Author: David A. Wang, MD

Patient Presentation:
60 year old right-handed male, presented with 3 weeks of right shoulder pain that began after he went to the driving range for the first time in the season.

History:
After hitting about 40 balls with irons, he switched to his driver and let it rip. After a few swings, he felt a twinge deep in his axilla that worsened with each shot. For the next few days, he had soreness in his axilla that resolved with rest. About four days later, he returned to the driving range, and pain immediately resumed with each swing, and progressed throughout the day. That night, he noted a large area of ecchymosis and swelling along his posterior arm, axilla and lateral flank. He later noticed a lump in his posterior axilla. He rested and used NSAIDs for 3-4 days and symptoms gradually improved. By the time of his initial visit, he no longer had pain with daily activities.

Physical Exam:
VS: WNL, no distress.
Musculoskeletal- Right Shoulder:
Inspection: Ecchymosis inside right axilla and onto right upper arm and flank. No atrophy, mass, or deformity.
Palpation: Tenderness along the posterior axillary wall with slight fullness. No tenderness of the SC joint, clavicle, AC joint, bicipital groove, biceps, triceps, anterior axillary wall.
Range Of Motion: Full Range of motion with flexion, abduction, and external rotation with mild axillary pain on abduction. Limited range of motion with internal rotation to L2 vs T10 with stiffness.
Strength: 5/5 without pain with abduction, external rotation, internal rotation.
Special Tests: Negative painful arc, Hawkins, Neers, Speeds, OBrien, Crossarm.
Neuro: Intact in axillary, median, ulnar and radial distribution with motor and sensory testing.

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