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Insidious onset of left shoulder pain
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Insidious onset of left shoulder pain - April 27, 2005 1:32:00 AM
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Alex Brenner PT MPT OCS
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47 year old female states that she has been having superior and lateral shoulder pain for 1 month. Pnt does not recall any trauma. The pain occurs mostly with overhead activities and radiates down the lateral shoulder to about the insertion of the left deltoid. AP and axillary views were obtained. What are the findings?
(all images obtained and used with permission)
[IMG]http://img.photobucket.com/albums/v85/brennerak/Shoulderlady2.jpg[/IMG]
[IMG]http://img.photobucket.com/albums/v85/brennerak/shoulderlady1.jpg[/IMG]
[IMG]http://img.photobucket.com/albums/v85/brennerak/shoulderlady3.jpg[/IMG]
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Alex Brenner, PT, MPT, OCS
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Re: Insidious onset of left shoulder pain - April 27, 2005 2:12:00 AM
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SJBird55
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I don't really see anything in the first two. I've never looked at images like the third one, so I don't know what "normal" should look like, so I can't comment on that one.
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Re: Insidious onset of left shoulder pain - April 27, 2005 3:37:00 AM
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ehanso
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I am not sure but there seems to be very little space between the humeral head and the acromial process. Probably impingement. Also there a couple of small radiolucent oval areas. Are these calicfications in the tendon.
Alex, What how do they grade the angle of the acromial process and what grade is this one?
Thanks for the interesting forum. Ed
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Re: Insidious onset of left shoulder pain - April 27, 2005 3:45:00 AM
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Synergy
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The humeral head appears to be anterior to the acromion in the first 2 views, but not so much in the axillary view.
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Chris Adams, PT, MPT
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Re: Insidious onset of left shoulder pain - April 27, 2005 4:21:00 AM
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JLS_PT_OCS
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She does not have a dislocation, the third view, called the "axillary' view, confirms this.
Her history is consistent with rotator cuff disease, and I would be interested in a Supraspinatus outlet view to look for her acromion morphology.
I see no evidence of calcific tendonitis, do not appreciate any significant AC arthrosis either.
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Insidious onset of left shoulder pain - April 27, 2005 10:32:00 AM
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UTDC
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I agree with Jason. I am also going to go out on a limb...w/ the usual disclaimer regarding my lap top monitor, etc. There appears to be a periosteal reaction at the proximal humeral metaphysis, visible on the Y view.
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Re: Insidious onset of left shoulder pain - April 27, 2005 1:55:00 PM
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KAK
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Anterior downward sloping of the acromion.
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Re: Insidious onset of left shoulder pain - April 27, 2005 3:19:00 PM
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jma
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Decreased space between the acromion and the humeral head. Downslope of the acromion. I know there are different classification types, maybe 1-4. I need to review that again.
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Re: Insidious onset of left shoulder pain - April 28, 2005 3:22:00 AM
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JLS_PT_OCS
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It's always hard to spot acromion type on these views, which is why the supraspinatus outlet view is needed. It does seem to be a morphologically Type III from here.
Type I Flat, Type II Curved, Type III Hooked
Rotator cuff disease and tear incidence go up as the numbers do...
For rotator cuff disease, you want to look at the insertions for enthesopathy or calcific tendonitis, not sure I see that here.
Jeff, the third view is an axillary, not a Y.
In the Y view, it is an en face view of the glenoid and doesn't require the abduction of the shoulder that the axillary view does. That's why it is used in trauma to look for dislocation. The scapula appears as the letter Y, hence the name. The axillary can be painful or impossible to get if the patient is in acute pain, and this series illustrates that she must not be a trauma case, as she has had the axillary view. Which is just as good to examine for dislocation.
Look forward to hearing the outcome...
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Insidious onset of left shoulder pain - April 28, 2005 3:49:00 PM
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UTDC
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thanks Jason, fingers working faster than the brain.
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Re: Insidious onset of left shoulder pain - April 28, 2005 10:00:00 PM
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fapt
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Does the patient have the rotator cuff problem?
I have no idea about the X-ray..
It seems nothing, i guess....
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夏之日，冬之夜，百歲之後，歸于其居。
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Re: Insidious onset of left shoulder pain - April 29, 2005 12:43:00 AM
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Alex Brenner PT MPT OCS
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Lin,
Yes, I think she probably does. On physical exam she has pain over the GH joint with resisted ER and abduction. She also has a positive Hawkins and Neer tests.
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Alex Brenner, PT, MPT, OCS
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Re: Insidious onset of left shoulder pain - April 29, 2005 5:41:00 AM
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JLS_PT_OCS
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Jeff, no prob, happens to me all the time.
You could sure school me on the spine films, bro!
Alex, you got an outlet view to post?
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Insidious onset of left shoulder pain - April 29, 2005 8:17:00 AM
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jma
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Is there abnormal scapulohumeral rhythm present as well?
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Re: Insidious onset of left shoulder pain - April 30, 2005 10:44:00 AM
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Alex Brenner PT MPT OCS
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jma,
Yes and she has a painful arc.
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Alex Brenner, PT, MPT, OCS
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Re: Insidious onset of left shoulder pain - April 30, 2005 12:04:00 PM
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jma
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Hmmm, sounds like impingement to me
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Re: Insidious onset of left shoulder pain - May 1, 2005 10:29:00 AM
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chiroortho
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Just a little supraspinatus tendinosis going on. Small oval opacity a little more proximal than usual noted to be moving in the first two views.
We don't know anything about the bursae (although the painful arc makes me think that it might be nothing more than subacromial bursitis), the labrum, the tendons.
My guess is supraspinatus tendinosis, the old fogeys' disease (I'm 45 so can testify that a 47 year old lady is an old fogey.)
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Greg Priest, DC, DABCO
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Re: Insidious onset of left shoulder pain - May 1, 2005 4:10:00 PM
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Jeep
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It appears there may be some early degenerative changes at the glenohumeral joint and within the capsule(there looks like an increased opacity within the joint, more noticable on the internal rotation view).
Alex- is the axillary view posted upside down? looks like the coracoid is on the bottom?
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Re: Insidious onset of left shoulder pain - May 1, 2005 11:28:00 PM
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Alex Brenner PT MPT OCS
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FINDINGS: The acromion process is laterally down-sloping. Small amorphous calcifications are seen at the upper edges of the glenohumeral joints. These are probably calcifications in the rotator cuffs indicating calcific tendinitis. An additional radiodensity is seen projecting superior to the coracoid process, possibly in the supraspinatus or possibly a bone island in the scapula. No fracture or malalignment is seen. The acromioclavicular joint is unremarkable.
[IMG]http://img.photobucket.com/albums/v85/brennerak/shoulderladyedit.jpg[/IMG]
Normal shoulder to compare the downward sloping acromion.
[IMG]http://img.photobucket.com/albums/v85/brennerak/NormalShoulderAP2.jpg[/IMG]
[IMG]http://img.photobucket.com/albums/v85/brennerak/Acromiontypes.jpg[/IMG]
These are the three acromion types found in the literature under the Bigliani classification and are the ones I learned in school. These are best viewed with the outlet y view that Jason mentioned above. There was a fairly recent study (The relative importance of acromial morphology and age with respect to rotator cuff pathology. Gill et al, J Shoulder Elbow Surgery 2002 11(4): 327-30) that found that 58% of their sample size over the age of 50 with full thickness rotator cuff tears also had a type III acromion.
Does a downward sloping acromion like the one found in our study predispose or correlate with a higher incidence of shoulder impingment?
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Alex Brenner, PT, MPT, OCS
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Re: Insidious onset of left shoulder pain - May 2, 2005 3:35:00 AM
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Shill
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Alex,
Are the last two films the same view? It seems so, but an interesting note is the difference in the superomedial angles of the scapula, in relation to the clavicle.
Just interesting to me at least.
Steve
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Steve Hill PT
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