This blog is devoted to the advancement of Sports and Orthopedic Rehabilitation. Discussions will center around various topics related to examination, evaluation and treatment strategies for musculoskeletal conditions.
Saturday, April 9, 2011
Posterior Shoulder Pain
This is a adult with complaints of chronic shoulder pain. Pain at activity, rest, and a noticable increase in symptoms at night. Look closely at the shoulder and tell me what you see that may be pathologic and where is it located.
Things I Know: 19 year old active male Chronic shoulder pain Pain with activity Pain with rest Increase in s/s at night
What i think is going on: Osteochondroma of the scapula which is relatively rare as far as bone tumors go, with only 4% of them in the scapula. Usually they present in the long bones, pelvis, and shoulder. I would assume that his pain during activity is mechanical pain that arises from compression of the surrounding muscles/tendons/nerves etc. Usually osteochondroma's begin growth during childhood and stop at maturity, so this would explain the chronicity of his pain.
S/S I would like to know about: When did he first start noticing pain in his shoulder? Is there swelling around the tumor? Are those movements with GH joint movement, or more specifically scapular movement (retraction/protraction)? Is it TTP? Does it hurt at night because of laying supine on it, or do the signs and symptoms increase regardless of position? Do you have any snapping sensations with movement of the shoulder? Do you have any numbness and tingling?
List of Differential Diagnoses for the same symptoms but without radiograph: *RTC Tendonitis *AC joint sprain *Arthritis of the GH or AC joint *Scapular mm strain due to postural syndrome ** AND of course, have to throw in the ole' pancoast tumor! :)
I agree with Ashley that it could be a tumor, due to the pain at night and at rest. However, it appears as if there is slight displacement of the distal clavicle that could be due to rupture of the AC ligament and a partial tear of the coracoclavicular ligament. If this was the case activity would cause pain, rest might cause pain due to positioning of arm and at night due to movement while he sleeps. I would like to know if there are specific positions of pain, if there are other symptoms such as fever, malaise and when the symptoms first began. I would like to see a bone scan done to rule out/in the possible bone tumor. Differential diagnosis: rotator cuff injury, scapular dysfunction
I see what Donya's saying, but I think it's just the particular view the image is taken in. The night pain immediately makes me think tumor. I don't want to jump to immediate conclusions, but if you look closely, you can see an outline of what looks like additional tissue growth between the 4th and 5th ribs. I would want to know what motions cause pain, or if any motion particularly exacerbates the pain. I'd want to know description of pain, what a neurological exam reveals, ROM deficits/strength limitations, and if he has accompanying symptoms indicative of a tumor. I'd also like to see pt's scapulothoracic rhythm. Is winging present?
To me, nothing immediately jumps out as a pathology. Based on his chronic onset I'd like to know if it was insidious or if there was a previous injury. Because nothing is overtly present, I could rule out what I don't see. I don't see: -fx of clavicle, humerus, scapula, or ribs -heterotopic ossification -AC joint separation or other signs of previous high force trauma -decreased joint space at GH or rough joint surface -Type II or III acromion
This would lead me to suspect something of a soft tissue origin like the ladies mentioned above.
Based on the information that I have it does seem suspicious that the patient has pain at rest and increased s/s at night which would suggest that there is a tumor. I would want to ask if there is any position that they can get into that will relieve the pain and therefore indicate that the pain is mechanical in nature and not tumor. I would not want to jump right into the conclusion that it was a tumor without further examination of the musculoskeletal system. I would want to know what activities the person is currently participating in because it is possible that the pain is chronic due to the fact they haven't let it rest and heal. I would want to palpate the soft tissues in order to determine if there could be damage to the tissue causing the pain. The radiograph doesn't contain anything that stands out as a cause of the pain to me but I'm not an experience radiologist either. It does appear that the distal clavicle appears to be separated from the acromion which would cause pain with activity but may or may not cause pain at rest. The GH joint doesn't appear to have much joint space but it is an IR view which is not the open packed position so it doesn't seem too important. I would also want to look at posture and screen the cervical and thoracic spine to see if the symptoms would stemming from somewhere else. Differential diagnosis would include: tumor, AC joint injury, cervical or thoracic nerve root impingement or injury, soft tissue injury of the shoulder/neck, RTC pathology, scapular dyskinesia, AC/GH arthritis.
I also don’t notice anything that stands out as being overtly wrong with the patient from looking at the radiograph. If all I had to go on was this radiograph then I would agree with Donya, that I also think the clavicle looks like it could be slightly separated from the acromion from a ruptured acromioclavicular ligament and possibly the coracoclavicular ligament. I agree that a tumor could be a possibility, but I wouldn’t put that at the top of my list due to the lack of information and with other possible pathologies that would be more likely to occur. Also just because it states that there is a significant increase in symptoms at night doesn’t mean that it is cancer, it could just be the way he sleeps or even a miscommunication and that he actually works 3rd shift doing overhead activity. I would like to know which specific activities cause pain, where the pain is located, how long the pain lasts, a description of the pain, how long the problem has been going on, and was there an activity that provoked the s/s. I would also perform special tests for possible impingement, rotator cuff, labral tear and shoulder instability.
I agree with Christine, I'm not ready to jump to conclusions with a tumor (I am also not going to rule it out at this point). Night pain with a shoulder can mean any one of a number of things, does this patient sleep on the involved side (which would obviously cause pain)or maybe they are sleeping on the opposite side and the involved UE is hanging. I agree with my colleagues, I need more subjective information on this patient's pain. I don't feel like this image tells me a lot therefore I, like those before me, would perform special tests to rule in/out soft tissue injury.
Like Donya, the first thing I notice is increased joint space at the AC joint, indicating a possible sprain or partial tear. It is definitely not a shoulder separation, nor do I see a fracture. Night pain is a red flag for cancer, but I would want more information before raising a suspicion of malignancy--including fever, malaise, weight loss, etc. The pain at night could simply be because the patient overdid it with activities during the day and he can feel the pain more when he is resting, or he could be sleeping in a position that causes mechanical pain. I would want to know what activities cause pain, and whether some activity modification would help to decrease the pain at rest/at night. Possible DDx could be RTC impingement or bursitis. If other consitutional s/s were present, I would suggest a bone scan or MRI be done to r/o cancer. If not, I would get a thorough history and description of the pain, and perform musculoskeletal/neuromuscular special testing on the shoulder to narrow down the source of the mechanical pain.
I believe this patient could possibly be suffering from a R shoulder separation (disruption between the junction of the clavicle and acromion)due to the increased widening at the AC joint and the widening of the coracoclavicular distance with this IR projection. The clavicle appears to be elevated from the acromion. This patient's complaints of chronic shoulder pain, pain with activity and rest, and increased pain at night is suspicious (night pain = tumor) but I would want to know more about his onset of pain and MOI. For example, because he is a 19 year old, it is possible that his injury occurred during a sporting event or it could be a FOOSH injrury. His increase in pain at night could be due to position especially if the mechanism of injury included a fall onto his scapula which would cause the clavicle to be forced anteriorly, possible tearing the ligaments and causing the apparent separation. If he were then to rest in the supine position, he would be re-creating the trauma which would cause an increase in his pain. My differential diagnosis would include fracture to the clavicle and/or scapula, AC arthritis (doubtful due to his age unless a family history), distal clavicle osteolysis, coracoid fracture, RTC tear, brusitis, and impingement.
I agree with Courtney when I first looked at the image nothing stood out. The GH joint looks unremarkable and the AC joint does possibly look like the clavicle may be elevated, but for the most part I think it looks okay. If it was AC joint, it wouldn't be chronic and painful all the time, something would relieve it, most likely rest, and that doesn't. Next I suspect cancer due to subjective statements above. I clicked on the picture to enlarge it and noticed on the medial border of the scapula there is something that looks radiodense between 3rd and 4th ribs. I looked up scapula cancer and osteochondroma of scapula and a few pics showed up leading me to suspect this. I would first do all special tests if I was evaluating this patient and had no images, and if nothing changed it at all, and it wasn't "adding up" I'd refer back to doctor.
Like others have noticed, there does seem to be increased joint space at the AC joint, however, it would not be the first diagnosis I would think of when hearing the patient’s symptoms, as well as the lack of an event that brought on the pain (that we know of…). Malignancy is something that I would keep in mind, but based on this radiograph (or rather my lack of skill and experience reading radiographs), it wouldn’t be the first conclusion I would make. Before concluding that the patient has a tumor, I would want to do a full musculoskeletal evaluation, know the patient’s family history, any change in bowel/bladder, unexplained weight loss, the results of any blood work he may have had done, etc.
I agree with all the previous comments and would have to agree that I would not rule out a tumor. Upon examination of the image, nothing huge stood out to me that could have been wrong but I could be missing something. I would really like to know if this patient's pain changes from activity to rest to night or if it is the same constant pain. I also would have liked to have had another view of this shoulder and possibly one of the other shoulder to compare the two images. It is possible that it could be a shoulder separation due to increased space between the R clavicle and acromion.
So far we have come up with tumor, displaced AC joint, decreased GH joint space, other soft tissue issues (RCT, Sprain, strain...), sleeping wrong, ribs compromised, and neck issues. I think it is obvious that there can't be anything really defining off of the x-ray that can be seen by myself or classmates. So, From what has been presented I would think that it is a moderatley severe partial rotator cuff tear/tendonitis without knowing anything else or doing tests. The pain in the shoulder during night could be position related, with pain also during regular rest and activity. Patients that I have encountered have experienced constant/chronic "achiness" with a partial tear with night pain because they like to sleep on it on that side. So I am going to go with that Dx. MRI might be reccomended after I have performed some tests, and obviously obtain a better subjective.
What I know: It is never good to be a 19 year old with chronic shoulder pain, pain with rest, activity, and increased pain with sleep.
What I don't know: Everything else, I am unaware of positions that provoke s/s, any possible MOI, functional movement of this patient's shoulder girdle, and his predominating posture. I am unable to get much information from viewing this x-ray, secondary to the previously taught concept of one view is no view...
If this was my patient and I had seen the x-ray prior to the initial eval, I would proceed with my evaluation as normal, collecting an in depth subjective history, running through objective special tests and movement screens. If I came back with something that fit the description of a musculosketelal condition I would continue treatment, otherwise I would refer, refer, refer...
I don't get much information from the x-ray, in regards to the shoulder joint. It looks pretty healthy. The scapula looks like it is in its normal position, in addition to the GH and AC joint. I wouldn't jump to conclusion of cancer based on "night pain". Pain at night is very common with shoulder injuries, especially if chronic. I would perform a typical shoulder eval, r/o any cervical injuries that could be causing pain in the shoulder. If it was reasonable chronic pain, from a previous or repeated injuries, and appeared to be musculoskeletal in origin (including C/S), I would treat without further need for imaging or tests. If nothing made sense, and the patient's pain wasn't changing with a few treatments, I would refer the patient back for further differential diagnosis. At this point... I would make sure the physician were aware of the "weird spot" on the x-ray. It appears to be between the 4th and 5th rib. For the most part, the lungs look healthy other than this interesting spot that could indicate a tumor or other type of lung cancer.
I agree with everyone who suspects osteochondroma. It really does become evident when you enlarge the picture in a larger window. I think a few people have pointed out the medial border of the scapula as the problem area and I would have to agree with this. Night pain that persists despite position change is a red flag for tumor/cancer. So more subjective information would be helpful but unfortunately we don't have that. A thorough exam would be required to rule out any causes of shoulder pain mentioned above, or pain being referred from the cervical spine. My list of DD: RC tear, labral tear, impingement (including posterior) as these can cause pain at night but are more position dependent. Also think about bursitis, biceps or calcific tendonitis, AC joint seperation ( I see what others are saying about it looking slightly elevated), TOS, C-pine radiculopathy.
Okay since my computer decided to lose connection this will be my second time trying to post this. I do agree with my classmates that state that the nightpain along with the complaint of pain no matter what could be indicative of malignancy and I see the possible soft tissue mass around the 4th and 5th rib. I however also agree that many chronic pain patients may have night pain without it being cancer and although I realize that it may just be the angle of the radiograph I believe there may be something worth looking into at the lateral clavicle at the AC joint. Possibly avascular necrosis? I would want more information from the patient such as when the pain began, if there was an injury that that they can remember, what the past medical history on that shoulder is, where the pain is located, and family history of cancer. The shoulder joint other than the AC joint does look pretty healthy to me as other classmates have said as well. I would make a referral back to the doctor based on what the patient told me on questioning.
At first glance, what popped out to me was the elevated appearance of the clavicle on the acromion suggesting a possible AC joint separation. However, this does not really line up with the subjective information given by the patient. A noticeable increase in pain at night, especially if it persists in all positions (which we do not know) is suggestive of something more serious. A closer look at the picture does show an abnormal area on the medial scapula which could be reason for further imaging. Like the others on this discussion board I would like to be able to ask the patient more questions. Was there a MOI that caused the pain to start? Is this his dominant arm? If so, is he involved in any throwing sports or in a job that requires repeated use of the shoulder. Has he found a way to reduce the pain? What really aggravates the pain? Where is the pain exactly and does it travel down the arm or up into the neck? DD for this would include RCT, impingement, AC joint separation, SLAP tear, biceps pathology, bursitis, and radiculopathy.
The subjective information given leads me to suspect a non-musculoskeletal issue is going on. The 19 year old has chronic shoulder pain reported at rest, with activity, and increased at night. The increased pain at night is a red flag and could possibly be indicative of a malignancy. The GHJ doesn't appear to have any pathology. I agree with my classmates that the clavicle looks slightly off however I do not believe it is too significant. There does appear to be a mass on the scapula in this image. I would like to see another view and perhaps a MRI to further distinguish any soft tissue abnormalities. I would ask the patient several things including: Does any position relieve the pain, what activities or sports is he doing, in what position does he sleep, was there an injury or specific trauma, any weight loss, significant fatigue, fever, or malaise? On my list of differential diagnoses I would include; AC joint separation, rotator cuff tendinitis, C-spine radiculopathy, rib dysfunction. Also nice call on the diff diagnosis of Pancoast tumor Ash!
I agree with many of my fellow classmates and their comments. To reiterate, we don’t have much to go on. We do know that the patient is a 19 year old male who presents with complaints of chronic shoulder pain. He reports pain with activity, rest, and a noted increase in symptoms at night. We don’t have any other subjective or objective findings to go on. Some questions I have include; was there any traumatic event that may be the cause of pain, are there any motions/positions that change or relieve symptoms, in what position does he sleep at night, can I get a more detailed description of the pain (e.g. burning, cramping, aching, etc), is there any numbness or tingling, does the pain radiate down his arm, has he ever experienced shoulder pain before the start of this episode, has he experienced fever/fatigue/malaise? Also, I would want to do a thorough musculoskeletal examination. The symptom of increased pain at night would definitely remain in the back of my mind and make me think possible tumor. When looking at the image, nothing instantly stands out to me. If I am still unsure on the cause of his symptoms following the evaluation, I would definitely refer back to his physician for further imaging to rule out/in possible tumor. My differential diagnosis would include AC joint sprain, RTC tendonitis, glenohumeral instability, labral tear, and TOS.
The first thing that I noticed in this radiograph is the radiodense area that a couple people (Sam, Courtney, etc) have mentioned. This would be the first thing that I would check out and hopefully there is another view to be able to identify if this is a fluke or if there really is something there. If I was in a position to order more radiology studies to be done I would maybe suggest an MRI for a more throughout look at the area. Otherwise, the radiograph looks fairly normal. There may be a decrease in the suprahumeral and glenohumeral joint spaces which could cause impingement, but this would not add up with the symptoms listed, and the decreased appearance of the space is likely due to the angle the radiograph is taken from. The subjective things I would want to get from him are pretty much what my classmates said above ways to relieve pain, what activity causes the pain, positions that increase pain more than others, history of injury, etc. The main question I would want to focus on is where exactly is the pain? And is the patient tender to palpation in any area? This would help to identify mechanical issues at the GH joint vs soft tissue soreness vs abnormal pain that does not fit into any category we can treat. My main concern would be to make sure that it is not cancer. The night pain is the biggest red flag that I see listed, and I would want to make sure this is looked at throughly before attempting any treatment.
When I look at the image I can see the clavicle is separated from the acromion, but for that injury to occur there had to be a traumatic incident and the patient doesn't report a certain incident and he has chronic pain with it. It could be something to do with scapular mechanics that eventually led to a separation of the AC joint. It's not just that the AC joint is elevated..that could just be the position of the image taken, but the acromion and clavicle are not touching. The increase in pain at night is definitely something that is red flag and make me suspect something else like tumor is going on. The tumor could be pushing upward on the bony structures. With the patient being so young it would be strange for it to be a pancoast tumor...but stranger things have happened in human body. I don't think this image alone with tell us if there is any soft tissue abnormalities and so an MRI is indicated for further investigation. I wouldn't rule out cervical radiculopathy because that can be chronic and refer to the shoulder. I would need to ask the patient more about what positions hurt him or what areas are tender to palpation
Since most people seem to think it’s an osteochondroma (and I can kind of see what they’re saying...), I decided to look it up and see if all the s/s really do match. Osteochondromas are typically diagnosed in patients age 10 to 30 – check! Does not result from injury – check! Knee and shoulder are more commonly involved – check! Hard, painless mass – don’t know, something to look for. Pressure or irritation with exercise – check! Soreness of adjacent muscles – I would assume this to be true based on the c/o “chronic pain.” More commonly occurs as a solitary tumor versus multiple lesions – I can only see one area of abnormality on the image given... in my limited experience in reading radiographs. More common in males than females (sometimes, depending on the source) – check! From what I can see, osteochondroma seems to be a pretty good prediction for what’s wrong. Good job everyone – not sure I would have picked up on that on my own!
There seems to be an increased space between the clavicle and the acromion. However, the first aspect of this picture that jumped out at me was the circular shaped object on the medial scapula. Due to the nature of pain at night and day, I would request additional imaging to rule in/out a tumor in this area. During my differential diagnosis, I would palpate scapular musculature as well as RTC and would test for hypo/hypermobility at the shoulder as well as the rest of the body to test for global ligament laxity. It is possible a rib could be displacing on a consistent basis through activity and weight from sleeping on it, leading to altered biomechanics of the soft tissue and musculature, causing the lump on the scapula seen in the xray.
As with most of the previous comments, because of the patient's history, I would be concerned of possible tumors, but would need a lot more detail about what is causing the pain (especially at night) and whether it can be reproduced with any activity or position. Upon first inspection of the radiograph, I felt like it could be a possible separation of the AC joint, but to fully appreciate this, I think there needs to be a comparison of the opposite shoulder. With closer inspection of the radiograph, I did notice a small circular object on the scapula that I can not identify and do not know if this would be a concern. My differential diagnosis would include AC joint sprain, rotator cuff tear, possible malignancy, as well as general mobility of the glenohumeral joint.
Based on the radiograph presented at the beginning of this case, it is safe to rule out fracture and possible. The glenohumeral joint is unremarkable with slight elevation of the clavical in the AC joint but nothing that would make me assume AC joint seperation. I agree with Ryan in the radiodense on the medial boarder of the scapula between the 3rd and 4th ribs. Along with s/s of night pain would lead me to suspision of possibility of cancer.
Differential Diagnoses: RTC impingement, RTC bursitis, AC joint seperation/sprain
I would also look into more diagnostics including bone scan or MRI to rule out possibility of cancer. When patients state night pain another thing to look at is if it is positional pain that can be decreased with movement of extremity from static position, but if present at all times then could lead to thoughts of cancer and referral back to MD.
As we are all frequently reminded, SAFETY first and you have to immediately recognize red flags when diagnosing your patients. To me, night pain is the red flad in this scenario immediately suspecting cancer before even looking closer at the radiograph. Pain is also not dependent on activity levels which leads me to believe that's it's not a musculoskeletal problem. When looking at an enlarged view of the image above, I did notice a slightly more dense area that looks like a dot on the medial border of the scapula. If all I had for diagnosing this patient was the radiograph, there is no way I could have come to the conclusion of a tumor. However, with the subjective above I would definitely heir on the side of caution and rule CA out first and foremost.
As others have said the first thing I noticed is the apparent increased space in the AC joint however I don’t know if I feel an exact pathology pops out at me. I would like to have more information as far as whether he had any previous injuries that could have led to these symptoms and would want to look into special tests to see if soft tissues were compromised. I would also like to know if there was an exact location of the pain and if anything makes it better or worse. As far as the unrelenting pain I would keep malignancy in the back of my head and would want to refer the patient back to their physician if we were not able to make any progress in therapy.
Things I Know:
ReplyDelete19 year old active male
Chronic shoulder pain
Pain with activity
Pain with rest
Increase in s/s at night
What i think is going on: Osteochondroma of the scapula which is relatively rare as far as bone tumors go, with only 4% of them in the scapula. Usually they present in the long bones, pelvis, and shoulder. I would assume that his pain during activity is mechanical pain that arises from compression of the surrounding muscles/tendons/nerves etc. Usually osteochondroma's begin growth during childhood and stop at maturity, so this would explain the chronicity of his pain.
S/S I would like to know about: When did he first start noticing pain in his shoulder? Is there swelling around the tumor? Are those movements with GH joint movement, or more specifically scapular movement (retraction/protraction)? Is it TTP? Does it hurt at night because of laying supine on it, or do the signs and symptoms increase regardless of position? Do you have any snapping sensations with movement of the shoulder? Do you have any numbness and tingling?
List of Differential Diagnoses for the same symptoms but without radiograph:
*RTC Tendonitis
*AC joint sprain
*Arthritis of the GH or AC joint
*Scapular mm strain due to postural syndrome
** AND of course, have to throw in the ole' pancoast tumor! :)
I agree with Ashley that it could be a tumor, due to the pain at night and at rest. However, it appears as if there is slight displacement of the distal clavicle that could be due to rupture of the AC ligament and a partial tear of the coracoclavicular ligament. If this was the case activity would cause pain, rest might cause pain due to positioning of arm and at night due to movement while he sleeps. I would like to know if there are specific positions of pain, if there are other symptoms such as fever, malaise and when the symptoms first began. I would like to see a bone scan done to rule out/in the possible bone tumor. Differential diagnosis: rotator cuff injury, scapular dysfunction
ReplyDeleteI see what Donya's saying, but I think it's just the particular view the image is taken in. The night pain immediately makes me think tumor. I don't want to jump to immediate conclusions, but if you look closely, you can see an outline of what looks like additional tissue growth between the 4th and 5th ribs. I would want to know what motions cause pain, or if any motion particularly exacerbates the pain. I'd want to know description of pain, what a neurological exam reveals, ROM deficits/strength limitations, and if he has accompanying symptoms indicative of a tumor. I'd also like to see pt's scapulothoracic rhythm. Is winging present?
ReplyDeleteDifferential Diagnoses: RTC involvement, arthritis, muscle strain/ligamentous sprain.
To me, nothing immediately jumps out as a pathology. Based on his chronic onset I'd like to know if it was insidious or if there was a previous injury. Because nothing is overtly present, I could rule out what I don't see.
ReplyDeleteI don't see:
-fx of clavicle, humerus, scapula, or ribs
-heterotopic ossification
-AC joint separation or other signs of previous high force trauma
-decreased joint space at GH or rough joint surface
-Type II or III acromion
This would lead me to suspect something of a soft tissue origin like the ladies mentioned above.
Based on the information that I have it does seem suspicious that the patient has pain at rest and increased s/s at night which would suggest that there is a tumor. I would want to ask if there is any position that they can get into that will relieve the pain and therefore indicate that the pain is mechanical in nature and not tumor. I would not want to jump right into the conclusion that it was a tumor without further examination of the musculoskeletal system. I would want to know what activities the person is currently participating in because it is possible that the pain is chronic due to the fact they haven't let it rest and heal. I would want to palpate the soft tissues in order to determine if there could be damage to the tissue causing the pain. The radiograph doesn't contain anything that stands out as a cause of the pain to me but I'm not an experience radiologist either. It does appear that the distal clavicle appears to be separated from the acromion which would cause pain with activity but may or may not cause pain at rest. The GH joint doesn't appear to have much joint space but it is an IR view which is not the open packed position so it doesn't seem too important. I would also want to look at posture and screen the cervical and thoracic spine to see if the symptoms would stemming from somewhere else. Differential diagnosis would include: tumor, AC joint injury, cervical or thoracic nerve root impingement or injury, soft tissue injury of the shoulder/neck, RTC pathology, scapular dyskinesia, AC/GH arthritis.
ReplyDeleteI also don’t notice anything that stands out as being overtly wrong with the patient from looking at the radiograph. If all I had to go on was this radiograph then I would agree with Donya, that I also think the clavicle looks like it could be slightly separated from the acromion from a ruptured acromioclavicular ligament and possibly the coracoclavicular ligament. I agree that a tumor could be a possibility, but I wouldn’t put that at the top of my list due to the lack of information and with other possible pathologies that would be more likely to occur. Also just because it states that there is a significant increase in symptoms at night doesn’t mean that it is cancer, it could just be the way he sleeps or even a miscommunication and that he actually works 3rd shift doing overhead activity. I would like to know which specific activities cause pain, where the pain is located, how long the pain lasts, a description of the pain, how long the problem has been going on, and was there an activity that provoked the s/s. I would also perform special tests for possible impingement, rotator cuff, labral tear and shoulder instability.
ReplyDeleteI agree with Christine, I'm not ready to jump to conclusions with a tumor (I am also not going to rule it out at this point). Night pain with a shoulder can mean any one of a number of things, does this patient sleep on the involved side (which would obviously cause pain)or maybe they are sleeping on the opposite side and the involved UE is hanging. I agree with my colleagues, I need more subjective information on this patient's pain. I don't feel like this image tells me a lot therefore I, like those before me, would perform special tests to rule in/out soft tissue injury.
ReplyDeleteLike Donya, the first thing I notice is increased joint space at the AC joint, indicating a possible sprain or partial tear. It is definitely not a shoulder separation, nor do I see a fracture. Night pain is a red flag for cancer, but I would want more information before raising a suspicion of malignancy--including fever, malaise, weight loss, etc. The pain at night could simply be because the patient overdid it with activities during the day and he can feel the pain more when he is resting, or he could be sleeping in a position that causes mechanical pain. I would want to know what activities cause pain, and whether some activity modification would help to decrease the pain at rest/at night. Possible DDx could be RTC impingement or bursitis. If other consitutional s/s were present, I would suggest a bone scan or MRI be done to r/o cancer. If not, I would get a thorough history and description of the pain, and perform musculoskeletal/neuromuscular special testing on the shoulder to narrow down the source of the mechanical pain.
ReplyDeleteI believe this patient could possibly be suffering from a R shoulder separation (disruption between the junction of the clavicle and acromion)due to the increased widening at the AC joint and the widening of the coracoclavicular distance with this IR projection. The clavicle appears to be elevated from the acromion. This patient's complaints of chronic shoulder pain, pain with activity and rest, and increased pain at night is suspicious (night pain = tumor) but I would want to know more about his onset of pain and MOI. For example, because he is a 19 year old, it is possible that his injury occurred during a sporting event or it could be a FOOSH injrury. His increase in pain at night could be due to position especially if the mechanism of injury included a fall onto his scapula which would cause the clavicle to be forced anteriorly, possible tearing the ligaments and causing the apparent separation. If he were then to rest in the supine position, he would be re-creating the trauma which would cause an increase in his pain. My differential diagnosis would include fracture to the clavicle and/or scapula, AC arthritis (doubtful due to his age unless a family history), distal clavicle osteolysis, coracoid fracture, RTC tear, brusitis, and impingement.
ReplyDeleteI agree with Courtney when I first looked at the image nothing stood out. The GH joint looks unremarkable and the AC joint does possibly look like the clavicle may be elevated, but for the most part I think it looks okay. If it was AC joint, it wouldn't be chronic and painful all the time, something would relieve it, most likely rest, and that doesn't. Next I suspect cancer due to subjective statements above. I clicked on the picture to enlarge it and noticed on the medial border of the scapula there is something that looks radiodense between 3rd and 4th ribs. I looked up scapula cancer and osteochondroma of scapula and a few pics showed up leading me to suspect this. I would first do all special tests if I was evaluating this patient and had no images, and if nothing changed it at all, and it wasn't "adding up" I'd refer back to doctor.
ReplyDeleteI looked up osteochondroma due to Ashley's post, I would have never came up with that.
ReplyDeleteLike others have noticed, there does seem to be increased joint space at the AC joint, however, it would not be the first diagnosis I would think of when hearing the patient’s symptoms, as well as the lack of an event that brought on the pain (that we know of…). Malignancy is something that I would keep in mind, but based on this radiograph (or rather my lack of skill and experience reading radiographs), it wouldn’t be the first conclusion I would make. Before concluding that the patient has a tumor, I would want to do a full musculoskeletal evaluation, know the patient’s family history, any change in bowel/bladder, unexplained weight loss, the results of any blood work he may have had done, etc.
ReplyDeleteI agree with all the previous comments and would have to agree that I would not rule out a tumor. Upon examination of the image, nothing huge stood out to me that could have been wrong but I could be missing something. I would really like to know if this patient's pain changes from activity to rest to night or if it is the same constant pain. I also would have liked to have had another view of this shoulder and possibly one of the other shoulder to compare the two images. It is possible that it could be a shoulder separation due to increased space between the R clavicle and acromion.
ReplyDeleteSo far we have come up with tumor, displaced AC joint, decreased GH joint space, other soft tissue issues (RCT, Sprain, strain...), sleeping wrong, ribs compromised, and neck issues. I think it is obvious that there can't be anything really defining off of the x-ray that can be seen by myself or classmates. So, From what has been presented I would think that it is a moderatley severe partial rotator cuff tear/tendonitis without knowing anything else or doing tests. The pain in the shoulder during night could be position related, with pain also during regular rest and activity. Patients that I have encountered have experienced constant/chronic "achiness" with a partial tear with night pain because they like to sleep on it on that side. So I am going to go with that Dx.
ReplyDeleteMRI might be reccomended after I have performed some tests, and obviously obtain a better subjective.
What I know: It is never good to be a 19 year old with chronic shoulder pain, pain with rest, activity, and increased pain with sleep.
ReplyDeleteWhat I don't know: Everything else, I am unaware of positions that provoke s/s, any possible MOI, functional movement of this patient's shoulder girdle, and his predominating posture. I am unable to get much information from viewing this x-ray, secondary to the previously taught concept of one view is no view...
If this was my patient and I had seen the x-ray prior to the initial eval, I would proceed with my evaluation as normal, collecting an in depth subjective history, running through objective special tests and movement screens. If I came back with something that fit the description of a musculosketelal condition I would continue treatment, otherwise I would refer, refer, refer...
I don't get much information from the x-ray, in regards to the shoulder joint. It looks pretty healthy. The scapula looks like it is in its normal position, in addition to the GH and AC joint. I wouldn't jump to conclusion of cancer based on "night pain". Pain at night is very common with shoulder injuries, especially if chronic. I would perform a typical shoulder eval, r/o any cervical injuries that could be causing pain in the shoulder. If it was reasonable chronic pain, from a previous or repeated injuries, and appeared to be musculoskeletal in origin (including C/S), I would treat without further need for imaging or tests. If nothing made sense, and the patient's pain wasn't changing with a few treatments, I would refer the patient back for further differential diagnosis. At this point... I would make sure the physician were aware of the "weird spot" on the x-ray. It appears to be between the 4th and 5th rib. For the most part, the lungs look healthy other than this interesting spot that could indicate a tumor or other type of lung cancer.
ReplyDeleteI agree with everyone who suspects osteochondroma. It really does become evident when you enlarge the picture in a larger window. I think a few people have pointed out the medial border of the scapula as the problem area and I would have to agree with this. Night pain that persists despite position change is a red flag for tumor/cancer. So more subjective information would be helpful but unfortunately we don't have that. A thorough exam would be required to rule out any causes of shoulder pain mentioned above, or pain being referred from the cervical spine. My list of DD: RC tear, labral tear, impingement (including posterior) as these can cause pain at night but are more position dependent. Also think about bursitis, biceps or calcific tendonitis, AC joint seperation ( I see what others are saying about it looking slightly elevated), TOS, C-pine radiculopathy.
ReplyDeleteOkay since my computer decided to lose connection this will be my second time trying to post this. I do agree with my classmates that state that the nightpain along with the complaint of pain no matter what could be indicative of malignancy and I see the possible soft tissue mass around the 4th and 5th rib. I however also agree that many chronic pain patients may have night pain without it being cancer and although I realize that it may just be the angle of the radiograph I believe there may be something worth looking into at the lateral clavicle at the AC joint. Possibly avascular necrosis? I would want more information from the patient such as when the pain began, if there was an injury that that they can remember, what the past medical history on that shoulder is, where the pain is located, and family history of cancer. The shoulder joint other than the AC joint does look pretty healthy to me as other classmates have said as well. I would make a referral back to the doctor based on what the patient told me on questioning.
ReplyDeleteAt first glance, what popped out to me was the elevated appearance of the clavicle on the acromion suggesting a possible AC joint separation. However, this does not really line up with the subjective information given by the patient. A noticeable increase in pain at night, especially if it persists in all positions (which we do not know) is suggestive of something more serious. A closer look at the picture does show an abnormal area on the medial scapula which could be reason for further imaging. Like the others on this discussion board I would like to be able to ask the patient more questions. Was there a MOI that caused the pain to start? Is this his dominant arm? If so, is he involved in any throwing sports or in a job that requires repeated use of the shoulder. Has he found a way to reduce the pain? What really aggravates the pain? Where is the pain exactly and does it travel down the arm or up into the neck? DD for this would include RCT, impingement, AC joint separation, SLAP tear, biceps pathology, bursitis, and radiculopathy.
ReplyDeleteThe subjective information given leads me to suspect a non-musculoskeletal issue is going on. The 19 year old has chronic shoulder pain reported at rest, with activity, and increased at night. The increased pain at night is a red flag and could possibly be indicative of a malignancy. The GHJ doesn't appear to have any pathology. I agree with my classmates that the clavicle looks slightly off however I do not believe it is too significant. There does appear to be a mass on the scapula in this image. I would like to see another view and perhaps a MRI to further distinguish any soft tissue abnormalities. I would ask the patient several things including: Does any position relieve the pain, what activities or sports is he doing, in what position does he sleep, was there an injury or specific trauma, any weight loss, significant fatigue, fever, or malaise? On my list of differential diagnoses I would include; AC joint separation, rotator cuff tendinitis, C-spine radiculopathy, rib dysfunction. Also nice call on the diff diagnosis of Pancoast tumor Ash!
ReplyDeleteI agree with many of my fellow classmates and their comments. To reiterate, we don’t have much to go on. We do know that the patient is a 19 year old male who presents with complaints of chronic shoulder pain. He reports pain with activity, rest, and a noted increase in symptoms at night. We don’t have any other subjective or objective findings to go on. Some questions I have include; was there any traumatic event that may be the cause of pain, are there any motions/positions that change or relieve symptoms, in what position does he sleep at night, can I get a more detailed description of the pain (e.g. burning, cramping, aching, etc), is there any numbness or tingling, does the pain radiate down his arm, has he ever experienced shoulder pain before the start of this episode, has he experienced fever/fatigue/malaise? Also, I would want to do a thorough musculoskeletal examination. The symptom of increased pain at night would definitely remain in the back of my mind and make me think possible tumor. When looking at the image, nothing instantly stands out to me. If I am still unsure on the cause of his symptoms following the evaluation, I would definitely refer back to his physician for further imaging to rule out/in possible tumor. My differential diagnosis would include AC joint sprain, RTC tendonitis, glenohumeral instability, labral tear, and TOS.
ReplyDeleteThe first thing that I noticed in this radiograph is the radiodense area that a couple people (Sam, Courtney, etc) have mentioned. This would be the first thing that I would check out and hopefully there is another view to be able to identify if this is a fluke or if there really is something there. If I was in a position to order more radiology studies to be done I would maybe suggest an MRI for a more throughout look at the area.
ReplyDeleteOtherwise, the radiograph looks fairly normal. There may be a decrease in the suprahumeral and glenohumeral joint spaces which could cause impingement, but this would not add up with the symptoms listed, and the decreased appearance of the space is likely due to the angle the radiograph is taken from.
The subjective things I would want to get from him are pretty much what my classmates said above ways to relieve pain, what activity causes the pain, positions that increase pain more than others, history of injury, etc. The main question I would want to focus on is where exactly is the pain? And is the patient tender to palpation in any area? This would help to identify mechanical issues at the GH joint vs soft tissue soreness vs abnormal pain that does not fit into any category we can treat.
My main concern would be to make sure that it is not cancer. The night pain is the biggest red flag that I see listed, and I would want to make sure this is looked at throughly before attempting any treatment.
When I look at the image I can see the clavicle is separated from the acromion, but for that injury to occur there had to be a traumatic incident and the patient doesn't report a certain incident and he has chronic pain with it. It could be something to do with scapular mechanics that eventually led to a separation of the AC joint. It's not just that the AC joint is elevated..that could just be the position of the image taken, but the acromion and clavicle are not touching. The increase in pain at night is definitely something that is red flag and make me suspect something else like tumor is going on. The tumor could be pushing upward on the bony structures. With the patient being so young it would be strange for it to be a pancoast tumor...but stranger things have happened in human body. I don't think this image alone with tell us if there is any soft tissue abnormalities and so an MRI is indicated for further investigation. I wouldn't rule out cervical radiculopathy because that can be chronic and refer to the shoulder. I would need to ask the patient more about what positions hurt him or what areas are tender to palpation
ReplyDeleteSince most people seem to think it’s an osteochondroma (and I can kind of see what they’re saying...), I decided to look it up and see if all the s/s really do match. Osteochondromas are typically diagnosed in patients age 10 to 30 – check! Does not result from injury – check! Knee and shoulder are more commonly involved – check! Hard, painless mass – don’t know, something to look for. Pressure or irritation with exercise – check! Soreness of adjacent muscles – I would assume this to be true based on the c/o “chronic pain.” More commonly occurs as a solitary tumor versus multiple lesions – I can only see one area of abnormality on the image given... in my limited experience in reading radiographs. More common in males than females (sometimes, depending on the source) – check! From what I can see, osteochondroma seems to be a pretty good prediction for what’s wrong. Good job everyone – not sure I would have picked up on that on my own!
ReplyDeleteThere seems to be an increased space between the clavicle and the acromion. However, the first aspect of this picture that jumped out at me was the circular shaped object on the medial scapula. Due to the nature of pain at night and day, I would request additional imaging to rule in/out a tumor in this area. During my differential diagnosis, I would palpate scapular musculature as well as RTC and would test for hypo/hypermobility at the shoulder as well as the rest of the body to test for global ligament laxity. It is possible a rib could be displacing on a consistent basis through activity and weight from sleeping on it, leading to altered biomechanics of the soft tissue and musculature, causing the lump on the scapula seen in the xray.
ReplyDeleteAs with most of the previous comments, because of the patient's history, I would be concerned of possible tumors, but would need a lot more detail about what is causing the pain (especially at night) and whether it can be reproduced with any activity or position. Upon first inspection of the radiograph, I felt like it could be a possible separation of the AC joint, but to fully appreciate this, I think there needs to be a comparison of the opposite shoulder. With closer inspection of the radiograph, I did notice a small circular object on the scapula that I can not identify and do not know if this would be a concern. My differential diagnosis would include AC joint sprain, rotator cuff tear, possible malignancy, as well as general mobility of the glenohumeral joint.
ReplyDeleteBased on the radiograph presented at the beginning of this case, it is safe to rule out fracture and possible. The glenohumeral joint is unremarkable with slight elevation of the clavical in the AC joint but nothing that would make me assume AC joint seperation. I agree with Ryan in the radiodense on the medial boarder of the scapula between the 3rd and 4th ribs. Along with s/s of night pain would lead me to suspision of possibility of cancer.
ReplyDeleteDifferential Diagnoses:
RTC impingement, RTC bursitis, AC joint seperation/sprain
I would also look into more diagnostics including bone scan or MRI to rule out possibility of cancer. When patients state night pain another thing to look at is if it is positional pain that can be decreased with movement of extremity from static position, but if present at all times then could lead to thoughts of cancer and referral back to MD.
As we are all frequently reminded, SAFETY first and you have to immediately recognize red flags when diagnosing your patients. To me, night pain is the red flad in this scenario immediately suspecting cancer before even looking closer at the radiograph. Pain is also not dependent on activity levels which leads me to believe that's it's not a musculoskeletal problem. When looking at an enlarged view of the image above, I did notice a slightly more dense area that looks like a dot on the medial border of the scapula. If all I had for diagnosing this patient was the radiograph, there is no way I could have come to the conclusion of a tumor. However, with the subjective above I would definitely heir on the side of caution and rule CA out first and foremost.
ReplyDeleteThis comment has been removed by the author.
ReplyDeleteAs others have said the first thing I noticed is the apparent increased space in the AC joint however I don’t know if I feel an exact pathology pops out at me. I would like to have more information as far as whether he had any previous injuries that could have led to these symptoms and would want to look into special tests to see if soft tissues were compromised. I would also like to know if there was an exact location of the pain and if anything makes it better or worse. As far as the unrelenting pain I would keep malignancy in the back of my head and would want to refer the patient back to their physician if we were not able to make any progress in therapy.
ReplyDelete