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case right shoulder pain
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case right shoulder pain - March 3, 2006 4:27:00 PM
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FLAOrthoPT
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From: West Palm Beach
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38 year old female, referral from orthopod for right shoulder impingement, insidious onset, no known etiology, no diabetes, no cardiac disease, no hypertension.
All dermatome, myotome, DTR testing negative.
All ROM negative
Isometric strong and some pain with ER and flexion.
Negative impingement
T Spine clear
C spine clear
complains of pain increasing with heavy lifting, vacuuming, cleaning the floor, bending over and doing chores.
Any guesses, diff. diagnosis here? I will add more objective data as we discuss-
Ben
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Re: case right shoulder pain - March 3, 2006 5:03:00 PM
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nari
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What about neurodynamic testing? ULNTTs?
Pain on bending over gives a lot of clues as to the origin.
Nari
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Re: case right shoulder pain - March 3, 2006 5:32:00 PM
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FLAOrthoPT
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all peripheral nerve testing biasing longitudinal neural mobility (ULNTT) were negative.
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Re: case right shoulder pain - March 3, 2006 6:05:00 PM
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Synergy
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What about special tests for labral pathology? Specific joint testing of GH, AC, and SC joints, i.e. normal translation, painful testing, etc.?
_____________________________
Chris Adams, PT, MPT
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Re: case right shoulder pain - March 3, 2006 10:47:00 PM
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lukee
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From: Sydney, Australia
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Any history of liver problems? any other compalints of peripheral joint pain,stiffness etc.
lukee
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Re: case right shoulder pain - March 4, 2006 12:52:00 AM
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SJBird55
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Any symptoms show up with her systems review?
Does she report any symptoms that indicate a systemic illness?
Anything else that she reports with the behavior of her symptoms?
What medications (both prescribed and over the counter)?
Can she lie on that right side at night?
What about night pain?
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Re: case right shoulder pain - March 4, 2006 3:07:00 AM
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Sean_Collins
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Quick question - "no diabetes, no cardiac disease, no hypertension" how was all of this determined? From patient report? What information was used - glucose tests? CLinical BP measures vs ambulatory or exercise induced BP tests? Stress test?
My only point is that these conditions are known to have a long phase of "pre clinical" (as in not diagnosed yet) build up. The great majority of patients "diagnosed" with cardiac disease, hypertension and diabetes had abnormalities for several years prior to those conditions being recognized or reaching the point of symptoms.
Worth collecting some information about how much effort has been invested to determine whether these conditions are present - especially if you are worried that an underlying systemic medical condition could be interacting in some way.
_____________________________
Sean M. Collins, PT, ScD, CCS
Associate Professor
Research Coordinator
Department of Physical Therapy
Coordinator, Graduate Program in Disability Outcomes
Adjunct Professor, Department of Work Environment
School of Health &
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Re: case right shoulder pain - March 4, 2006 4:16:00 AM
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FLAOrthoPT
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in patient history, stop looking into things so deeply
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Re: case right shoulder pain - March 4, 2006 4:17:00 AM
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FLAOrthoPT
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god you new englanders are so **** uptight! especially you buggers out in the boonies of massachussettes (i am from a CT/Mass border town so I am alowed to make fun of you)
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Re: case right shoulder pain - March 4, 2006 4:17:00 PM
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pwrandall
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I'm thinking along the same lines a Chris here. Anything show with labral testing or biceps special tests. It sounds musculotendinous due to positive isometric testing and no symptoms with PROM. You didn't mention if any imaging studies had been done, but I'm guessing you omitted that on purpose.
PETE
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Re: case right shoulder pain - March 4, 2006 11:49:00 PM
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Sean_Collins
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From: Massachusetts
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All I am saying is that if you obtain such information merely from a patient history and that history does not include any tests as I had described - then those medical issues should not just be ruled out as considerations. How can someone investigate a case without considering all scales - including deep?
Also - Lowell is 25 miles north of Boston and has a population of 125,000 - hardly the boonies. Uptight perhaps, but boonies, not exactly.
_____________________________
Sean M. Collins, PT, ScD, CCS
Associate Professor
Research Coordinator
Department of Physical Therapy
Coordinator, Graduate Program in Disability Outcomes
Adjunct Professor, Department of Work Environment
School of Health &
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Re: case right shoulder pain - March 5, 2006 2:41:00 AM
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FLAOrthoPT
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MRI and X ray of c spine and shoulder negative. Seriously, stop reading into it so much. I am saying for a fact that they are all negative and all clear. I do not want to totally point you in the direction of the case, but I also do not want you getting hung up on cardiac issues or something else it is not. Here is some more info.
She admits she was hospitalized 5 months ago for irregular period with severe cramping to the point she went to the ER. They ran EKG and it was negative.
All special testing of labrum and ligaments of shoulder complex negaitve. Palpation of her flank while stabilizing for sidelying PROM of her shoulder revealed general guarding. You palpate her abdomen and find intense guarding and reboounding over her right lower abdominal quadrant.
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Re: case right shoulder pain - March 5, 2006 4:16:00 AM
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jma
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Did this patient have a fever?
Did the patient have any previous surgeries in the lower quadrant area?
Did the insidous onset occur while moving a heavier than usual object?
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Re: case right shoulder pain - March 5, 2006 6:02:00 AM
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Andrew M. Ball PT PhD
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Back up. Let's start with some subjective basics that we missed before jumping into objective test after objective test, or palpating anything.
First let's ask the 7 essential questions for general health screening:
Fatigue? Malaise? Weakness, Fever/Chills? Unexplained weight gain or loss? Nausea? Parathesia/Numbness?
Then (being that the NMS exam has been completed), we want to consider which organ systems may refer pain to the shoulder. That would generally be Cardiovascular, Pulmonary, and GI. As such, let's ask some additional organ specific questions:
Cardio: Dyspnea? Orthopnea? Palpitations? Pain/Seats? Syncope? Peripheral Edema? Cough?
Pulmonary: Dyspnea? Tachypnea? Cough? Hemoptysis? Sputum? Stridor? Wheezing? Clubbing?
Upper GI: Dysphagia? Nausea? Vomiting? Heatburn/Indigestion? Specific Food Intolerance?
Lower GI: Constipation? Caliber? Diarrhea? Change in Color? Change in continence?
Drew
_____________________________
Dr. Andrew M. Ball, PT, DPT, Ph.D.
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Re: case right shoulder pain - March 5, 2006 6:42:00 AM
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FLAOrthoPT
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here we go now you're talking:
ah the old systems review. Cardio is clear, pulm is clear, upper GI pt does have occasional heartburn takes tums as needed, lower GI negative. Does have slight fever, does have slightly elevated pulse.
So yes, the Doc is on the right path. Shows you how even with a referral from an ortho for the shoulder, doesn't mean they have done a thorough system review especially if there are even minute findings such as the painful strong resistance testing. So, now that we're all on the right path, and got the gist of not being fooled by minor ortho problems being confused for the true source of pain, let's keep diff diag this one.
Remember, it is a flag if severity of symptoms do not match problem or testing. So, at this point what do you do? do you treat, do you refer, do you refer back to ortho or to primary or to another specialist, how do you handle this? what are your hypothesis at this point for two or three possible diff diag?
Ben
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Re: case right shoulder pain - March 5, 2006 6:48:00 AM
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jma
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I'd refer them back to the PCP.
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Re: case right shoulder pain - March 5, 2006 7:08:00 AM
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FLAOrthoPT
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do you report findings to ortho? do you tiptoe aroound? do you refer them to ob gyn, do you tell them to do this asap, do you not show sense of concern, etc, any working hypotheses?
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Re: case right shoulder pain - March 5, 2006 7:15:00 AM
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jma
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Absolutely with a report of the findings, which may not be consistent with an orthopedic problem. Back to general MD, who may or may not have to refer elsewhere, i.e ob gyn.
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Re: case right shoulder pain - March 5, 2006 7:27:00 AM
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SJBird55
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In this case, I'd dig a bit more.
I'd report the inconsistencies and what was not found upon evaluation of the shoulder. Then, I'd report the unanticipated findings.
You need to find out how long she has had a low grade fever. You could check the inguinal lymph nodes. You could do the reisisted straight leg raise or resisted hip flexion in supine (possible abscess).
You also need to dig a bit deeper with the behavior of her symptoms. Also... reassess the pain diagram to be sure that shoulder pain is the only location of symptoms. (Heavy lifting and bending over are not consistent complaints normally reported with shoulder impingement.)
You need to know if she has had a change in the amount of tums she consumes recently. At the same time, review the medications she is taking (both over the counter and prescribed). (ulcer?)
Is she pregnant/could she be pregnant? When did she last menstruate? (ovary issue, ectopic pregnancy?)
We all must be sitting here at the same time... I'd report everything to the ortho and communicate whether I was referring the patient to the primary or to the ob/gyn. It depends on the patient's response to the additional stuff. And depending on the responses to the above, I wouldn't put it in the patient's lap if I was concerned. I'd pick up the phone myself and communicate to whoever was triaging that day at whichever office and communicate the findings and discuss the options.
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Re: case right shoulder pain - March 5, 2006 10:34:00 AM
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Andrew M. Ball PT PhD
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From: Charlotte, NC
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Ben raises a great point. To whom do we communicate, and when? Before making any decision on our options:
1. Treat
2. Treat and Refer
3. Refer
I'd want to know a few more things, at least to communicate information in the most efficient and effective manner, and in a way that the MD/DO is going to hear.
Let's review what we know:
We have a patient with shoulder pain diagnosed as impingement, with clinical findings that do not match that diagnosis. Furthermore, NMS tests for ligaments and labrum are negative. (Have we cleared the neck too?) Patient has a fever, and has occasional heartburn (which may or may not be significant). She had an irregular period 5 months ago and was hosptialized with severe cramping (which may or may not be associated), and palpation of her abdomen (right lower quadrant rebounding) is painful.
With respect to fever, low-grade fevers of 100 degrees or higher for 2 or more weeks are significant, so what do we think? How long has this patient had the fever? If a clinically significant fever, we want to think about what causes fever. The three most common causes are occult infection, RA, and metastatic cancer.
Take into account the fact that the abdomen is tender to palpation, (especially in the right-lower quadrant) the fact that the patient has intermittent heartburn symptoms, and the fact that the patient has a clinically significant fever, and my working hypothesis becomes possible appendicitis or soon-to-be ruptured appendix. Still could be issues with the female reproductive system (ovarian cyst, ruptured ectopic or CA), as SJ points out, but that would be inconsistent with some of the other GI symptoms reported. Nevertheless, some of these OB/Gyn symptoms can be quite serious as well.
As I work in a hospital outpatient clinic, these would be the findings that I'd report to the intake coordinator, upon transfer from the rehabilitation department, over to our emergency department. Given the information as I understand it, there is reasonable potential for appendicitis, and/or ruptured ectopic. If the former is correct, who knows when the appendix will burst. If it's a ruptured ectopic, that's very serious too. This patient is going to the ED, and I'm not consulting with the Ortho, nor the PCP. Time is a factor. I'll call the PCP and let them know what's going on after I get back from the ED.
_____________________________
Dr. Andrew M. Ball, PT, DPT, Ph.D.
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