Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Foundation Year Doctor working in the Emergency Department. Your next patient is Joe Mama- a 45-year-old gentleman presenting with shoulder pain. Please take a history and perform an appropriate examination.
Patient History:
Your name is Joe Mama 45 year old – construction worker.
Your right shoulder has been getting gradually worse every day. The right shoulder pain first started around a few months ago. The pain is sharp and does not radiate. You rate the pain as 7/10. It is worsened by movement and improved with rest.
You play tennis regularly (if asked specifically, you are right-handed) but since the pain started, you no longer play as much with your mates, which is bothering you. You also have night pain around your right shoulder, which sometimes can make it difficult to fall asleep.
You feel your right shoulder has weakened since the pain started, and you now struggle to lift your right arm up from your waist.
No numbness/ tingling/ abnormal sensations in the limbs. You haven't noticed any shoulder mass, swelling, or deformity. No fever. No red skin. Other than the pain and shoulder weakness. You feel well in general. No night sweats/weight loss. No shortness of breath. No recent trauma or fall. No neck pain. No previous history of fracture/ dislocation. No stiffness.
Ideas, Concerns, Expectations:
You have no idea what is going on - you are usually fit as a fiddle. You are concerned that the pain is causing many physical problems at work ( you work as a construction worker). You are now unable to lift any heavy objects with your right arm due to the pain. You hope to get better as soon as possible.
Past Medical History:
Nil
Drug History:
Nil
NDKA
Family History:
Rheumatoid arthritis
Type 2 diabetes
Social History:
You work as a construction worker, which often involves lifting heavy objects.
You smoke around 5-10 cigarettes a day for ten years.
You occasionally drink around 1-2 pints of beer when going out with friends for a meal.
Examination Findings:
Pain and weakness in initiating shoulder abduction – indicating supraspinatus tear. Tenderness over rotator cuff structure on palpation. Muscle wasting at regions of the right rotator cuff muscles might be present.
Drop arm test positive (passively abduct shoulder, then ask patient to lower abducted arm slowly to the waist. If arm drops after reaching 90degree- indicates massive rotator cuff tear)
Pain elicited and range of movement limited by pain in shoulder movements.
Cross-arm test – negative (acromioclavicular problems). No shoulder pain arc elicited (70° – 120°) (subacromial impingement). No localised pain/tenderness over the acromioclavicular joint and no restriction of passive, horizontal movement of the arm across the body when the elbow is extended (acromioclavicular disorder).
Differentials:
Rotator cuff disorders: rotator cuff Injury/ tear, tendonitis…etc.
To rule out rotator cuff rupture
Other considerations:
Fracture
Adhesive capsulitis
Osteoarthritis
To rule out joint infection/dislocation
Investigations:
Bedside:
Observations
Bloods:
Consider routine blood tests for baseline
Imaging:
Consider XR Shoulder to exclude bony pathology e.g. fracture/osteoarthritis/dislocation/opacities in calcific tendonitis/ anatomical abnormalities such as superior migration of humeral head relative to glenoid, pseudo subluxation of the humeral head relative to glenoid.
U/S to assess rotator cuff structure / detect tears, effusion
MRI shoulder to look for any underlying soft tissue shoulder pathology, i.e. shoulder instability, full/ partial tears, effusion…etc.
MR/CT arthrography – to look for tears/effusion if appropriate
If referred neck pain is suspected, consider cervical spine XR
Management (Rorator Cuff Injury):