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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?
George is a 68-year-old semi-retired builder who has been experiencing right shoulder pain for approximately eight years. He reports that the pain is primarily located at the back of his right shoulder, but it also extends, though less prominently, to the front of his shoulder.
Diagnostic Reasoning Question
How do the duration and locations of this man’s shoulder pain inform the diagnostic process?
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- Chronic Pain Duration – Shoulder pain persisting for several years qualifies as a chronic condition. In an elderly individual, chronic shoulder pain often points to degenerative processes, such as osteoarthritis, tendinopathy, or chronic rotator cuff pathology.
- Posterior Shoulder Pain – Pain localized at the back of the shoulder is less common than anterolateral shoulder pain and may indicate involvement of the infraspinatus and teres minor muscles, which are part of the rotator cuff or the posterior glenohumeral joint capsule. Potential conditions include posterior rotator cuff tendinopathy or tears, posterior capsulitis, or posterior labral tears.
- Anterior Shoulder Pain – The additional anterior pain suggests that multiple structures might be involved, potentially including the subscapularis muscle, biceps tendon, or subacromial space. This combination of posterior and anterior shoulder pain could indicate a more complex or widespread pathology.
What are the pain characteristics?
What are the aggravating and relieving factors?
What has been the course of the pain?
George describes his shoulder pain as a “deep ache.” He notes that over the past five or six years, the pain has been intermittent but has progressively worsened in frequency, duration, and severity. In the last six months, he has experienced almost constant pain, with its intensity fluctuating based on his activity level. Although he occasionally works with his son as a builder, his activities have become increasingly limited due to the pain. He reports that the pain is most severe early in the morning, waking him with a feeling of deep ache and stiffness in his shoulder. While the pain and stiffness improve somewhat after he gets up, they progressively worsen throughout the day, depending on his activity level. Additionally, the pain sometimes keeps him awake at night, preventing him from sleeping on his right side. He finds that taking painkillers and applying hot packs helps to reduce the pain.
Diagnostic Reasoning Question 1
What underlying shoulder conditions or pathologies could be responsible for George’s deep, aching shoulder pain?
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The deep, aching nature of the shoulder pain suggests that it likely originates from within the shoulder joint or deeper shoulder musculature, rather than from more superficial structures.
Diagnostic Reasoning Question 2
How does a progressively worsening history of shoulder pain in terms of frequency, duration, and intensity inform the diagnostic process?
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These findings provide several important insights that help inform the diagnostic process:
Degenerative or Chronic Conditions
- Osteoarthritis – Progressive worsening of pain over time is characteristic of degenerative joint diseases such as osteoarthritis. Osteoarthritis involves the gradual breakdown of cartilage within the shoulder joint, leading to increased pain and stiffness, particularly during movement.
- Chronic Tendinopathy – Conditions like rotator cuff tendinopathy often begin with mild, intermittent pain that gradually becomes more frequent and severe over time. This progression is due to the cumulative effects of inflammation and tendon degeneration.
Inflammation and Mechanical Factors
- Inflammatory Conditions – The presence of progressively increasing pain over several years may suggest an underlying inflammatory condition, such as bursitis or tendinitis. These inflammatory processes typically cause pain that worsens with activity and can lead to persistent discomfort, particularly in the morning or after periods of rest.
- Mechanical and Structural Issues – The history of worsening pain may also indicate mechanical issues such as subacromial impingement syndrome or rotator cuff tears. These conditions typically cause pain that is exacerbated by specific movements and activities, leading to progressive worsening as structural damage accumulates.
Diagnostic Reasoning Question 3
How does George’s report of pain and difficulty sleeping when lying on the affected side contribute to the diagnostic process?
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Shoulder pain that disrupts sleep and prevents lying on the affected side often indicates conditions such as a rotator cuff tear, subacromial impingement, acromioclavicular or glenohumeral joint injury, or osteoarthritis. Nocturnal pain is particularly concerning and typically warrants further investigation, as it may signal more significant underlying pathology.
Are there any associated symptoms?
Upon further questioning, George reports a significant loss of range of motion in his right shoulder, particularly when attempting to work overhead. He also experiences difficulty with daily activities such as combing his hair or reaching for his hip pocket. Additionally, he has noticed a grating sensation deep within the shoulder during certain movements.
Diagnostic Reasoning Question 1
How does his reported loss of motion and difficulty with daily activities contribute to the diagnostic process?
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His report of significant loss of shoulder range of motion and difficulty with daily activities suggests potential structural or functional impairments within the glenohumeral joint. Common conditions indicated by these symptoms include adhesive capsulitis (frozen shoulder), rotator cuff tears or tendinopathy, and glenohumeral osteoarthritis. These conditions are often associated with stiffness and restricted mobility, which align with the patient’s described difficulties.
Diagnostic Reasoning Question 2
How does the presence of a deep grating sensation during shoulder movement contribute to the diagnostic process?
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The presence of a deep grating sensation during shoulder movement suggests potential degenerative changes or structural damage within the joint. This sensation, often referred to as crepitus, may indicate conditions such as advanced osteoarthritis.
Crepitus within a joint should be distinguished from the cracking or popping sounds caused by ligaments or tendons slipping over bony surfaces during movement.
Is there any past history that may be relevant to the current complaint?
George reports that over the years, he has had to limit his activities on several occasions due to right shoulder pain, likely caused by overexertion. He also recalls two significant falls that resulted in right shoulder injuries. One particularly notable incident occurred in his early twenties, leading to a hospital visit where he was informed that he had nearly dislocated his shoulder.
His medical history includes a diagnosis of early-stage emphysema, likely due to prolonged exposure to sawdust inhalation. Additionally, he has been experiencing increasing depression, which he attributes to his reduced ability to work with his son and participate in activities like lawn bowls. Although his doctor recommended antidepressants, he has opted not to take them.
Diagnostic Reasoning Question
ViewHide Suggested Answer
George’s long history of shoulder problems, spanning several decades and including two significant traumas to his right shoulder, suggests a clinical background of both ligamentous and muscular injuries. This history greatly increases the likelihood that his current symptoms are due to degenerative changes, making secondary osteoarthritis a probable diagnosis.
Additionally, the chronic nature of his condition and the resulting functional impairment have likely contributed to the development of depression. This psychosocial aspect of his health raises a yellow flag regarding his overall prognosis, indicating that his mental health should be carefully considered in his treatment plan.
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.
- Does your pain disappear even for a short time? “Not really. It fluctuates.”
- Does the pain wake you up at night? “The pain keeps me awake on occasions, and I am unable to sleep on my right side.”
- Have you recently had any fever, chills, or night sweats? “No.”
- Have you had any unexplained weight loss recently? “No.”
- Does your shoulder pain come on at times of stress? “No.”
- Does your pain seem to be associated with eating certain types of food or drinking alcohol? “No.”
- Do you have a history of cancer, respiratory disease, or heart disease? “I have been told that I have emphysema.”
- Do you have any breathing difficulties or a history of smoking? “No.”
- Do you have diabetes? “No.”
Diagnostic Reasoning Question
Do any of the patient’s answers raise a red flag?
ViewHide Suggested Answer
The continuous nature of his pain and its impact on his sleep are concerning, even though these symptoms are common in shoulder conditions. Imaging studies should be conducted to assess for the presence of secondary osteoarthritis and to rule out any serious underlying pathology.
Differential Diagnosis
Diagnostic Reasoning Question
Based on the available history, how would you prioritize the list of differential diagnoses?
ViewHide Suggested Answer
- Glenohumeral osteoarthritis
- Adhesive capsulitis
- Subacromial impingement syndrome
- Rotator cuff or bicipital tendinopathy
- Rotator cuff tear
- Acromioclavicular joint osteoarthritis
- Labral tear
- Subacromial bursitis
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
George’s vital signs are generally within normal limits, with the exception of a slight increase in blood pressure.
Diagnostic Reasoning Question
What is the significance of normal vital signs?
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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, George appears to be in generally good health, aside from being slightly overweight. There is noticeable muscle wasting in his right shoulder, with the deltoid showing reduced bulk compared to the left side and the spine of the scapula appearing more prominent on the right. Additionally, his chest is slightly deeper in the anterior-posterior dimension than normal. Despite this, he does not exhibit any signs of breathing difficulty.
Diagnostic Reasoning Question
ViewHide Suggested Answer
- Atrophy of Deltoid and Scapular Spine Prominence – The atrophy of the right deltoid muscle and the prominence of the spine of the scapula suggest chronic disuse or possible denervation. Potential causes include rotator cuff pathology, osteoarthritis, adhesive capsulitis, or injury to the axillary nerve or other nerves supplying the rotator cuff muscles. Given the patient’s long history of impaired use of the right shoulder, disuse atrophy is more likely.
- Chest Configuration – A slightly deeper anterior-posterior chest dimension may indicate underlying chronic lung conditions, such as chronic obstructive pulmonary disease (COPD) or emphysema, potentially leading to a “barrel chest” appearance. Although the patient does not currently exhibit breathing difficulties, this chest configuration could suggest early-stage respiratory issues, which may coexist with musculoskeletal problems.
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Range of Motion
George is asked to perform Apley’s Scratch tests to assess his shoulder’s active range of motion. He shows limitations in all three maneuvers, with the most significant restriction occurring when attempting to reach behind his head to touch the opposite shoulder.
Specific ranges of active motion are then assessed, revealing significant limitations. Abduction is particularly restricted, with the range reduced to less than 90 degrees, accompanied by a ‘hitching’ motion of the shoulder. All other active and passive shoulder movements are similarly limited, with mild pain present at the end range of each movement.
As George performs the Apley’s Scratch tests and the specific range of motion assessment, he reports a grating sensation, which is also audible. In response, you palpate his shoulder, placing your fingers over the anterior and posterior aspects of the glenohumeral joint while he repeats the movements. This allows you to confirm the presence of the grating sensation during the movements.
Diagnostic Reasoning Question 1
How do the results of the Apley’s Scratch tests inform the diagnostic process?
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The patient’s limited range of motion in all Apley’s Scratch tests suggests a global restriction of movement, indicating a condition that affects the joint as a whole rather than isolated muscle or tendon issues. His significant difficulty with abduction and external rotation, particularly when attempting to reach behind his head, is consistent with the typical presentation of osteoarthritis.
Diagnostic Reasoning Question 2
How does the palpable and audible grating during the range of motion examination inform the diagnostic process?
ViewHide Suggested Answer
- Palpable Crepitus – Indicates the roughening of opposing cartilage surfaces, typically due to erosion or the presence of granulation tissue in joints affected by chronic inflammatory or non-inflammatory arthritis.
- Audible Crepitus – The presence of audible crepitus suggests significant roughening or irregularities of the joint surfaces, typically due to severe cartilage degeneration, as seen in advanced osteoarthritis.
Diagnostic Reasoning Question 3
What does “hitching” of the shoulder during attempted abduction indicate?
ViewHide Suggested Answer
The hitching observed during attempted abduction suggests that the scapulothoracic joint is compensating more than the glenohumeral joint, indicating a disruption in the normal “scapulohumeral rhythm.” This excessive scapulothoracic compensation, resulting in the hitching motion, is often referred to as the “shoulder shrug sign.”
Please watch the videos below to see how Apley’s Scratch tests are performed and how Scapulohumeral Rhythm is assessed.
Palpation
Upon palpation of the right shoulder, tenderness is noted over both the anterior and posterior margins of the glenohumeral joint. The anterior aspect of the right glenohumeral joint appears and feels more prominent compared to the left. Additionally, there is a noticeable reduction in the muscle tone and bulk of the right deltoid, making the acromion more palpable. The tone and bulk of the supraspinatus muscle are also diminished.
Diagnostic Reasoning Question 1
What does tenderness over both the anterior and posterior margins of the glenohumeral joint indicate?
ViewHide Suggested Answer
Tenderness over the joint margins suggests involvement of the glenohumeral joint itself. This could indicate underlying issues such as synovitis, labral tears, or joint degeneration.
Diagnostic Reasoning Question 2
What does the prominence of the anterior aspect of his right glenohumeral joint indicate?
ViewHide Suggested Answer
A prominent anterior aspect of the glenohumeral joint could be due to:
- Atrophy of the anterior deltoid
- Glenohumeral joint instability, potentially leading to anterior subluxation of the humeral head
- Structural changes in the glenoid or humeral head, such as bone spurs or deformities
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
Based on the clinical findings so far, there is a strong suspicion that this patient may be suffering from glenohumeral osteoarthritis, adhesive capsulitis, or possibly both. Since there are no definitive tests for these conditions, several special tests were attempted, with modifications to accommodate the patient’s limitations.
The Empty Can test reveals weakness and reproduces the patient’s shoulder pain, although it could only be performed at approximately 75 degrees of shoulder abduction, rather than the usual full abduction position.
Diagnostic Reasoning Question
What is the purpose of the Empty Can test, and what do the findings in this patient indicate?
ViewHide Suggested Answer
The Empty Can test is primarily used to detect supraspinatus tears, tendinopathy, and muscle weakness. In this patient, the test could only be performed at 75 degrees of abduction instead of the normal 90 degrees or higher, indicating a significant restriction in shoulder range of motion. This limitation may suggest underlying stiffness (e.g., adhesive capsulitis), joint pathology (e.g., osteoarthritis), or pain inhibition that prevents full abduction.
Please watch the video below if you wish to see how the Empty Can test is performed.
The Gagey Hyperabduction test is performed, revealing that glenohumeral joint movement is limited to approximately 50 degrees.
Diagnostic Reasoning Question
What is the Gagey Hyperabduction test designed to assess, and what does the finding in this patient suggest?
ViewHide Suggested Answer
The Gagey Hyperabduction test is typically used to assess laxity in the glenohumeral joint. The test in this patient revealed significant restriction, with glenohumeral abduction limited to only 50 degrees, whereas approximately 90 degrees is considered normal.
To see how the Gagey Hyperabduction test is performed, please watch the video below.
The Compression Rotation (Crank) test is performed and results in pain and crepitation, although it can only be performed at approximately 75 degrees of shoulder abduction.
Diagnostic Reasoning Question
What is the purpose of the Compression Rotation test, and what do the findings in this patient indicate?
ViewHide Suggested Answer
The Compression Rotation test is designed to assess for labral tears and is typically performed with the arm abducted to 160 degrees. In this patient, the test was conducted with the arm below horizontal, but the compressive load applied to the glenohumeral joint produced crepitus and pain, both of which are consistent with osteoarthritis.
Please watch the video below to see how the Compression Rotation test is performed.
The Neer Impingement test elicits pain at 70 degrees of elevation.
Diagnostic Reasoning Question
What is the purpose of the Neer Impingement test, and what does the finding in this patient indicate?
ViewHide Suggested Answer
The Neer Impingement test is designed to detect subacromial impingement syndrome. In this patient, the moderately positive result suggests compression of pain-sensitive structures, such as the subacromial bursa or supraspinatus tendon, which are often involved in cases of glenohumeral osteoarthritis.
Please watch the video below if you wish to see how the Neer Impingement test is performed.
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 of the right shoulder is performed and reveals advanced osteoarthritis of the glenohumeral joint.
Diagnosis
Diagnostic Reasoning Question
Based on the available information, what is the most likely diagnosis?
ViewHide Suggested Answer
Moderate to severe osteoarthritis of the glenohumeral joint.
References and Suggested Further Readings
Shapiro J, Zuckerman JD. Glenohumeral arthroplasty: indications and preoperative considerations. Instr Course Lect. 2002;51:3-10.
Anderson B. Glenohumeral osteoarthritis. www.uptodate.com.
Nakagawa Y, Hyakuna K, Otani S, Hashitani M, Nakamura T. Epidemiologic study of glenohumeral osteoarthritis with plain radiography. J Shoulder Elbow Surg. 1999;8(6):580.
Thomas M et al. Glenohumeral osteoarthritis. Shoulder & Elbow 2016, Vol. 8(3) 203–214.
Stovitz S. Evaluation of the adult with shoulder complaints. www.uptodate.com.
Arden N, Nevitt MC. Osteoarthritis: Epidemiology. Best Practice & Research Clinical Rheumatology. Vol. 20, No. 1, pp. 3–25, 2006.
Arden N, Nevitt MC. Osteoarthritis: Epidemiology. Best Practice & Research Clinical Rheumatology. Vol. 20, No. 1, pp. 3–25, 2006.
Osteoarthritis Snapshot. Australian Institute of Health and Welfare. www.aihw.gov.au/reports/chronic-musculoskeletal-conditions/osteoarthritis/contents/what-is-osteoarthritis.
Vina ER, Kwoh CK. Epidemiology of Osteoarthritis: Literature update. Curr Opin Rheumatol. 2018 March ; 30(2): 160–167.
Travell JGb, Simons DG. Myofascial pain and dysfunction: The Trigger Point Manual. Baltimore: Williams and Wilkins.
Srbely JZ, Dickey JP, Lowerison M, Edwards AM, Nolet PS, Wong LL. Stimulation of myofascial trigger points with ultrasound induces segmental antinociceptive effects: A randomized controlled study. Pain. 2008 Oct 15;139(2):260–6.
Baxter, D. (2008) Low Intensity Laser Therapy. Chapter 11 in: Electrotherapy : Evidence Based Practice.
Draper, D. O. et al. (2010). “Thermal ultrasound decreases tissue stiffness of trigger points in upper trapezius muscles.” Physiotherapy Theory and Practice 26(3): 167-172.
Review Quiz
1. What is 2+2?
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The answer is????
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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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