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A 22-year-old male patient who lives at home with his parents reported an insidious onset of intermittent left shoulder pain, with occasional referral of pain into upper left arm that began 2 weeks ago. The patient denies numbness or tingling into the left upper extremity. The pain increased sufficiently this past week to prompt patient to see a physician, who diagnosed the condition as rotator cuff impingement, and prescribed physical therapy and NSAIDs. The patient was also placed on work restrictions; maximum lift limited to 10 lbs. the patient has no past history of left shoulder pain and his past medical and surgical history is unremarkable. The patient reported stiffness and soreness of the left shoulder upon arising in the morning and again at the end of the day after working. Difficulty was also reported with putting on a jacket, driving to work which takes 45 minutes, and the use of a hedge trimmer. The patient reported that the shoulder pain interrupts his sleep 2 to 3 times every night, and that he was having difficulty combing his hair, brushing his teeth, or lifting his arm without pain. He also reported that he enjoyed swimming but cannot swim the crawl or backstroke because of the pain. The patient described “cracking” and “popping” of the shoulder with activity. Pain rated at 5 to 6 out of 10 on a visual analogue scale.

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What structure(s) do you suspect to be involved in this patient?

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Based on the findings from the physical examination, what is your provisional diagnosis?

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What could the history of pain with certain overhead movements indicate?

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Pain with overhead movements has been associated with an ischemic wringing out of the less vascular portion of the supraspinatus tendon -- the so-called arc of pain. The painful part is caused by a rubbing of the underside of the acromion against a structure located within the subacromial space.

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Why do you think the patient’s symptoms are worsened with certain functional and recreational activities?

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The functional and recreational activities noted to cause an increase in the patient symptoms all involve a decrease in the subacromial space.

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Does this presentation/history warrant a Cyriax upper quarter/quadrant scanning examination?

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An upper quarter screening examination would not be necessary with this patient.

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What should the physical examination include with this patient?

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The physical examination of the patient should include observation, an inspection for muscle atrophy, palpation examination for areas of tenderness and crepitation, measurements of active and passive range of motion, including observation of symmetry of scapulothoracic motion, muscle testing of all major muscles about the shoulder, and special tests. The cervical ...

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