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A 37 yr old presents with a 7 month history of job-related progressive pain and loss of left shoulder movement. She also reported a 2 year history of mild right wrist and hand pain related to overuse. The patient’s job involved monitoring incoming mail, which required repeated opening and lifting of mail packages. The patient reported that the symptoms had a fairly abrupt onset consisting of very severe left shoulder and neck pain. Within several days, she also had left forearm and thumb pain of lesser severity. At or around the onset of pain, she also noted weakness of the left shoulder. There was no history of macrotrauma to the left shoulder. After 3 months, she was having difficulties performing her job functions and sought medical attention. Her primary care physician the diagnosis of work-related frozen shoulder induced by repetitive use injury from mail and package opening and prescribed range of motion exercises to be performed at home. The condition worsened, with increased pain and complete loss of shoulder range of motion. She was no longer able to work and was placed on disability for 2 months. She also reported pain related sleep disturbance. Her current symptoms were described as diffuse pain in the shoulder girdle, with some radiation of the pain into the hand, thumb, index finger, ring finger, and little fingers. The patient reported no recent immunizations, or febrile illness. She had a medical history of mitral valve prolapse. There was no family history of neuromuscular disease. During her latest visit to the primary care physician, physical therapy was prescribed, again with a diagnosis of frozen shoulder.

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What aspects of the subjective history cause you to be concerned?

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There are several aspects from the subjective history that should cause the clinician concern. These include the progression of pain and loss of function over a period of seven months, the sudden and abrupt onset of the symptoms (if the clinician suspected an overuse injury that should typically have been accompanied by a gradual onset of symptoms), the complete loss of shoulder range of motion, and the distribution of symptoms that do not appear to follow any recognized dermatomal or peripheral nerve pattern.

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Does this patient warrant an upper quarter screening examination?

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This patient clearly warrants an upper quarter screening examination.

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The physical examination revealed the following findings:

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  • There was marked visible atrophy of ipsilateral spinatii, deltoid, and serratus anterior muscles.
  • There was scapular winging, accentuated by having the patient hold her arms forward horizontally against resistance.
  • Motor power of the left shoulder musculature, rated at four of five for the left deltoid, biceps, and triceps on manual muscle testing, was influenced by pain.
  • Both light touch sensation and reflexes of the upper extremities were normal.
  • Results of Spurling's test were negative.
  • Left shoulder ...

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