Author: Katherine Fahy, MD
Co Author #1: Emily Miller, MD
Senior Editor: Kristine Karlson, MD, FAMSSM
Editor: Drew Duerson, MD

Patient Presentation:
A right-handed 39-year-old woman was referred to Sports Medicine clinic for a one year history of right shoulder pain with no inciting event or trauma.

History:
She described a clicking sensation that developed into intermittent sharp pain in her upper arm. The pain was aggravated by exercise, including punching or axial loading. She enjoyed doing traveling rings though had stopped when the pain started. Her other activities included occasional rock climbing and weight training. She noted a history of irregular menses.

She was previously referred to physical therapy for suspected subacromial impingement syndrome though had persistent pain despite physical therapy and activity modification. In the two months prior to her telehealth visit, her pain had worsened and was bothering her at nighttime and with daily activity. She described pain deep inside her shoulder as well as pain in her upper arm when rolling on it at night. An MRI was ordered for further evaluation.

Physical Exam:
Initial exam performed through telehealth given COVID pandemic.
Vitals: Body mass index 23.49
General: Awake, alert, no acute distress.

Right Shoulder: Slightly rounded shoulders. No visible deformity or atrophy. Tenderness over the anterior and superior shoulder.
Range of motion (in degrees): Flexion 180, (left 180), Abduction: 180, (left 180), External Rotation: 80, (left 80), Internal Rotation: mid-upper back bilaterally.
Strength assessment limited by telehealth exam but pain with supraspinatus testing.
Positive Hawkins Kennedy and Neer tests.
Negative Speed's test.
Negative cross arm test.
Mild scapular dyskinesia.
Neurologic exam: Sensation grossly intact.
Vascular: Radial pulse present.

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