A 72-year-old man comes to the physician because of shoulder pain, which has been present for 3 weeks and began after a mild fall that was braced by his outstretched arm. The pain is felt over his lateral shoulder and often keeps him awake at night. It also makes it difficult for him to lift anything overhead.
Passive range of motion is normal; however, range of motion with any resistance is limited and the patient is unable to maintain 90 degrees of abduction. There is weakness with abduction and external rotation.
Which of the following is the most likely diagnosis?

Question

A 72-year-old man comes to the physician because of shoulder pain, which has been present for 3 weeks and began after a mild fall that was braced by his outstretched arm.  The pain is felt over his lateral shoulder and often keeps him awake at night.  It also makes it difficult for him to lift anything overhead.
Passive range of motion is normal; however, range of motion with any resistance is limited and the patient is unable to maintain 90 degrees of abduction.  There is weakness with abduction and external rotation.
Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec193a_991a_a2e3_853d_eb2f8492b2d0_MD0002_00 This patient's shoulder pain (common causes listed in the above table) is most likely due to a rotator cuff tear. Shoulder pain increased with reaching upward can be due to rotator cuff impingement or tear, frozen shoulder, or osteoarthritis. Rotator cuff tears mainly occur in patients > age 40 usually after a fall braced by an outstretched arm. Patients typically present with pain on the lateral deltoid that is worsened with raising the arm or any overhead activity and pain with external rotation and abduction. Examination shows the drop arm sign (unable to smoothly control shoulder adduction) and weakness with external rotation. An MRI or musculoskeletal ultrasound can accurately diagnose a rotator cuff tear. Treatment usually involves surgery, with best results if performed within 6 weeks of the injury. (Choice A) Cervical nerve root impingement usually occurs at C5-C6 due to disc herniation, spinal stenosis, or degenerative arthritis. Patients typically present with neck and shoulder pain, normal active and passive range of motion, and normal strength. Shoulder motion does not affect the pain, as seen in this patient. (Choice B) Frozen shoulder (adhesive capsulitis) is associated with stiffness and marked limitation with all active and passive motion, which is not seen in this patient. (Choice C) Osteoarthritis of the shoulder often presents with posterior shoulder pain. Active and passive motion is limited and the patient and examiner may note pain and crepitus on lifting. (Choice D) Both rotator cuff tendinopathy/impingement and tear present with similar symptoms (e.g., pain with reaching, external rotation, and abduction). However, rotator cuff tendinopathy/impingement does not exhibit weakness with external rotation (as seen in this patient). Educational objective: Rotator cuff tear usually presents with shoulder pain when reaching overhead as well as with weakness during abduction and external rotation. Best results are obtained if surgical repair is performed within 6 weeks of the inciting injury. __________ References: Chronic shoulder pain: part I. Evaluation and diagnosis. (http://www.ncbi.nlm.nih.gov/pubmed/18326164) Shoulder osteoarthritis: diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/18788237)

A 72-Year-Old Man Comes to the Physician Because of Shoulder