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To enhance your diagnostic reasoning skills, follow these steps:
- Review the Information: Carefully read through the content in each section of the case scenario.
- Consider the Question: Reflect on the Diagnostic Reasoning Question presented. Take your time to think about your answer.
- Compare Your Answer: Attempt to answer the question before viewing our suggested answer. When ready, click “View Suggested Answer” to compare it with your own.
Repeat these steps for each section of the case scenario. Please note that the suggested answers are only indicative and not exhaustive. They serve as guidelines and should not be considered complete answers.
Patient’s History
In the sections below, you will find case history information designed to guide you through a systematic approach to performing a focused and relevant case history. This process will help you narrow down the potential causes of the patient’s complaint. As you go through the material, we encourage you to answer the questions provided to test and enhance your diagnostic reasoning skills.
Who is the patient and where is the pain?
When was the onset and what caused the onset?
Nina is a 29-year-old computer programmer who presents with right shoulder pain. She says that the pain is interfering with her fitness plan which includes weightlifting at the gym. She points to the anterior aspect of her right shoulder as the primary site of the pain. The pain has evolved gradually over 4 to 5 months, and she does not remember injuring her shoulder.
Diagnostic Reasoning Question
What differential diagnoses should be considered for patients presenting with anterior shoulder pain?
ViewHide Suggested Answer
- Proximal biceps brachii tendinopathy or tear
- Subacromial impingement syndrome
- Rotator cuff tendinopathy or tear
- Glenohumeral joint injury or arthritis
- Myofascial pain syndrome (e.g., the infraspinatus, pectoralis major and pectoralis minor muscles)
- Acromioclavicular joint injury or arthritis
- Glenoid labral tears
- Adhesive capsulitis
- Cervical or thoracic spine dysfunction
- Cervical radiculopathy
What are the pain characteristics?
What are the aggravating and relieving factors?
What has been the course of the pain?
Nina describes her shoulder pain as an ache and rates it as a 7 out of 10 in intensity at its worst. Her pain is aggravated when performing biceps curls and overhead exercises at the gym. She also feels pain when she sleeps on her right side. In the last 2 weeks, she has noticed that even brushing her hair aggravates her shoulder pain. Rest and ice application provide relief. She reports that she attempted to perform shoulder exercises and stretches that she found on the Internet, but they caused further aggravation of her pain, so she stopped doing them.
Diagnostic Reasoning Question 1
How do the activities that exacerbate her symptoms aid in the diagnostic process?
ViewHide Suggested Answer
The exacerbation of her pain during biceps curls and overhead exercises, coupled with relief upon rest, strongly suggests the involvement of the biceps muscle or other conditions like subacromial impingement. Furthermore, the pain experienced while brushing her hair indicates that movements involving flexion or abduction with external rotation provide additional evidence for the involvement of the biceps tendon and/or subacromial structures.
Diagnostic Reasoning Question 2
What shoulder conditions can cause pain when attempting to sleep on the involved side?
ViewHide Suggested Answer
Pain that worsens when lying on the affected side is a common symptom in various shoulder disorders. While this symptom alone may not pinpoint a specific diagnosis, it can help confirm that the pain originates from a local source within the shoulder.
Several shoulder conditions can cause pain when lying on the involved side:
- Rotator cuff injuries – Pain may worsen due to compression of the injured tendon against the bony structures of the shoulder joint.
- Shoulder Impingement Syndrome – Pain can occur as inflamed structures within the shoulder joint become compressed.
- Adhesive Capsulitis – Pain and stiffness in the shoulder joint can disrupt sleep and cause discomfort, especially during the inflammatory phase of the condition.
- Bursitis – Inflammation of the bursa sacs in the shoulder can cause pain due to compression of the inflamed bursa.
- Acromioclavicular Joint Sprain – Compression of the joint would lead to increased pain.
Are there any associated symptoms?
Upon further inquiry, Nina denies experiencing any weakness, numbness, tingling, or clicking in her shoulder.
Diagnostic Reasoning Question 1
How does Nina’s absence of weakness, numbness, and tingling contribute to the diagnostic process?
ViewHide Suggested Answer
The absence of these symptoms suggests that Nina’s shoulder pain is unlikely to be caused by nerve compression.
Diagnostic Reasoning Question 2
How does the absence of clicking inform the diagnostic process?
ViewHide Suggested Answer
Clicking is typically associated with joint instability, glenoid labral tears, or transverse humeral ligament ruptures. The absence of clicking in this patient suggests that these conditions are unlikely.
Is there any past history that may be relevant to the current complaint?
Nina has no prior history of issues with her right shoulder. She recalls having a greenstick fracture in her right radius at the age of 7, but she has had no problems with it since her recovery.
Diagnostic Reasoning Question
In what ways does Nina’s past history contribute to the diagnostic process?
ViewHide Suggested Answer
The absence of prior issues with her right shoulder suggests that her current symptoms are not related to a recurring or chronic shoulder problem. This helps narrow down the potential causes of her shoulder pain, focusing more on recent injuries or conditions rather than long-standing issues.
It is unlikely that a history of a Green Stick fracture in the right radius, particularly without any subsequent issues or complications, would cause shoulder issues later in life. However, depending on the nature of the injury and subsequent healing process, indirect factors, such as altered biomechanics or compensatory movements, could contribute to shoulder issues over time.
Are there any red flags?
The following questions are asked to identify any “red flags” that could suggest serious pathology. Even if the patient has previously mentioned related information during the case history, it is recommended to revisit these questions to ensure a comprehensive evaluation.
- Do your symptoms disappear even for a short time? “Yes. When I rest my arm.”
- Does the pain wake you up at night? “Yes, if I sleep on my right side.”
- Do you feel weak in your arms? “Maybe, but I think it has to do with the pain.”
- Have you recently experienced any fever, chills, night sweats, or vomiting? “No.”
- Have you recently had any unexplained weight loss? “No.”
- Do you have a history of cancer or HIV? “No.”
Diagnostic Reasoning Question
Do any of Nina’s answers raise a red flag?
ViewHide Suggested Answer
None of Nina’s responses raises a red flag. However, depending on the results of the physical examination, imaging studies may be indicated to rule out serious pathology.
Differential Diagnosis
Diagnostic Reasoning Question
Based on the available history, how would you prioritize the list of differential diagnoses?
ViewHide Suggested Answer
- Biceps brachii tendinopathy or tear
- Subacromial impingement syndrome
- Rotator cuff tendinopathy or tear
- Myofascial pain syndrome (e.g., the infraspinatus, pectoralis major, and pectoralis minor muscles)
- Glenohumeral joint injury or arthritis
- Acromioclavicular joint injury or arthritis
- Glenoid labral tear
Reflection Point
Pause and consider whether the key elements of a thorough and relevant patient history have been addressed. Are there any additional questions you would have asked? If so, what are they, and why would they be important?
Before reviewing the physical examination findings below, take a moment to reflect on which physical examination procedures you would perform to accurately assess this patient.
Physical Examination
In the sections below, you will find physical examination findings for this patient. The material outlines a systematic approach to conducting a focused and relevant physical examination aimed at narrowing down the potential causes of the patient’s complaint. As you review the material, we encourage you to answer the questions provided to test and enhance your clinical reasoning and diagnostic skills. Additionally, consider whether all essential elements of the physical examination have been thoroughly addressed.
Vital Signs
Nina’s vital signs are within normal limits.
Diagnostic Reasoning Question
What is the significance of normal vital signs?
ViewHide Suggested Answer
Normal vital signs typically indicate that there are no immediate life-threatening conditions. Particularly, normal temperature indicates the absence of acute infection.
Inspection
Upon inspection, there is no evidence of deformity or muscle wasting in the shoulder or upper arm. Viewed from behind, the outline of her neck and thorax appears symmetrical. Her lateral posture shows spinal curves that are all within normal limits.
Diagnostic Reasoning Question
What is the clinical importance of the absence of deformity and muscle wasting in Nina’s shoulder region?
ViewHide Suggested Answer
The absence of deformity is reassuring, indicating that a muscle rupture is unlikely. Additionally, the lack of muscle wasting, despite a chronic condition, indicates that Nina has maintained sufficient activity to preserve muscle bulk. If muscle wasting were present, it could have pointed to potential neurological involvement.
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Range of Motion
Upon performing the Apley’s Scratch tests, Nina successfully reaches across her chest to touch the opposite shoulder and can reach behind her waist. However, when she attempts to reach behind her head to touch the opposite shoulder, she experiences a sharp exacerbation of pain in her right anterior shoulder.
Diagnostic Reasoning Question
How do the results of the Apley’s Scratch tests inform the diagnostic process?
ViewHide Suggested Answer
The exacerbation of pain when reaching behind her head implicates difficulty with movements involving abduction and external rotation. This could indicate subacromial impingement or tendinopathy.
Please watch the video below to see how the Apley’s Scratch test is performed.
The Scapulohumeral Rhythm is assessed and found to be normal. The Painful Arc test is also performed, with negative results. Additionally, all passive ranges of motion are evaluated and confirmed to be within normal limits.
Diagnostic Reasoning Question
What do the results of the Scapulohumeral Rhythm assessment and the Painful Arc test indicate?
ViewHide Suggested Answer
The Scapulohumeral Rhythm assessment is designed to detect abnormal scapular movement patterns, known as “scapular dyskinesis.” Such abnormalities are often due to weakness, poor motor control, or imbalances in the scapular stabilizing muscles, which can contribute to conditions like subacromial impingement or rotator cuff pathology. The normal findings in this patient suggest that these conditions are unlikely.
Additionally, the negative result of the Painful Arc test further supports the absence of subacromial impingement.
Please watch the videos below if you wish to see how the Scapulohumeral Rhythm assessment and the Painful Arc test are performed.
Muscle Strength Testing
Muscle strength testing reveals weakness in right elbow flexion, forearm supination, and shoulder flexion, all of which elicit pain in the anterior shoulder.
Diagnostic Reasoning Question
How do these findings contribute to the diagnostic process?
ViewHide Suggested Answer
The weakness and pain observed during elbow flexion, forearm supination, and shoulder flexion all involve the contraction of the biceps muscle. The presence of anterior shoulder pain during these actions strongly suggests biceps involvement, with the long head of the biceps tendon likely being the primary source.
Palpation
During palpation of the right shoulder, Nina reports sharp pain localized directly over the area between the greater and lesser tubercles. The biceps muscle belly is also tender to palpation, though the intensity is mild. There is no tenderness or nodularity with referred pain upon palpation of the infraspinatus, upper trapezius, anterior deltoid, or pectoralis minor. All palpated muscles, including the biceps, exhibit normal tonicity. Functional examinations of the cervical and thoracic vertebral motion segments, as well as the right glenohumeral and elbow joints, are all found to be normal.
Diagnostic Reasoning Question 1
What is the significance of detecting pain directly over the area between the greater and lesser tubercles?
ViewHide Suggested Answer
This pain location corresponds to the region of the proximal tendon of the long head of the biceps, a key clinical finding in cases of proximal biceps tendinopathy.
Diagnostic Reasoning Question 2
What is the relevance of performing a functional assessment of the cervical and thoracic spine in patients with suspected subacromial impingement or shoulder tendinopathy?
ViewHide Suggested Answer
Cervical or upper thoracic spine dysfunction can disrupt shoulder biomechanics, potentially contributing to the development of subacromial impingement or shoulder tendinopathy. Assessing these spinal regions helps identify any contributing factors that may need to be addressed to fully resolve the shoulder condition.
Neurological Examination
Given the weakness detected in the right upper extremity during muscle strength testing, a neurological screening examination for the C5 to T1 nerve roots is performed and found to be normal.
Diagnostic Reasoning Question
How can the presence of weakness during muscle strength testing be reconciled with the normal findings from the neurological examination of the C5 to T1 nerve roots?
ViewHide Suggested Answer
The observed weakness during muscle strength testing, despite normal neurological examination results, suggests that the weakness is not neurologically based. Instead, it is likely due to pain triggered by the loading of the muscles during testing.
To learn more about the Neurological Examination of the C5 to T1 Nerve Roots, please watch the video below.
Reflection Point
Considering the patient’s history and examination findings thus far, take a moment to reflect on which special tests would be most appropriate to further evaluate this patient.
Special Tests
Ludington’s test is performed and yields a negative result, as both biceps tendons are palpable during muscle contraction. However, the procedure reproduces the patient’s right anterior shoulder pain. Speed’s and Yergason’s tests are also conducted, and both elicit the patient’s right anterior shoulder pain without any other significant findings.
Diagnostic Reasoning Question
What do these test results suggest?
ViewHide Suggested Answer
Ludington’s test is primarily used to detect ruptures of the long head of the biceps. A negative result in this patient suggests that a rupture is unlikely. However, the reproduction of pain during this test indicates possible biceps tendinopathy. The pain elicited during Speed’s and Yergason’s tests further supports the likelihood of tendinopathy in the long head of the biceps.
To see how these tests are performed, please watch the videos below.
The Hawkins-Kennedy and Neer Impingement tests are performed and yield negative results.
Diagnostic Reasoning Question
What do these test results suggest?
ViewHide Suggested Answer
The negative Hawkins-Kennedy and Neer Impingement tests indicate that subacromial impingement is unlikely. However, in cases of bicipital tendinopathy, these tests may sometimes be positive if the rotator cuff structures are also involved. The negative results in Nina suggest that the condition is likely isolated to the biceps tendon.
To learn how these tests are performed, please watch the videos below.
Reflection Point
Please pause and assess whether all the essential elements of a thorough and relevant physical examination have been completed for this patient. Are there any additional procedures you would have performed? If so, why?
Imaging
Plain Radiography – The plain radiography of the right shoulder is unremarkable, indicating no evidence of shoulder pathologies such as glenohumeral osteoarthritis (which is unlikely in a patient of this age) or acromioclavicular joint involvement. It also rules out the presence of an acromial spur, eliminating it as a complicating or predisposing factor for subacromial impingement syndrome.
Diagnostic Ultrasound – The ultrasound reveals localized thickening of the long head of the biceps tendon adjacent to the upper end of the bicipital groove. No instability within the bicipital groove is detected during internal and external rotation of the shoulder under muscle load.
Diagnosis
Diagnostic Reasoning Question
Based on the available information, what is the most likely diagnosis?
ViewHide Suggested Answer
Tendinopathy of the long head of the biceps.
References and Suggested Further Readings
Diplock et al. The long head of biceps at the shoulder: a scoping review. BMC Musculoskeletal Disorders, volume 24, Article number: 232 (2023).
Vaughan A, Hulkower S. Evaluation of the adult with shoulder complaints. Jun 14, 2023. www.uptodate.com.
Simons S, Dixon J. Biceps tendinopathy and tendon rupture. www.uptodate.com.
Salvo J. Bicipital Tendon Injuries. emedicine.medscape.com.
Tendinopathy. www.bestpractice.bmj.com.
Krupp et al. Long Head of the Biceps Tendon Pain: Differential Diagnosis and Treatment. Journal of Orthopaedic & Sports Physical Therapy, 2009 Volume:39 Issue:2 Pages:55–70.
Pfefer M. Chiropractic management of tendinopathy: a literature synthesis. J Manipulative Physiol Ther. 2009 Jan;32(1):41-52.
Nho J. et al. Long head of the biceps tendinopathy: diagnosis and management. J Am Acad Orthop Surg. 2010;18(11):645.
Travell J, Simons D. Myofascial pain and dysfunction: The Trigger Point Manual. Baltimore: Williams and Wilkins.
Srbely J. et al. Stimulation of myofascial trigger points with ultrasound induces segmental antinociceptive effects: A randomized controlled study. Pain. 2008 Oct 15;139(2):260–6.
Watson T. Ultrasound therapy. www.electrotherapy.org/modality/ultrasound-therapy.
Watson T. Laser Therapy. www.electrotherapy.org/modality/laser-therapy.
Baxter, D. (2008) Low Intensity Laser Therapy. Chapter 11 in : Electrotherapy : Evidence Based Practice.
Draper, D. et al. (2010). “Thermal ultrasound decreases tissue stiffness of trigger points in upper trapezius muscles.” Physiotherapy Theory and Practice 26(3): 167-172.
Disclaimer: The acemsk.com website (including text, graphics, downloadable resources, and videos) is intended to provide general health information for educational purposes only. This information is not a substitute for personal consultation with a qualified healthcare professional. Always seek the advice of a healthcare professional for any questions regarding your condition, symptoms, and appropriate treatments.
Copyright © Educom Pty Ltd: All content on the acemsk.com website, including text, graphics, videos, and downloadable files, is the property of Educom Continuing Education, a division of Educom Pty Ltd, and is protected by copyright and other intellectual property laws under international conventions. Unauthorized use or duplication of this material without express written permission from Educom Pty Ltd is strictly prohibited.
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