Case of the Week: Upper Trapezius Pain in 49F
Case of the Week
Upper Trapezius Pain in 49F
Image Credit: By RSatUSZ - PACS UniversitätsSpitalZürich, CC BY-SA 4.0, Wikimedia Commons.
CC: Upper trapezius pain in a 49F after a traumatic injury.
HPI: This 49-year-old female had a traumatic fall 10 weeks ago. She was able to lift her arm away from her body immediately after the incident. She developed pain in the ‘shoulder region.’ When you ask her to show you the location of her shoulder pain she puts the opposite onto her left shoulder in the upper trapezius region. She tells you that her MRI shows a rotator cuff tear.
What is the most likely diagnosis?
PMH: Patient has no significant medical or surgical history. No oncologic history.
PE: Physical exam shows no muscle wasting on visual inspection. Rotator cuff rated 5/5. Hawkins and Neers creates ‘shoulder pain’ into the upper trapezius muscle. Mildly tender bicipital groove on palpation. Yergason’s was negative. Kemp’s test in the cervical spine was positive for neck and upper shoulder pain. There is palpatory tenderness along the upper trapezius muscle which recreates her pain location.
Imaging: MRI demonstrated a 4 mm x 6 mm articular surface partial thickness supraspinatus tear. Radiographs do not demonstrate osteoarthritis or soft tissue abnormalities.
Diagnosis: Cervicogenic pain with associated myofascial pain.