Author: William Denq, MD
Co Author #1: David Petron, MD

Patient Presentation:
30 year old pilot presents to clinic with complaints of worsening right shoulder pain over the past several months.

History:
30 year old pilot presents to clinic with complaints of worsening right shoulder pain over the past several months. He reports weakness and pain in the right shoulder that has been progressively worsening despite home physical therapy and frequent workout routines at the gym. The pain is located at the lateral aspect of his shoulder as well as the area around his clavicle. The pain is up to a 9 out of 10 at its worst. He reports that he has difficulty lifting things above his head with his right hand and that he is now experiencing significant discomfort when he tries to sleep. He has attempted different modalities including a back strap to help him slightly. However, the pain has become persistent and ibuprofen and acetaminophen are no longer working. He reports that his neck has been bothering him as well. No neck pain currently. Denies fevers, chills, recent injury/trauma, paresthesias.

Of note, he was seen 7 months prior for bilateral shoulder pain and low back pain that had been slowly developing for several years. He reported that sitting for long periods of time as a pilot seems to worsen his pain. It worsened with bench pressing, lateral arm lift and sleeping. At the time, it was noted that there was atrophy in the upper trapezius. He was diagnosed with acute pain of both shoulders and chronic midline low back pain with a recommendation for MRI of the right shoulder and physical therapy for shoulder and low back and core strengthening.

No medical history. No surgical history. Does not smoke. Drinks alcohol occasionally. No drugs. Mother with some type of muscle problem. No other family history.

Physical Exam:
Alert and Oriented x 3
Constitutional: Well appearing male
Skin: No rashes, erythema, or induration
Pulmonary: No labored breathing, no wheezing
Cardiovascular: Distal pulses intact, well perfused
Musculoskeletal Exam:
Shoulder Exam: Inspection - No deformity, erythema, edema, ecchymoses. Muscle atrophy noted of the right trapezius Case Photo #1 and scapular winging noted on the right Case Photo #2 .


Palpation: No tenderness to palpation at the acromion, humeral head, bicipital groove, coracoid process, sternoclavicular joint, clavicle, AC joint, trapezius, rhomboids.
Range of motion: Early rotation of the scapula winging in active abduction, hiking noted of the right, full forward flexion, external rotation, internal rotation to L1 versus T10.
Strength 4/5 resisted abduction on the right. 5/5 in resisted ROM
Special testing: Neer's negative, Hawkin's negative, empty can negative, cross arm negative, impingement negative, apprehension test negative, sulcus sign negative, Speed's negative, clunk negative.
Neurovascular: Intact, capillary refill less than 2 seconds.

Click here to continue. Challenge yourself by writing down a broad differential diagnosis before moving to the next slide.