of the “special tests” in your decision making for hypothesis generation?

E

[helenrshep]

A few questions – what do we think about the elbow findings? Seems like there might be two things going on. Same question as Anna – did you palpate around the elbow and the deltoid tuberosity? Wondering about referral vs local muscular involvement.

What led you to doing the anterior slide test? And was the “positive” findings the true positive -clicking and reproduction of symptoms? For apprehension/relocation was it familiar pain?

Per Eric’s post: I would have done the radic cluster probably first (Spurling, distraction, ULTT, cervical rotation) and looked at ruling at the neck/neural involvement before I did shoulder special tests. The research on shoulder special tests is so bad that I would have wanted to use the stuff that IS well researched to rule out my differentials first.

Can we also talk about an elbow “screen”? I tend to do AROM with OP and resistance, palpation, and grip strength… what do y’all do? I also think you might need to take a closer look at her elbow given the findings.

[Taylor Blattenberger]

Probably could have clarified my thoughts prior to adding the objective:
So my top presubjective differentials for this patient were:
-Adhesive Capsulitis
-Impingement
-RC tear
-Labrum

After hearing the lack of “Stiffness” and she gestured a few times that showed her AROM was at least not severely limited, I moved adhesive capsulitis down my list. After all subjective questioning I was thinking more impingement due to the contractile aggs and a position of flexion/IR being provocative. I also added lateral epicondylalgia secondary to the odd elbow/grip reports.

In terms of elbow clearing and the positives there:
When I cleared the elbow I felt as if the findings were more biceps related and felt I could move away from the “elbow” and relate this more to proximal issues. Important to note that I tested all wrist motions with resistance in lengthened positions so there was no indication of a contractile pathology here.

[Taylor Blattenberger]

So I did not clear the cervical spine. I didn’t move forward with this because all the aggs seemed to be shoulder related and my neck questions came up negative. In retrospect I could have smashed the cluster and removed any doubt there.

I attempted to utilize the impingement cluster to rule in my primary post-subjective differential, but got 0/3. In fact I was very perplexed to come up with (-) ER testing. I really went looking for something here and got proved wrong. So I had to move on.

From there I attempted to think more about the aggravating factors and what tissues were being stressed. I thought about the biceps (+) I got earlier and the sensitivity to extension (dips) horizontal abduction (push ups) and weight bearing in general. With this I pivoted to anterior instability and possible labral pathology.

I started with apprehension/relocation more out of an extension of my PROM exam of shoulder IR/ER at 90. I noted the pain, but did not take this as a great * finding. I chose compressive labral ST due to the WB sensitivity. This was somewhat positive and the fact that the grind was (+) with an anterior GH head shift fit my other findings.

[pbarrettcoleman]

Or just manipulate the thoracic spine.

Don’t give away all the secrets Eric!

As far as clusters of tests, I really like to see for a RTC tendinopathy: ER in different positions of length and location; Full Can in different positions; and (+) TTP to the supraspinatus. I’m not sure if you did those two tests during your exam, but it looks like ER wasn’t that positive, but did you play with it (put it in more lengthened and challenging positions?)

For instance, when I see her resisted abduction being positive, I wonder what her Full Can in abduction would look like and whether a Scap Assist test would help that or not. Then that leads me to looking into scap position, mobility, and MMT of periscapular muscles to build a case to treat that.

As far as labral, I always find that trickier. It seems like you have a fair cluster of anterior instability tests to say that’s what’s going on, but does that fit what her A/PROM looks like? Does she have lots of movement in some directions? Did her ER 90/90 go for days?

[helenrshep]

I like Barrett’s impingement cluster and totally agree about the labral involvement points he made. I have a hard time thinking she wound up with a labral tear from a “bump” a year ago. Does she seem to be hyper-mobile in general? And what did the apprehension test look like on her non-involved side? I’m on board with the biceps involvement based on your thought process, Taylor.

Also – it’s interesting to me that you had adhesive capsulitis as first on your differentials (or maybe your list wasn’t in order). That one is usually further down on my list just because I feel it isn’t quite as common as impingement or other RTC issues. What were your thoughts with that?

[awilson12]

This is speculation and maybe a flawed theory but to Helen’s point of a very trivial trauma leading to a labral tear- I agree that doesn’t seem to match. But with onset of elbow symptoms first could that not being playing into changed mechanics at the shoulder that is revealing some underlying pathology? Any thoughts on this?

In terms of choosing testing clusters for labrum- I like how we talked about in the course and try to use that method during my exam. I attempt (still a work in progress) to take the patients aggravating factors and mechanism of injury and use those to guide special testing. Ex- a compressive type injury would lead me more towards using a cluster with compression rotation, anterior slide, O’Brien’s to mimic forces of MOI and challenge potential structures at fault.

[lacarroll]

I’m thinking along the same lines as Helen- what does her other shoulder look like as far as hypermobility? And does she have a history of playing an overhead sport as a kid/younger adult that may have contributed to some instability that is just now getting noticed because of the other issues going on? And as far as using a cluster of tests, especially with SLAP/bicep concerns, I think adding Speed’s or biceps load II could have (maybe?) given some differentiation to the mechanism of the injury, like Anna was saying, because the bump just doesn’t seem like enough of an impact to have done that much damage at the shoulder.

[Steven Lagasse]

Taylor, there a lot of ideas and moving parts in this discussion. It looks like you undoubtedly have more ideas in your head now. Perhaps take a step back, digest some of this, and make a plan for the next visit?

The patient’s symptoms appear to be bouncing back and forth from shoulder to elbow. The patient also demonstrates grip weakness. With this information, do you feel a cervical radiculopathy cluster is warranted? If negative, perhaps spend more time ruling-out at the shoulder and elbow rather than ruling-in?

After all, as Eric said, concomitant pathology in the shoulder makes things ambiguous. Perhaps if you rule-out additional competing differentials using those test clusters we’ve spoken of in the OMPTS courses, the culprit will begin to surface on its own. Even if this is not the case, it can clear up some of the ambiguity, and allow you to begin treating with more clarity.

Hopefully I’m not merely stating what is already obvious.. *insert cold sweat emoji*

[Taylor Blattenberger]

Awesome guys! Thanks so much for the questions and ideas.

Obviously my exam left me with more questions than answers and I wanted to make part of my second day a bit more evaluation to try and clear the mud. What I found were again, more questions. Day 2 she had (+) H-K and (+) painful arc and her ER was now mildly painful. Impingement? I also cleared her C-spine and performed a neuro exam as I realize my negligence, and got all (-)s. Finally, I tested her grip strength which revealed painless weakness (50% of her unaffected and non-dominant hand). What???

I was so lost, and I feel I may have shown this in my mannerisms because I noticed some confusion from the patient as well. I ended up taking a step back and moving forward much as Steve described. It wasn’t the neck, and probably wasn’t the elbow. A majority of her symptoms were provoked with shoulder movements so I was confident it was some sort of shoulder pathology.

All things considered, the special tests I performed did not help me much. If anything they hurt my treatment at first. Although, if they came back with a recognizable pattern I would have been able to be more specific in my treatment selections and maybe make some quicker improvements. I feel that the use of these tests should be taken with a large grain of salt. If a pattern exists, great! We can move quickly through an algorithm. But if it doesn’t, recognize the poor psychometrics and potential for concomitant pathology. Treat the impairments, be as specific as possible, and reassess, reassess, reassess.

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