Author: Eda Akyar, MD, MPH
Co Author #1: Nicole Boniquit Levy, MD
Co Author #2: Caitlin A. Nicholson, MD
Senior Editor: Kristine Karlson, MD, FAMSSM
Editor: Katherine Fahy, MD

Patient Presentation:
49-year-old right-handed male presented with a history of asthma and paroxysmal atrial fibrillation presented with 3 months of right shoulder pain. The patient first noticed pain with bicep curls. His pain localized to the distal aspect of the right biceps and the deltoid area. He rated his pain as 3-6 out of 10 and reported radiation of pain to his anterolateral shoulder and occasional radiation down to his thumb. His pain was worse with flexion, internal rotation, sleeping on right shoulder, and with heavy lifting. He reported no restriction in range of motion. The patient endorsed weakness and denied numbness and tingling. Symptoms improved with rest. No history of trauma or known injury. No history of fever, chills, weight loss, chest pain, or shortness of breath.

History:
Five years prior, the patient was diagnosed with right biceps tendonitis and a possible labral tear after catching his arm in a narrow doorway in an externally rotated position. His symptoms resolved with rest and physical therapy. He reported that he was a former smoker with an 8 pack-year history. He denied a personal history of cancer. His mother had a history of ovarian cancer.

Physical Exam:
Vital signs: Within normal limits.
The patient was well appearing and in no acute distress.
Skin: Intact with no rashes or discoloration.
Cardiovascular: 2+ radial pulses, no evidence of edema in bilateral upper extremities.
Neurologic: Normal strength and sensation in bilateral axillary, median, ulnar, and radial distributions.


Bilateral Shoulder Exam:
No obvious deformities. There was no tenderness to palpation along the clavicle, acromion, bicipital groove, or humerus bilaterally.
Range of motion: Normal flexion, abduction, and external rotation bilaterally. Internal rotation to T9 on the left, to L1 on the right. Rotator cuff strength testing 5/5 bilaterally.
Right shoulder: Negative Hawkins, Neer, Jobe's test. Positive Speeds and O'Brien's tests.

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