Comprehensive Upper Quadrant Screening and Shoulder Differential Diagnosis

Clinical Case Study: 29-Year-Old Female with Shoulder Pain

• Patient Profile:

  • Demographics: 29-year-old woman.
  • History of Present Illness: Insidious onset of right (R) shoulder pain beginning 8 months prior to the initial exam.
  • Progression: Symptoms steadily worsened over the last 5 months, specifically involving a loss of mobility and increased pain.
  • Previous Medical Consultations:
    • Primary Care Physician (PCP): No imaging performed. Diagnosis was "Right shoulder pain." Prescribed NSAIDs (provided initial immediate relief) and a handout for shoulder range of motion (ROM) exercises to be performed $2 \times / \text{day}$.
    • Orthopedic Surgeon: Shoulder radiography was negative. Diagnosis was "Frozen Shoulder." Administered a corticosteroid injection.
    • Physical Therapy (PT): Attended PT $2 \times / \text{week}$ for 4 weeks.
    • Imaging: Ultrasonography revealed a partial thickness tear at the supraspinatus.
    • PT Treatment/Response: Initially showed some improvement in pain and mobility but plateaued after 2 weeks. Treatments included modalities for pain/inflammation reduction, manual therapy (soft tissue mobilization and joint mobilization), and therapeutic exercise.

• Physical Therapy Interview Findings:

  • Pain Characteristics: Deep ache in the right shoulder with stabbing pain at extreme ranges; occasional referral into the upper arm region.
  • Functional Impact: All Activities of Daily Living (ADLs) involving the use of the Right Upper Extremity (R UE) are affected.
  • Sleep Profile: Difficulty sleeping at night. Hard to find a comfortable position; often awakened and must get up to move the arm to achieve relief.
  • Aggravating Factors: Moving the R shoulder; touching certain areas (patient states: "if someone bumps into me I almost go to my knees with pain").
  • Cervical Involvement: Occasional R-sided cervical pain which is increasing.
  • Systems Review: Gastrointestinal (GI) and Cardiopulmonary (CP) functions reported as normal.
  • Pain Localization: Denies pain referral distal to the proximal arm.
  • Medical History: Past Medical History (PMHX) is unremarkable.
  • Family History: Family history of lung cancer.
  • Constitutional Symptoms: Patient reports, "Feel like I don't have much energy past few months."
  • Social History: Raising two children (ages 6 and 2).

• Review of Systems (Physical Findings):

  • Vitals:
    • Pulse: $72\,pps$
    • Blood Pressure (BP): $128/84\,mmHg$
    • Weight: $140\,lbs$; Height: $5'7''$
    • BMI: $21.9$
  • Integumentary: Normal.
  • Mobility: All movements independent except R UE, which is limited in all planes and reproduces pain with observed distress.

• Physical Examination - Tests and Measures:

  • Pain Scale:
    • At rest: $4/10$
    • During movement: $5-6/10$
    • End range: $8-9/10$
  • Posture: Cervical forward posture; right shoulder is forward and high.
  • Active Range of Motion (AROM):
    • R Shoulder: Flexion (Flex), Abduction (Abd), External Rotation (ER), and Internal Rotation (IR) are all limited by approximately $50\%$.
    • Cervical: Forward bending (FB) and Left Side Bending (LSB) limited by $25\%$ with positive ($+$) left scapula pain/tightness. All other motions are within normal limits (WNL).
  • Passive Range of Motion (PROM) - R Shoulder: All motions guarded and painful.
    • Flexion: $70^{\circ}$ (Empty end feel)
    • Extension: $18^{\circ}$
    • ER: $20^{\circ}$ (Empty end feel)
    • IR: $25^{\circ}$ (Capsular end feel)
    • Abduction: $65^{\circ}$ (Empty end feel)
  • MMT: Deferred.
  • Neurological: Normal Deep Tendon Reflexes (DTRs) and sensation.
  • Accessory Motion: All glides restricted. Distraction provided no relief.
  • Palpation: Tenderness from the anterior joint to the acromial borders. Positive ($+$) Tap test at the scapular spine.

• Outcome and Final Diagnosis:

  • Diagnostic Findings:
    • Bone Scan: Focal intake at the scapula.
    • CT/MRI: Lytic lesion in the glenoid and coracoid.
  • Diagnosis: Osteoblastoma.
  • Imaging Detail: A Short Tau Inversion Recovery (STIR) sequence of an MRI demonstrated a high signal intensity lesion in the coracoid with surrounding soft-tissue edema.

Comparison: Frozen Shoulder Syndrome (FSS) vs. Neoplasms

• Shoulder Girdle Neoplasms Mimicking Frozen Shoulder (Robinson et al., 2003):
  • Neoplasms often present with insidious onset and mimic early-to-middle course stages of FSS, including musculoskeletal signs and negative initial radiographs.
  • True FSS Presentation ($n=50$):
    • Mean Age: $60$
    • Duration of symptoms: $10\,\text{weeks}$
    • History of Cancer: $6/50$
    • Fatigue Scale (RAND SF-36): $52 \pm 16$
  • Neoplasm Presentation ($n=7$):
    • Mean Age: $38$
    • Duration of symptoms: $5\,\text{months}$
    • History of Cancer: $1/7$
    • Presence of discrete bony tenderness (Clavicle, coracoid, humeral head, scapular spine and body).
    • Positive Tap Test.
    • Fatigue Scale (RAND SF-36): $32 \pm 7$ (Lower score indicates higher fatigue).

Anatomy and Common Shoulder Disorders

• The Three Major Bones of the Shoulder:

  • Clavicle (Collarbone).
  • Humerus.
  • Scapula (including the Acromion and Coracoid process).

• The Four Shoulder Joints:

  • Sternoclavicular (SC).
  • Acromioclavicular (AC).
  • Glenohumeral (GH).
  • Thoracoscapular (often considered a functional joint).

• Rotator Cuff Muscles:

  • Subscapularis (Anterior).
  • Supraspinatus (Superior).
  • Infraspinatus (Posterior).
  • Teres minor (Posterior).

• Top 5 Most Common Shoulder Disorders (Maloney & Ryder, 2003):

  1. Rotator Cuff disorders ($>40\,\text{years old}$).
  2. Bursitis and tendonitis.
  3. Impingement syndrome.
  4. Calcific tendonitis.
  5. Glenohumeral Instability (common in young, active populations).
  6. Adhesive Capsulitis (Frozen shoulder).
  7. Osteoarthritis (OA) of the GH joint ($>50\,\text{years old}$), AC joint, or SC joint.
  8. SLAP lesion (Superior Labrum, Anterior to Posterior).

• Secondary Soft Tissues involved in Acute Pain:

  • Supraspinatus tendon.
  • Other rotator cuff muscles.
  • Subacromial bursa.
  • Joint capsule and intra/extra-articular structures.

Systemic Causes of Joint Pain

• General Systemic Factors:
  • Allergic reactions (e.g., to antibiotics).
  • Medication side effects (Statins, prolonged corticosteroids).
  • Chemical/Environmental factors (delayed reaction).
  • Sexually Transmitted Infections (STIs: HIV, syphilis, chlamydia, gonorrhea).
  • Infectious Arthritis, Infective Endocarditis, and Lyme Disease.
  • Autoimmune/Rheumatic: Rheumatoid Arthritis, Lupus, Scleroderma, Polymyositis.
  • Cancer: Leukemia.
  • Infections: Tuberculosis, Acute Rheumatic Fever.
  • Organ Disease: Chronic liver disease (causing arthralgias), Inflammatory Bowel Disease (Crohn’s disease).
  • Psychological: Anxiety or Major Depressive Disorder.
  • Other: Fibromyalgia, Artificial Sweeteners.

Referred Pain Patterns to the Shoulder

• Most Common Reflected Source: Cervical Spine (Dermatomal referral).

  • $C5$ is the #1 referral source.
  • $C4$ refers to the AC joint.

• Visceral Sources of Referred Pain:

  • Heart: Angina or Myocardial Infarction (MI).
  • Lung: Pleuritic conditions, apical tumors.
  • Diaphragm: Stimulated by the Phrenic nerve ($C3-C5$). Impingement on the central diaphragm refers pain to the suprascapular area, upper trapezius, and posterior shoulder (rarely anterior).
  • Liver and Gallbladder: Right shoulder referral via the phrenic nerve or right splanchnic nerves.
  • GI System: Gastritis.
  • Spleen: Kehr’s Sign (Left shoulder pain associated with spleen damage).
  • Pancreas: Pancreatitis.
  • Gynecological: Ectopic Pregnancy.
  • Rena/Urologic: Kidney disorders or abdominal aortic aneurysms.

Screening for Specific Pathologies

• Oncological Screening:

  • Past history of cancer.
  • Age ($<20$ or $>50$).
  • Insidious onset.
  • Empty end feel on PROM.
  • Constitutional signs (Weight loss, fatigue).
  • Associated neurological symptoms or suspicious palpation/bony tenderness.

• Pulmonary Screening:

  • Sharp, localized pain aggravated by respiration.
  • Pain worsens with recumbency.
  • Pain relieved by "autosplinting" (lying on the painful side).
  • Pleuritic components: cough, wheezing, tachypnea, dyspnea.

• Cardiovascular Screening (Angina/MI):

  • Pain starts $3-5\,\text{minutes}$ after exercise (including upper extremity exercise).
  • Pain relieved by Nitroglycerin.
  • Pain unaffected by position, breathing, or movement.

• GI and Renal Screening:

  • Shoulder pain occurring $2-4\,\text{hours}$ after taking NSAIDs (GI irritation/bleeding).
  • Pain (or relief) occurring $30\,\text{minutes}$ to $2\,\text{hours}$ after eating.
  • Lower GI/Liver: Bilateral Carpal Tunnel Syndrome (B CTS) due to increased serum ammonia and urea levels (peripheral nerve dysfunction).

Rheumatoid Arthritis (RA)

• Pathogenesis:

  • Autoantibodies (Rheumatoid Factor) react with immunoglobulins in blood and synovium.
  • Cytokines: Tumor Necrosis Factor (TNF) stimulates interleukins, causing massive inflammation.
  • TNF stimulates protein-degrading enzymes that lyse cartilage and destroy soft tissue.
  • TNF inhibits bone formation and induces resorbtion.
  • Synovial Attack: Thickening and swelling lead to "Pannus." The synovium loses the ability to lubricate/nourish the joint, destroying collagen and tendon.

• Clinical Onset:

  • Gradual onset over weeks/months.
  • Overwhelming malaise and fatigue.
  • Diffuse musculoskeletal pain.
  • Morning stiffness lasting longer than $45\,\text{minutes}$.
  • Common involvement of MTPs (Metatarsophalangeal) and MCPs (Metacarpophalangeal).

• Red Flags for Rheumatic Disease:

  • Symmetrical and bilateral symptoms (e.g., bilateral carpal tunnel).
  • Signs of inflammation that come and go (exacerbation and remission).
  • Associated dermatological signs (rashes, Raynaud’s phenomenon).

Medication-Induced Symptoms

• Core Principle: Medications may be the most common cause of systemically induced neuro-musculoskeletal signs.
• Specific Examples:
  • Statins (Lipitor, Zocor): Relatied to muscle pain/myalgias.
  • NSAIDs: Irritate the GI system; ulceration occurs in $15-30\%$ of chronic users.
  • Cardura (ACE Inhibitor): Used for HTN and cholesterol.
  • Flomax: Acts on the SNS for enlarged prostate.

Clinical Reasoning and Interview Questions

• Night Pain: "Does your pain ever wake you at night?"
  • Follow-up: "How do you get back to sleep?"
  • Cancer-specific: Pain is usually intense and constant. Nothing relieves it, or it gets progressively worse.
• Injury/Trauma: "Injuries in the last week?"
  • Follow-up: "Where were you hit?"
  • Connection: Left shoulder pain ($+$, Kehr's sign) may indicate spleen damage from trauma.
• Fatigue: "Unusual fatigue in the last few weeks?"
  • Follow-up: "Are there constitutional signs?"
  • Significance: Low energy may indicate systemic illness, cardiac issues, or malignancy.

Summary Statistics

• Upper Extremity Complaints: 2nd most common complaint in primary care (Karnath, 2003).
• Chronic Joint Pain Prevalence:
  • Shoulder: $9.0\%$
  • Elbow: $4.5\%$
  • Hip: $9.0\%$
  • Wrist: $6.5\%$
  • Knee: $20.3\%$
  • Ankle: $6.7\%$
  • Fingers: $9.0\%$
  • Toes: $3.7\%$
  • Any chronic joint pain: $31.0\%$
• Frozen Shoulder Stages: Typically develops slowly in three stages: Painful stage, Frozen stage, and Thawing stage. Each can last months.