Author: Nathan Cardoos, MD
Co Author #1: Lee Mancini, MD
Co Author #2: John Herbert Stevenson, MD

Patient Presentation:
Shoulder pain and winged scapula

History:
A 19-year-old college student, landscaper and recreational weightlifter presented to his primary care provider with a “powerful dull pain” in his right upper back and shoulder that awoke him from sleep. The severe pain lasted 5 hours and was followed by soreness, decreased range of motion and weakness. The patient denied any recent or past trauma or injury. Personal medical history, surgical history and family history were unremarkable.
 
Two weeks prior to the onset of pain, his general physical activity level had been significantly decreased due to a diagnosis of infectious mononucleosis(confirmed by monospot).
 
At his initial sports medicine visit one week after the painful episode, he had pain with shoulder abduction >90º and mildly decreased internal rotation. He was diagnosed with shoulder impingement syndrome and latissimus dorsi strain and referred to physical therapy.
 
He returned 8 weeks later without completing any of the prescribed physical therapy. He reported resolution of the pain but noted 3-4 weeks of “bulging in the back of his shoulder” and difficulty performing the military press exercise.

Physical Exam:
Right shoulder:
No skin changes, edema or erythema were present. The trapezius muscles were symmetric with normal tone. Moderate medial winging of the right scapula was noted, which was exacerbated with wall push-ups. There was no tenderness to palpation over the entirety of the shoulder or scapula.
Active abduction of the right shoulder was 130º. Forward flexion was 160º. External and internal rotation were normal. Normal ROM of the left shoulder.
Biceps, triceps, deltoids and grip strength were 5/5. Empty can test was 5/5 strength and without pain. External and internal rotation strength were 4+/5.
Neer’s, Hawkin’s, Speed’s, Cross arm and O’Brien’s tests were negative.
Radial pulses were normal bilaterally. Brisk capillary refill was present bilaterally. Sensation was intact to light touch in the bilateral upper extremities. Biceps reflexes were normal and symmetric.
Neck: Full ROM was present in all planes and Spurling’s test was negative.

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