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Case study #2: 38 yo female presented with 3/12 Hx of increasing right shoulder pain. Gradual onset, nil obvious incident. Most noticeable when holding arm elevated. E.g. when hanging washing. During history she moved from describing 'pain' to describing ‘weakness’. 1/
Well known to clinic, with a history of ‘fibromyalgia’ and intermittent multi-site presentations of pain. Suffers depression and anxiety. Stressed. Recently separated from partner. Generally keeps active with walking and spin. 2/
On exam. Full shoulder range. Scapula rhythm a little off. Jobes mildly weak with mild pain. *Substantial loss of isolated external rotation weakness* without pain.
Cervical spine; full range. Normal upper limb reflexes. 3/
Cervical spine; full range. Normal upper limb reflexes. 3/
Thoughts:
- Normal for patient to present with generalised pain, but she reported a specific aggravating activity
- Significant isolated weakness was concerning.
- Given age and absence of traumatic mechanism, unlikely to be a cuff tear. 4/
- Normal for patient to present with generalised pain, but she reported a specific aggravating activity
- Significant isolated weakness was concerning.
- Given age and absence of traumatic mechanism, unlikely to be a cuff tear. 4/
Impression: The overriding feature is frank isolated external rotation weakness, without obvious cause. Must refer for imaging and nerve conduction tests. 5/
Results: Confirmed Spinoglenoid cyst compressing suprascapula nerve, and denervating infraspinatus. Underwent decompression surgery. Routine rehab followed and patient returned to normal function. 6/
Management reasoning:
1. There is frank and unexplained weakness. If we don’t know the cause, don’t muck about. Patient must be investigated. It’s rare (I've never seen one in 25 years) to see insidious and pain free cuff tears in middle age. 7/
1. There is frank and unexplained weakness. If we don’t know the cause, don’t muck about. Patient must be investigated. It’s rare (I've never seen one in 25 years) to see insidious and pain free cuff tears in middle age. 7/
2. It's important to adopt ‘fresh eyes’ with patients you know well, but who present with new problems. 8/
3. Allow patients to talk openly without interruption. Where able, avoid priming patients with your own words. I initially asked about pain. It was only after speaking freely herself that she referred to weakness. 9/
4. Keep psychosocial factors in mind, but don’t reach for them too early in the process of coming to a diagnosis. Particularly in those already living with a label of Chronic Pain. 10/
5. Specific signs – frank weakness, swelling, loss of movement, etc - usually have specific causes. Endeavour to uncover them. Contrary to an increasingly dominant narrative, specific problems often require specific management. End.
