Case of the Week: 49 y/o Male: Atraumatic & Stiff Shoulder
49 y/o Male: Atraumatic & Stiff Shoulder
CC: 49 y/o male with 4 month atraumatic stiff right shoulder without pain.
HPI: 49 y/o male, advertising executive, with a 4 month history atraumatic stiff right shoulder pain. In the summertime he spent 5 hours shoveling dirt in his backyard. The next day he developed severe pain in his shoulder with limited range of motion. He attended physical therapy and chiropractic which helped regaining his strength and most of his range of motion. Over time the pain subsided but he continues to have limited external rotation. The patient stated that prior to this incident he had full external rotation that was equivalent to his opposite shoulder. No previous history of shoulder problems and no shoulder surgical history.
PMH: Unremarkable
What does your physical exam look like?
Would you order additional imaging aside from the radiographs?
What is your differential diagnosis?
How would you manage this patient?
PE: Right PROM pain free with F 170°, ABD 170°, ER 30° (left shoulder ER 70°). Rotator cuff was rated 5/5 and pain free. Impingement tests were negative. Speed’s, crossbody and O’Brien were negative. Stable shoulder on examination.
Diagnostic Ultrasound: subdeltoid subacromial bursitis.
Radiographs: Mild glenohumeral joint osteoarthritis with good joint preservation. A small ‘‘teardrop’’ osteophyte and glenoid sclerosis. Downsloping type 3 acromion. No calcifications, fractures or dislocations.
Diagnostic Ultrasound: Biceps tendon intact. The subscapularis and supraspinatus tendon mildly inhomogeneous. Infraspinatus intact. Fluid noted in subdeltoid subacromial bursa.
Diagnosis: Asymptomatic mild glenohumeral joint osteoarthritis with scarring of the rotator interval and loss of external rotation.
Management: This patient likely developed impingement and subdeltoid subacromial bursitis from his repetitive activity. Over time the impingement and bursitis settled down but left him with residual scarring of the rotator interval and pain free limited external rotation. Recommendation was physical therapy with a daily stretching program targeting the rotator interval and anterior glenohumeral joint capsule (external rotation). Education about his downsloping type 3 acromion and activity modification for impingement zone activities. No other treatment required.