This topic contains 16 replies, has 2 voices, and was last updated by 
Scott Glidden August 22, 2018 at 7:40 pm.
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Carl Nottoli, DC
Great points, Chris. Scott, thanks for the passive ROM information.
As Chris pointed out, even if you don’t know the diagnosis right now it’s ok. But you can’t try to subvert it because it’s difficult.
Start by giving us all the first 7 order history points and we can help you formulate your differential. Then we know what tests would be relevant to rule in/out a given diagnosis.
Scott Glidden
Here we go:
73 year old male
Weakness and stiffness in both shoulders for last 3 months, but much worse over last 2 weeks.
7/10 sore/weak in morning
2-3/10 sore week by end of afternoon
P+ rest, plus gets better as the day progresses
P- any activity with shoulders, especially that which requires him to reach overhead.Codman’s: Mild catch bilaterally, but can stop arm from dropping
Speed’s: Negative
Supraspinatus Press: Mild ache at top of shoulderShoulder Abduction: B 90 degrees (“just won’t go past that”)
Palpation: Mild adhesion at B infraspinatus, subscap, R teres minorDDX:
1) Arthritic AC joints
2) Bilateral mild degenerative tear of supraspinatus
3) Adhesion listed above
4) possible drug interactionReasoning: Problem worse in morning but better throughout day points to arthritis. The codman’s and press tests, as well as age, point to degenerative tears. Adhesion was present, but not prominent in palpation. MD’s believe that drug interaction is a possible cause, and since it IS possible for soreness and aches to be a side effect I have no reason to doubt them (especially since its out of my scope).
My plan was to treat adhesion present to take tension off of supraspinatus and unload arthritic joints since I cannot directly treat #1 or #2. My plan then changed once ALL improvement was revealed to be reflexive at the next visit–I told him we should give it 2 more appointments to see if we could get any improvement and if there is none we could get imaging and come up with another plan. Patient cancelled remaining appointments and wants to meet up in a few weeks once the drug interaction possibility has settled down.
Thoughts?
Christopher Stepien
Awesome Scott!
That’s a relatively complete history, exam, and Dx.
I’m curious how it feels or what you think of writing all of that out? You don’t have to answer, unless you want to.
Thoughts on the Dx:
Load: Did he happen to say if there were any loading factors leading to 3 months ago through now? (This would help us pinpoint the damaged tissue).
Sx: You initially said his symptoms were constant. Which part of the diagnosis is reverse compatible with constant?
Provocative: Did any provocative movements reproduce his soreness, weakness, or stiffness? Did any neck motions provoke his CCx? (This would help us determine which tissue is responsible for his soreness. If there was no provocative movement of his C/Cx, that’s a yellow/red flag for treatment being ineffective.)
Dx Adhesion: With his range suddenly and noticeably decreasing, adhesion wouldn’t do that. It prioritizes “structure” over “adhesion”. The question becomes with palpation, do you feel enough adhesion pull tight to justify putting it on the list at all?Seems to me this might be a load management type case instead of treatment.
Scott Glidden
Load: Some yard work, but nothing out of the ordinary
Sx: A drug reaction would be constant but considering he is a financial adviser an injured disc could potentially be constant as well.
Provocative: abducting his arms reproduced the symptoms, but I admittedly did not have him challenge his cervical ROM while performing arm movements.
Dx Adhesion: I don’t believe the adhesion pulled tight enough to warrant the problem–further evaluation of his neck would be warranted.
Carl Nottoli, DC
Nice work unpacking this case further. To get more specific about symptom location, where around the shoulder is the pain? Is it a focal spot, is it diffuse?
Narrowing down the specifics of the sx location will help you better determine what lives there and what refers there. That way if the cervical tests are warranted it will help you narrow down where to test in more detail.
Scott Glidden
Well gentlemen, I had some very interesting findings.
UCF: 12
CF: 45
CTF 62
CR-L 69%
CR-R 82%adhesion present at several locations, but none were provocative of problem.
At each end range I also passively abducted his arms to 120 degrees and here is the level of discomfort at each test:
UCF: 8-9/10
CF: 6-7/10
CTF: 4/10
All ranges elicited a jump by 2 points when adduction reached 90 degrees and then quickly went away.The pain pattern is achy/weak into both arms but NOT forearms.
Arm flexion is 170 degrees and painless bilaterally.
The symptoms are the worst when abducting to 90 degrees with straight arms.
The symptoms are much better when abduction to 90 degrees with forearms flexed anteriorly 90 degrees.
When he adducts his arms across midline at chest level it elicits a 1-2/10 level of symptoms.I suggested we get an MRI and he is on board for that.
At this point my best ddx is early central cord syndrome, which could be confirmed by MRI.
Scott Glidden
He also reported having trouble opening a jar in the morning but it got better throughout the day.
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