A 48-year-old painter, who spends much of his professional time painting ceilings, complains of left anterior shoulder pain, and inability to raise his arm above shoulder height without pain. The patient reports a medical history of rotator cuff impingement and suspected tear of his left shoulder of several years duration that was operated on last year. The past medical history also includes generalized arthritis in both upper extremities.
After this brief history, what is your best working hypothesis?
The best working hypothesis for this patient would be shoulder impingement syndrome/bicipital tendinitis.
Does the patient's condition warrant a scan examination? Why or why not?
This patient warrants an upper quarter screening examination as a number of structures and conditions can refer pain to the shoulder.
What is your differential diagnosis?
The potential causes of shoulder pain are numerous. The differential diagnosis for shoulder pain in association with inability to raise the arm above shoulder height would include shoulder dislocation/separation, synovitis, tendinous and capsular lesions, acute arthritis, neuritis, and cervical referral.
The physical examination revealed the following findings:
- No observable muscle atrophy around the left shoulder.
- Tenderness to palpation over the left bicipital groove.
- Shoulder abduction in either direction of glenohumeral rotation is painful.
- Muscle strength is good throughout, except for left forearm supination (good minus) and left elbow flexion (good). Resisted left elbow flexion with the forearm fully pronated is mildly uncomfortable, whereas resisted elbow flexion in supination is most definitely painful.
- There is normal joint play present in all joints of both shoulder girdles except for tightness of the posterior glenohumeral joint capsules.
- The following special tests were positive: impingement sign, and Speed’s.
What most likely accounts for this individual's anterior shoulder pain?
List five provocative tests implicating lesions of the biceps brachii tendon.
Biceps instability test, Ludington's test, Yergason’s sign, Speed’s test, and DeAnquin’s test.
How is the bicipital groove best palpated?
The bicipital groove is best palpated by positioning the humerus in about 10 degrees of internal rotation, which places the long tendon facing directly anteriorly. The tendon can then be palpated 6 cm below the acromion.
Why is the biceps sometimes referred to as the 5th rotator cuff muscle?
Having made a provisional diagnosis, describe the various stages of your intervention?
How would you describe the pathological process behind this condition to the patient?