Bilateral Shoulder Pain #2

Chief Complaint: A 48 year-old male with a history of C8 ASIA A injury presents with 3 months of worsening shoulder pain.

DOMAIN A: DATA ACQUISITION

+ What are the key components of this patient’s history and physical examination?

Relevant History:

  • How did this begin? Onset and context of symptoms?
  • Location, duration, intensity, quality, radiation, constant/intermittent, aggravating/alleviating factors?
  • Is the pain unilateral or bilateral?
  • Is there associated changes in terms of weakness, numbness, tingling, bowel/bladder dysfunction?
  • What is the history of the SCI? How long ago was it, what was the etiology, hospital course, workup, treatment, etc.?
  • Any workup or treatment so far for this pain?
  • Functional history and current functional status, including equipment usage?
  • What kind of wheelchair does the patient use? Manual/power? How old is the chair? Is it in a good state?
  • Family history?
  • Past Medical and Surgical History?
  • Social and work history?
  • Medications?

Relevant Physical Examination:

  • Vital signs
  • Inspection
  • Palpation
  • Manual muscle testing of bilateral upper and lower extremities
  • Sensory and reflex testing of bilateral upper and lower extremities
  • Special testing: Hawkins, Neer, O’Brien, Speed, Painful Arc, Empty Can, Drop Arm Test, Scarf
 

DOMAIN B: PROBLEM SOLVING

The patient is a 48 year-old male who sustained a traumatic C8 ASIA A injury 3 years ago in a surfing accident. He is modified independent and utilizes a manual wheelchair for mobility. On physical examination, he demonstrates 5/5 strength in elbow flexion, wrist extension, and elbow extension bilaterally, with 3/5 strength in his finger flexors, 0/5 strength in 5th digit abduction bilaterally, and 0/5 strength in bilateral lower extremities. He has 3+ patellar and achilles reflexes with several beats of ankle clonus bilaterally. He has pain with Hawkins and Empty Can maneuvers bilaterally. His wheelchair appears to fit him well and be in good condition.

+ What is your differential diagnosis for this patient's shoulder pain?

  • Rotator cuff tear, rotator cuff impingement, subacromial bursitis, glenohumeral joint arthritis, acromioclavicular arthritis, myofascial pain, cervical radiculopathy, Parsonage-Turner Syndrome

+ How would you proceed with this patient?

  • Bilateral shoulder x-rays
  • Physical therapy
  • Oral acetaminophen and/or NSAIDs, topical ice/heat, topical diclofenac gel
  • Consider shoulder injections (subacromial bursa, glenohumeral joint, acromioclavicular joint)

+ Challenge Question

  • What would you write on the physical therapy prescription?**

+ Challenge Answer

  • Physical therapy: 2-3 times per week for 6-8 weeks, focused on strengthening posterior shoulder girdle/rotator cuff and scapular stabilizer musculature, with stretching of anterior shoulder musculature. Heat, ice, massage as needed. Home exercise program.
  • These patients often have an imbalance of anterior "pushing" muscles being far stronger than posterior "pull" muscles.
 

DOMAIN C: PATIENT MANAGEMENT

Workup reveals:

  • Bilateral shoulder x-rays: mild glenohumeral joint space narrowing with subchondral sclerosis.

  • The patient performs your suggested treatment regimen and returns to your office 2 months later noting no improvement in pain.  You perform bilateral subacromial bursa corticosteroid injections with minimal benefit. 

+ What is your next step, and why?

  • MRI of bilateral shoulders to better elucidate the cause of the patient's pain by examining soft tissue structures such as the rotator cuff musculature, bursae, articular cartilage, and labrum.

+ Your next step leads to the following:

  • MRI of bilateral shoulders reveals no significant soft tissue abnormalities. There is again minimal degenerative changes of the glenohumeral joint bilaterally.
  • You inform the patient of these results.
 

DOMAIN D: SYSTEMS-BASED PRACTICE

The patient notes that his pain is worsening and he can no longer work at the post office.

+ How would you proceed?

  • I would repeat vital signs and physical exam to see if anything has changed objectively. I would inquire as to any symptomatic or neurologic changes.

+ Further investigation reveals the following:

  • The patient feels weaker in his arms, specifically that it is more difficult to push his wheelchair over the past few weeks. On examination, he demonstrates increased hyperreflexia compared to baseline.

+ What is your next step, and why?

  • I would obtain an MRI of the cervical spine. I am concerned for a progressive lesion in the cervical spinal cord, given the patient’s worsening pain, weakness, and hyperreflexia.

+ Your next step leads to the following:

  • MRI of the cervical spine reveals a cystic intramedullary expansion spanning from C5-T2.

+ How would you proceed?

  • Neurosurgery consultation for syringomyelia to consider possible shunting and/or other surgical interventions. I would also discuss that short-term disability permissions is a reasonable pursuit at this time, and that I am happy to assist with the necessary paperwork.
 

DOMAIN E: INTERPERSONAL AND COMMUNICATION SKILLS

You recommend neurosurgical consultation to the patient.  This is the role-playing portion of our case.  Pretend that I’m the patient.

Patient: “Doctor, I actually feel like the therapy and home exercises have started to kick in.  I know if I keep lifting weights and getting stronger my pain will get better.  I’m not going to see the surgeon.”

+ What is your response?

  • I am so glad that you are so invested in your health! You have faced a lot of challenges, and your motivation and discipline to improve yourself is admirable. Unfortunately, given that we were not able to identify a true source of your pain in your shoulders, and that our interventions did not provide you significant benefit until possibly right now, the most likely cause of your symptoms is actually the fluid that has built up in your neck that we identified on MRI. This is not something that can be rehabilitated with physical therapy and exercise, and does require surgical intervention to treat, or we risk losing more function in your arms in terms of strength and sensation. Please let me know if any of that does not make sense, and I would be more than happy to explain in more detail. In addition, what particular concerns do you have about speaking with a neurosurgeon? Is there anything about this consult that I can help explain? I want to reassure you that we are not signing you up for surgery; we are merely exploring your options and having a conversation with a neurosurgeon to see what he or she might be able to offer you. Does that sound all right? Would you possibly be open to seeing the neurosurgeon and listening to their thoughts?
  • Note: Always keep syringomyelia in mind in patients with history of SCI who develop progressive pain or functional loss. This diagnosis can be easy to miss!