Author: Kristopher Tupper, DO
Senior Editor: Christian Fulmer, DO
Editor: Laika Nur, MD

Patient Presentation:
20 year old right-handed women’s lacrosse goalie presented with left shoulder pain and weakness.

History:
The pain started 4 months ago and had an insidious onset without prior injury or trauma. She described the pain as deep, but non-specific. The pain was worse with flexion and abduction. She also had decreased overhead mobility. She noted numbness with abduction above shoulder level and intermittent numbness of her third through fifth digits of her left hand. She did not have a preceding viral illness. She denied tick or insect bites. She had not had any recent vaccinations. She denied family history of neurologic disease. She did not have any involvement of her other limbs. The pain and weakness did not impact her performance and she is still able to do push ups and planks. She tried cupping, physical therapy and dry needling without improvement.

Physical Exam:
Neck: nontender w/ normal ROM and strength
Vascular: 2+ radial and ulnar pulses symmetric
No skin lesions or palpable masses
Peripheral Neurologic Exam:
Upper Extremity sensation intact — C5-T1
Upper Extremity motor grossly intact — C5-T1
2+ deep tendon reflexes — Biceps (C5), BR (C6), Triceps (C7)
Positive Tinel’s at cubital tunnel of LEFT elbow
Cranial nerves
Cranial Nerve XI motor weakness on LEFT
Left Scapula: Winging that is more pronounced with scaption (scapular plane elevation) and less pronounced with wall pushups Case Photo #1
Left Shoulder:
Atrophy Case Photo #2
Drooping
Weak shrug Case Photo #3
Active ROM painful and limited
Flexion 90 degrees
Abduction 70 degrees
Passive ROM full and non-painful
Reduced strength
Supraspinatus 3.5/5
Infraspinatus 4.5/5
Trapezius 4/5
Normal 5/5 strength
Sternocleidomastoid
Subscapularis
Biceps
Serratus anterior
Other Special Tests
Negative impingement (Neer’s and Hawkin’s)
Negative O’Brien’s and Speed’s
No anterior or posterior instability with load & shift

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