Things don’t add up

60 old female

 with right  shoulder pain after falling onto a child’s bicycle onto that shoulder.

Palliative: direct pressure (hmm…that’s weird)

Provocative: movement/loading in front or above 90 degrees abduction.

Intensity: 2/10, 8/10

Quality: sharp and dull

Just finished cancer treatment for breast cancer (Thank you ID for that 

diagnosis), and has been declared cancer free. PET scan is scheduled 

for later this month. Primary ordered plain film which were unremarkable.

SA: 80 degrees on the right with pain in the lateral arm and shoulder.

Pushup test: “Good luck with that.”

Dx: Rotator cuff/labral tear, cancer, weakness, adhesion

I ordered MRA, and in the meantime we did 2 treatments with the same 

response. Improved ROM to 100 degrees, but back to 80 degrees for 

follow 

up visits. Biggest issue is that she cannot tolerate ranges of motion 

required for movement. She can’t get to 90 degrees without pain which 

makes infra and teres minimally effective. She can’t get past 90 degrees 

on subscap either. Inferior capsule has a lot of protective tension 

anywhere 

past 90 degrees. She has adhesion in the deltoid where she fell, and 

we’ve 

made some change to that.

MRA came back without a lot of degeneration, but no full thickness 

tears.

1. Supraspinatus and infraspinatus tendinosis with superimposed low-

grade partial-thickness Bursal sided tears; no focal full thickness defect or 

tendon retraction.

2. Moderate acromioclavicular osteoarthrosis.

3. Mild subacromial-subdeltoid bursitis.

With the imaging, I was hopeful to have more answers, but now I have 

more questions than before. What could be limiting her range of motion so 

severely? Could the tendinosis be so severe that it creates all the 

protective tension? I have not seen such

intense pain and limited function without a big pathology.