Author: Bernadette Pendergraph, MD
Senior Editor: Justin Mark Young, MD
Editor: Scott Rand, MD
Right shoulder pain after a fall onto an outstretched hand.
36-year-old male right hand dominant hiker presents with anterior right shoulder pain after falling onto an outstretched hand. His pain is aggravated with reaching behind as well as with overhead activities which causes a click in his shoulder. He reports weakness with lifting and occasional numbness into his axilla. His work involves lifting boxes which aggravates his pain. He uses diclofenac gel as well as ibuprofen and acetaminophen with mild improvement in his symptoms.
His past medical history includes Klippel-Feil Syndrome, recently diagnosed diabetes mellitus, and prior ventriculoperitoneal shunt placement for head trauma as a child.
His right shoulder exam has no atrophy but an elevated right scapula with a prominent medial border. His sitting posture is kyphotic with shoulders rolled anteriorly. He has tenderness of the proximal biceps tendon and acromioclavicular joint. His active range of the shoulder includes forward flexion of 160 degrees, abduction of 160 degrees, external rotation of 45 degrees, and internal rotation to L1. His rotator cuff strength for supraspinatus is 4/5, external rotation is 5/5, and internal rotation is 4/5. Neer, Hawkins, and Obrien tests are positive. His crossover test is negative.
Cervical spine motion is normal with a negative Spurling maneuver. His strength, reflexes and sensation to light touch are intact.
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