Author: Justin Mark Young, MD
Co Author #1: Arthur A. Islas, MD, MPH, FAWM
Co Author #2: Justin M. Wright, MD

Patient Presentation:
A 67 year-old, left-handed fly-fisherman with no significant past medical history complains of left shoulder pain. He notes associated left arm weakness and cannot cast his fishing rod due to pain. There is difficulty raising his arm above his shoulder and lifting light weights causes pain over his lateral shoulder. He initially presented to his PCP for this pain, but when rest, NSAIDs, and physical therapy did not improve his pain, the PCP consulted Sports Medicine. The patient thinks his pain started when he fell from a six foot ladder four months prior. He went to the ER at that time and x-rays were negative for fracture. He is still undergoing physical therapy. He has noticed a lump on his left arm, proximal to the lateral elbow, but thinks this has been there for at least a year. This lump is similar to one that he has noticed on his back for years. He denies numbness, tingling, or recent weight loss.

History:
Past medical history:
Controlled hypertension for more than 5 years
GERD

Medications: telmisartan, esomeprazole, aspirin

Physical Exam:
Normal vital signs.
Heart - regular rate and rhythm.
Lungs - clear to auscultation

The patient has normal posture.
There is a mass over the left proximal lateral elbow, in the region of the brachioradialis. There is no pain with palpation. The mass is fixed and rubbery in texture. The left arm is larger than the right. Case Photo #1

On examination of the left shoulder, the patient has full abduction, forward flexion, horizontal flexion, internal rotation, and external rotation. However, with full flexion of the arm he reports pain over the brachioradialis. The same pain is reported with supination. The left shoulder is nontender.

In the left arm, there is 5/5 strength in abduction (empty and full can), external rotation, and internal rotation. Hawkin's and Neer's tests are negative. O'Brien's is negative. Yergeson's does cause pain over the lateral upper arm. Speed's test causes pain only with motion in full extension.

Click here to continue. Challenge yourself by writing down a broad differential diagnosis before moving to the next slide.