Author: Laika Nur, MD
Co Author #1: Amy Leu, MD
Senior Editor: Yaowen (Eliot) Hu, MD, MBA
Editor: Ian McKeag, MD, MS

Patient Presentation:
26-year-old left-handed male with chronic dermatitis presents with left shoulder pain and superior left-sided chest wall pain.

History:
26-year-old left-handed male with chronic dermatitis presents with left shoulder pain and superior left-sided chest wall pain. There was no acute injury and he first noticed his symptoms on a ski trip with his family a few weeks ago. He recalled doing more pull-ups to increase endurance and then subsequently had gradual onset of shoulder pain. He has difficulty describing the exact location of the pain, but he notes that the shoulder pain is worse with abduction.

He also feels that his chest wall swelling has increased in size and has become more tender. He denies ecchymosis and recalls that he fell several times while skiing, but cannot pinpoint a specific injury. He was evaluated at an out-of-state urgent care for these complaints 3 weeks ago and was told that his chest and shoulder x-rays were normal. Rest, ice, and elevation were recommended at the time which he does not feel has helped. He otherwise denies shortness of breath, leg swelling, pleuritic pain, or fevers.

Physical Exam:
Vital signs: BP 129/86, HR 91 bpm, BMI 24, temperature 98.2 degree F
Inspection: Notable fullness over the left chest and shoulder throughout secondary respiration stress
Palpation: No tenderness to palpation over the left chest or shoulder, negative piano key and no crepitus over the AC joint.
ROM: Full active range of motion of the shoulder with anterior shoulder pain at end range of motion with abduction.
Strength: 5/5 strength at deltoid, supraspinatus, triceps, biceps, internal and external rotators.
Some pain at shoulder with resisted internal rotation
Neurovascular: Sensation intact C4-C8, 2+ radial pulses
Special tests: Mildly positive impingement signs (Neer, Hawkins). Negative drop arm test. Negative crossover test. Negative crank test. Negative Speed/Yergason. Negative OBriens test.
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