A 65-year-old man comes to the clinic with pain in his right shoulder over the past few weeks. He works as a house painter and has been experiencing pain when he reaches for objects or lifts his arm above his head. The patient has no recent history of trauma to the shoulder. Vital signs are normal. There is no tenderness distal to the lateral edge of the acromion or over the acromioclavicular joint. Strength, sensation, and arterial pulses in the upper extremities are normal and symmetric. Passive range of motion in the shoulder is full in all directions. However, when the shoulder is internally rotated, the thumb is pointed toward the floor, and the arm is passively raised in front of the patient, the patient experiences reproduction of his pain at 60 degrees of flexion; continued passive motion above the patient's head further increases the pain. Which of the following is most likely responsible for this patient's condition?

Question

A 65-year-old man comes to the clinic with pain in his right shoulder over the past few weeks.  He works as a house painter and has been experiencing pain when he reaches for objects or lifts his arm above his head.  The patient has no recent history of trauma to the shoulder.  Vital signs are normal.  There is no tenderness distal to the lateral edge of the acromion or over the acromioclavicular joint.  Strength, sensation, and arterial pulses in the upper extremities are normal and symmetric.  Passive range of motion in the shoulder is full in all directions.  However, when the shoulder is internally rotated, the thumb is pointed toward the floor, and the arm is passively raised in front of the patient, the patient experiences reproduction of his pain at 60 degrees of flexion; continued passive motion above the patient's head further increases the pain.  Which of the following is most likely responsible for this patient's condition?

Quizplus · Accepted Answer

11ec25c8_d975_1b13_bc81_59a7f5d78241_MD0003_00 This patient with subacute shoulder pain on abduction most likely has rotator cuff tendinopathy (RCT). RCT results from repetitive activity above shoulder height (eg, painting ceilings) and is common in middle-aged and older individuals. Chronic tensile loading and compression by surrounding structures can cause microtears, fibrosis, and inflammatory calcification in the rotator cuff tendons (especially supraspinatus). Pain may also emanate from the subacromial bursa and the tendon of the long head of the biceps. On flexion or abduction of the humerus, the space between the humeral head and acromion is reduced, causing pressure on the supraspinatus tendon and subacromial bursa. Impingement syndrome, a characteristic of RCT, refers to compression of these soft tissue structures. Impingement can be demonstrated with the Neer test: With the patient's shoulder internally rotated and forearm pronated, the examiner stabilizes the scapula and flexes the humerus. Reproduction of the pain is considered a positive test. space Untreated, chronic RCT can increase the risk for rotator cuff tear. Patients with a tear typically present with weakness of abduction following a fall or other minor trauma (Choice C). rotator cuff tear (Choice A) Adhesive capsulitis ("frozen shoulder") is characterized by fibrosis and contracture of the glenohumeral joint capsule. It can occur in patients with underlying shoulder pathology (including RCT), but examination would show decreased passive range of motion. (Choice B) Acromioclavicular arthritis is common in patients with chronic overuse of the shoulder. It presents with pain in the shoulder when lifting the arm overhead or across the body, and frequently coexists with other overuse injuries (including RCT). However, patients typically have tenderness, swelling, or deformity in the acromioclavicular space. (Choice E) Pain can be referred to the shoulder from cervical nerve root impingement, diaphragmatic irritation (eg, intrathoracic tumor), myocardial ischemia, or hepatobiliary disease. Cervical radiculopathy typically presents with pain and paresthesias of the neck and arm along with upper extremity weakness. However, referred pain would not cause impingement signs and would not be exacerbated by shoulder movement. (Choice F) Rupture of the tendon of the long head of the biceps may occasionally be seen with overuse in older patients. It typically causes sudden onset of pain, often with an audible pop and visible bulge. Educational objective: Rotator cuff tendinopathy (RCT) is most common in patients who perform repetitive arm movement above shoulder height. It presents with subacute pain on abduction. Impingement syndrome refers to compression of soft tissue structures between the humeral head and acromion and is a characteristic feature of RCT.

A 65-Year-Old Man Comes to the Clinic with Pain in His