Background
This insidious shoulder pain case focuses on comprehensive history taking, interpretation of imaging and physical examination findings and management planning in constrained occupational settings.
Minimum Level
New graduate Physiotherapist
History
David is a 53 year old audio-visual technician who installs TV, speaker and other wired systems. He has worked in this occupation for over 25 years.
Does this extended history of working in this occupation affect your reasoning on likely diagnoses and potential causes? How so?
Mentor’s reasoning:
He recently completed a two week job installing home entertainment systems for a new residential complex. This involved installation of wiring in awkward overhead positions and carrying heavy supplies up multiple flights of stairs.
In the second week of this job, he noticed a lingering Right (dominant) shoulder pain which worsened each day. This pain has continued at the same intensity for four weeks since completing the job.
What further clarifying questions might you ask regarding this information?
David currently notices the shoulder pain most with overhead positions, particularly with fine motor tasks like wiring, and when working under benchtops and desks. He also has pain at night when side lying on either side.
How does this information affect your diagnostic reasoning?
What are your three most likely diagnoses at this stage?
He is unable to rest from his job or avoid overhead positions as he is works alone in his own business.
In light of this, provide some suggestions relating to David’s working environment that we might integrate into our management.
On the advice of his doctor, David tried paracetamol for one week but with no effect.
Does this impact your diagnostic reasoning?
Imaging
David was referred for an ultrasound of the shoulder and X-ray of the neck.
The ultrasound showed a partial tear in his Supraspinatus tendon and some calcification at the rotator cuff insertion.
Discuss the ultrasound findings and the accuracy of ultrasound for shoulder injuries.
His X-ray showed spondylosis with Right > Left facet degeneration and some Right-sided exit foramen narrowing around C4 and C5.
Discuss the X-ray findings and the accuracy of X-ray for neck conditions.
Physical examination
David’s shoulder range is not restricted but he experiences shoulder pain at end range flexion and abduction from 80 degrees onwards.
Does this match your expected findings given your top three potential diagnoses above? Does it affect the order of your most likely diagnoses?
You perform a Hawkins-Kennedy test which causes shoulder pain and has reduced range compared to the Left side.
Discuss what constitutes a positive Hawkins-Kennedy test and what it may indicate.
In the apprehension position, David experiences shoulder pain similar to his presenting symptoms.
Discuss a positive result in the Apprehension test and whether you think David’s test is positive.
On palpation, there are no symptomatic areas.
Does this affect your diagnostic reasoning?
On isometric muscle tests (IMT), David is strong and has no symptoms.
Explain why IMT in neutral may not trigger symptoms of a rotator cuff injury.
Describe which tests you would perform for the Cervical Spine and A/C joint.
Management planning
Discuss your two most likely diagnoses and justify each one based on the available information.
What is the likelihood of both pathologies co-existing?
Select three management approaches and how you would apply them to David’s injury. Remember that he is already quite strong due to the nature of his work and he is unable to restrict or avoid work.
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