Author: Tyler Schmitz, DO
Senior Editor: Siobhan Statuta, MD, FAMSSM
Editor: Adil Malik, MD

Patient Presentation:
A 56 year old healthy, active, right hand dominant woman comes in with a chief complaint of left shoulder pain.

History:
The pain gradually started the previous week after removing her robe and subsequently worsened the following day after reaching down to pick up a pumpkin. The pain is localized to the anterior shoulder and is provoked with any shoulder movement. As a result of progressive worsening of the pain, she went to the urgent care center where she was imaged. X-rays were unremarkable, and she was provided a sling for comfort. Since then, she reports a mass has formed in her anterior shoulder region. Pain is rated an 8 out of 10 in severity and she has been using ibuprofen and topical analgesics for relief. She works as a paralegal which is primarily a desk job. She notes that she exercises for health and fitness regularly, but has been unable to return to work or the gym due to her discomfort.

Physical Exam:
A pleasant, well-nourished, well-developed female in mild discomfort and guarding her left shoulder which limits the exam of this joint. No gross deformities observed. There is a palpable, tender, immobile mass just anterior to the medial bicipital groove measuring approximately 1.5 cm in diameter without overlying skin changes. Active range of motion is to 70 degrees with abduction and flexion, and 30 degrees external rotation. Passive range of motion is to 90 degrees of abduction, external rotation to 60 degrees, and internal rotation to 30 degrees with significant guarding. Strength is a 4 out of 5 on resisted abduction, external rotation, and internal rotation. Internal rotation provokes the most pain. Drop arm test is negative. Impingement testing, empty can testing, and Speeds tests are all painful.

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