+ What are the key components of this patient’s history and physical examination, and why?

Relevant History:

• What are the pain characteristics? What is the onset, context, location, duration, aggravating/alleviating factors, quality, radiation, severity?
• Was there trauma/injury?
• Has this happened before?
• Other relevant symptoms: is there pain anywhere else? Numbness/tingling/weakness?
• Functional history and current functional status?
• What has he done so far to treat the problem? Has there been any workup/imaging?
• Past Medical and Surgical History?
• Medications?
• Social history? Occupation? Is patient able to work with this pain?

Relevant Physical Examination:

• Vital signs
• Inspection with comparison to contralateral side (note any atrophy, deformities, postural abnormalities)
• Palpation of the affected shoulder (palpate glenohumeral joint, peri-shoulder muscles, AC joint, subacromial space, proximal biceps tendon, clavicle)
• Passive and active range of motion comparison of the shoulders
• Manual muscle testing (myotome scan), isolated rotator cuff strength testing (isolating and testing supraspinatus, infraspinatus, teres minor, subscapularis)
• Sensory and reflex testing
• Special testing: Spurling, cervical facet joint loading challenge, Empty Can, Speed, Yergason, Hawkins, Neer, O’Brien, Scarf, Painful Arc, Drop-arm Test

+ Challenge Question

• What are you looking for with the O’Brien test? How would you perform the O’Brien test?

+ Challenge Answer

• The O’Brien test is a test to assess for a labrum tear of the shoulder or acromioclavicular joint (AC joint) arthropathy. It is performed by asking the patient to flex their shoulder to 90 degrees and adduct it towards the midline, holding their arm straight out anteriorly in front of them, elbow extended, internally rotated, forearm pronated with thumb pointing towards the ground. The patient then provides active resistance as the examiner pushes inferiorly on the extended arm. If the patient’s shoulder pain is reproduced with this test, then the test is positive and suggestive of a labrum tear or AC joint arthropathy, as long as the patient subsequently supinates their forearm and the test is repeated with reduced or absent pain in the supinated position.

+ What is your differential diagnosis for this patient?

• Rotator cuff tear, rotator cuff tendinopathy, subacromial subdeltoid bursitis, calcific tendonitis, biceps tendonitis, labrum tear, glenohumeral arthritis, AC joint arthritis, myofascial pain, cervical radiculopathy, cervical facet joint dysfunction

+ Describe the course of treatment you would prescribe for this patient.

• Physical therapy for 4-8 week trial with home exercise program. PT should emphasize rotator cuff, scapular stabilizer, and cervical paraspinal progressive strengthening, stretching, postural mechanics, and safe lifting technique.
• Acetaminophen, NSAIDs, topical heat/ice/NSAIDs, TENS machine, massage
• If pain is too limiting to participate in physical therapy, consider shoulder x-ray or corticosteroid injection.

+ What would you suggest next?

• It would be appropriate at this time to ask the patient if he feels satisfied enough with his pain and functional improvements such that he can live his life and do all the activities he wants to do to his satisfaction. It is appropriate to ask whether he would like you to do more to treat his pain. If he still feels too limited by his pain and impaired function, then it is reasonable to discuss ordering a left shoulder x-ray and possibly a left shoulder MRI.

+ Your next steps ultimately result in the following:

• Left shoulder x-ray reveals mild glenohumeral and, AC joint arthritis, as well as cystic changes of the greater tuberosity of the humerus. Left shoulder MRI reveals partial thickness bursal-sided tear of the supraspinatus.

+ What treatment would you recommend based on these imaging findings?

• It would be most appropriate to offer a subacromial subdeltoid corticosteroid injection for pain relief and for improved tolerance to exercise. Given enough pain relief, the hope is that the patient can rehabilitate through this problem and not require any additional injection or other intervention beyond exercise and over-the-counter pain medications. If the patient denies wanting an injection, a discussion could be initiated regarding the potential benefits of orthopedic surgical intervention.

+ What would you change about your previous recommendation if the patient had a history of diabetes?

• I would educate the patient on the risks of using corticosteroids with a focus on blood sugar changes following a corticosteroid injection, as well as the increased risk of infection and poor tissue healing in the setting of diabetes. I would advise the patient to closely monitor their blood sugar following the injection, and to let his primary care physician know that he will be having this injection done so that plans can be made regarding diabetes management following the injection. I would also inform the patient that I would send a copy of my note to his primary care physician so that he or she remains informed as well.

+ What is your response? Pretend I'm the patient's brother.

• First, always obtain express written consent from the patient to talk to anyone other than his or herself. If the patient has not designated his brother as an authorized contact, then you must calmly and politely explain that you cannot comment on his questions. If the brother is indeed an authorized contact (which is more likely to be the case on the oral board examination), then you should calmly and politely explain your rationale for treatment. Before explaining, it is a good idea to ask if the patient is nearby and available to talk. It is also a good idea to ask the brother what the brother’s and the patient’s thoughts are regarding his current treatment. An acceptable response would be: “I understand your question and concerns, and I appreciate the seriousness of your brother’s problem. I know you care for your brother and want what is best for him. I apologize if there has been any confusion regarding his diagnosis or treatment plan. I would be happy to discuss this with you today. Could you please tell me what you know of your brother’s problem, including the treatments we’ve tried so far? Our treatment program is designed to progress from conservative to invasive in a stepwise fashion, trying to treat your brother with the least invasive methods possible. If a certain intervention fails to solve his problem, then we proceed to the next step, which tends to be more invasive but which may also be necessary to benefit him. It is true that surgical repair of his torn tendon is an option. However, surgery is the most invasive of his options and comes with increased risks as a result. Of course, should he desire surgery, or should all his other options fail him, then I would be more than happy to have the discussion with him regarding risks vs. benefits of surgery, as well as a referral to a surgeon to treat his problem. Are there any other questions I can help answer today?”

• Note: It’s important to remember when speaking to individuals other than the patient that you will need express written consent from the patient to discuss the patient’s personal health information with them. It is also a great idea to ask if the patient is available to contribute to the discussion, or if you can set up a time when all three of you can meet to discuss the case together. Essentially, involve the patient himself/herself as much as possible. Do not allow yourself to become flustered by the occasional aggression of other individuals, and always act in the patient’s best interest.