Maria Margarita A. MejiaNovember 18, 2010

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Identifying DataRN, 63 y/o Filipino female, right-handedRoman CatholicFrom CaviteInformants

Patient: Good reliabilityDaughter: Good reliability

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Chief ComplaintLeft shoulder painLimited movement of the shoulder joint

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History of Present Illness10 days PTC

Experienced pain (10/10) and immobilization of the left shoulder while laundering foam mattress

Movement before injury: tossing the mattress over

Radiation of pain and immobilization to the forearm

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History of Present Illness10 days PTC

No popping sound or dislocations were notedAssociated with the following symptoms:

SwellingFever for 2 days took paracetamolDifficulty of sleeping for 3-4 days

No consult done

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History of Present Illness8 days PTC

• Sought consult at a private clinic – prescribed the following medications:– Paracetamol + Vitamin B (1 tab TID) did not

afford pain relief– Amlodipine, 5mg (once a day)– Roxithromycin (1 tab, BID)

• Advised x-ray of the shoulder – read as posterior dislocation of the right shoulder joint

• Self-medicated with Diclofenac (Voltaren) – (+) pain relief

History of Present IllnessOn the day of consult

• Persistence of symptoms prompted consult at a private clinic where she was prescribed Celecoxib 200mg tablet, twice a day

• Referred to our institution for consult

Other HistoryPertinent ROS Functional HistoryNo Fever, weight gain or

weight loss, easy fatigability

No Headache, seizures, blurring of vision, ear problems

No Dyspnea, cough, coldsNo Palpitations, chest painNo Nausea, vomitingNo Dysuria, frequency(+) stomach irritation

Unilateral hand useDifficulty bathing and

doing household choresAble to eat and write

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Other HistoryPast Medical History Personal-Social History

Cardiac hypertrophyHypertension (?)

RetiredMarriedLiving with her daughter

in Cavite

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Vitals: BP 110/70, 36.4oC (afebrile), RR 20, HR 78

• General: conscious, coherent, alert, not in cardiorespiratory distress

• HEENT: Anicteric sclerae, pink palpebral conjunctiva, neck veins non-distended, no cervicolymphadenopathies

• Chest: Symmetric chest expansion, no retractions , clear breath sounds

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Physical Exam

Physical ExamCardiovascular: Adynamic precordium,

distinct heart sounds, regular cardiac rate and rhythm

Abdomen: Flat, no masses palpated, normoactive bowel sounds

Digital rectal exam: not done

Physical ExaminationExtremities: Full and equal pulses, fair skin

color, good skin turgor; swollen and tender left shoulder

DTR:UER:++UEL: not testedLE: ++ (bilateral)

Sensory: intact in all levelsROM: restricted for the left shoulder joint(+) drop-arm test

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Manual Muscle Testing(Upper Extremity)

Right Left

Shoulder abduction 5/5 2/5

Shoulder adduction 5/5 2/5

Shoulder flexion 5/5 2/5

Shoulder extension 5/5 2/5

Elbow flexion 5/5 2/5

Elbow extension 5/5 2/5

Wrist flexion 5/5 4/5

Wrist extension 5/5 4/5

Manual Muscle Testing (Lower Extremity)

Right Left

Hip flexors 5/5 5/5

Knee extensors 5/5 5/5

Ankle dorsiflexors 5/5 5/5

Long toe extensors 5/5 5/5

Ankle plantar flexors 5/5 5/5

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Neurological ExaminationCN I: not doneCN II, III: pupils 2-

3mm, equally brisk reaction to light

CN III, IV, VI: full EOMs

CN V: intact V1, V2, V3; good masseter muscle tone;

CN VII: no facial asymmetry

CN VIII: gross hearing intact

CN IX, X: can swallow

CN XI: good shoulder shrug

CN XII: tongue midline

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Primary Impression• Adhesive capsulitis (frozen shoulder) rule out

Shoulder Impingement Syndrome

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Salient Features• 63 year old, female• Acute onset• First episode• Acquired injury while flipping heavy object • Pain and inflammation on the left shoulder• Accompanied by fever and difficulty of

sleeping• Unable to abduct left shoulder joint

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Shoulder Impingement Syndrome Salient Features +/-63 year old, female +Acute onset -First episode +Acquired injury while flipping heavy object

+/-

Pain and inflammation on the left shoulder

+

Accompanied by fever and difficulty of sleeping

+

Unable to abduct shoulder joint +

Shoulder Joint DislocationSalient Features +/-63 year old, female +/-Acute onset +/-First episode -Acquired injury while flipping heavy object

+/-

Pain and inflammation on the left shoulder

+/-

Accompanied by fever and difficulty of sleeping

-

Unable to abduct shoulder joint +/-

OsteoarthritisSalient Features +/-63 year old, female +Acute onset -First episode -Acquired injury while flipping heavy object

+/-

Pain and inflammation on the left shoulder

+/-

Accompanied by fever and difficulty of sleeping

-

Unable to abduct shoulder joint +/-

Adhesive Capsulitis“Frozen Shoulder” – 1934 by CodmanAdhesive capsulitis – 1946 by NeviaserCharacteristics:

PainRestriction of active and passive movement of

glenohumeral joint / global loss of functionUsually with normal radiologic findingsCommon in females, 40-60 y/o

Adhesive Capsulitis• Associated with DM, hyperthyroidism,

ishemic heart disease, inflammatory arthritis and cervical spondylosis

• Glenohumeral joint synovial capsule is often involved in this disease process

• ROM loss disease in structures outside the synovial capsule glenohumeral joint (e.g. coracohumeral ligament, soft tissues in the rotator interval, the subscapularis muscle, and the subacromial bursae)

Adhesive CapsulitisActive process of

hyperplastic fibroplasia and excessive type III collagen secretion soft-tissue contractures other structures

Adhesive Capsulitis

Synovial capsule of glenohumeral joint is involved

• Stages:– “Freezing phase” –

pain; 3 to 6 months– “Frozen phase” –

progressive stiffness and movement restriction; 3 to 18 months

– “Thawing phase” – resolution; slow recovery of motion

Impingement SyndromeMechanical impingement of the rotator

cuff tendonUsually occurs when the shoulder is

placed in the forward-flexed and internally rotated position

Common in older personsRotator cuff disease, GH joint

degenerative diseasePain and positioning of the patient

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Laboratory TestsLaboratory Test RationaleCBC with differential count

Baseline values; r/o infections, inflammation

ESR Baseline; r/o rheumatoid conditions

Blood Glucose r/o hypoglycemia or DMThyroid function tests r/o thyroid dysfunction

Special TestsImpingement test: Inject 10 mL of 1%

lidocaine solution into the subacromial space. Repeat testing for an impingement sign. Elimination or significant reduction of pain constitutes a positive impingement test.

Drop arm test: The patient places the arm in maximum elevation in the scapular plane and then lowers it slowly (the test can be repeated following subacromial injection of lidocaine). Sudden dropping of the arm suggests a rotator cuff tear.

Imaging StudiesStandard radiographic studies (4

views)MRI – imaging study of choiceArthrography – to assess integrity of

the joint

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ManagementGoals:

Pain relief - NSAIDsRestore motion

Self-limited process but disabling pressing problem

Aggressive physical therapy to regain motionCorticosteroid injections for anti-

inflammation during the “freezing phase”Manual manipulation – last resort for

treatment

Maria Margarita A. MejiaNovember 18, 2010

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