A 70 y.o. woman had the sudden onset of pain in the shoulder when reaching over her head. She is now unable to lift the arm past the shoulder and it is painful anteriorly .
What is your differential?
normal shoulder in a 70 y.o.
Our patient had biceps tendonitis caused by accordion playing.
Biceps tendonitis-is characterized by pain with overhead activities, pain in the front of the shoulder, and pain with repetitive motions i.e., swimming tennis, weightlifting . It commonly occurs with osteoarthritis. It can result in acute pain when stress is applied. Interestingly, accordion players and cymbal players are prone to this problem.
Shoulder pain affects 20% of individuals over the age of 65 with rotator cuff tears, labral tears and osteoarthritis being the most common causes. To review some of the common causes:
Rotator cuff tear- the rotator cuff has three external rotators. There are a series of tests used to diagnose a tear
Empty can test - extend the arm and raise it to shoulder height. Turn the hand down with palm open and thumb pointing to the floor as if you are pouring from a can. Press down at the elbow. This tests the supraspinatus.
If the rotator cuff is injured the arm cannot resist downward pressure
2. drop arm test-raise your arm over head in an arc and slowly drop it down to your side. If you cannot achieve a slow descent, there may be a tear at the supraspinatus.
3. lag sign test- bend the arm at the elbow to 90 degrees and rotate it to the side as if you are throwing a ball. If you cannot hold it there you may have a supraspinatus tendon tear.
4. Infraspinatus test- bend the arm at the elbow while holding it in front of you with knuckles pointed forward. If inward pressure is placed on the arm and pain results this suggests an infraspinatus tear.
5. lift off test- identifies a tear in the subscapularis tendon which promotes internal rotation. Place the back of your hand against the center of the lower back and then try to lift your hand off your back. Pain suggests injury to the subscapularis.
Labral tear-is diagnosed with the O’Brien’s test-bring the arm up to shoulder height and cross 15 degrees to the midline, then internally rotate the hand and press down. If they have pain in the back of the shoulder joint that suggests a labral tear. If you turn the palm up and push down and they have pain ANTERIORLY in the shoulder it is likely to be AC joint pain and can be due to arthritis.
And…two much less common shoulder problems
Adhesive capsulitis- or frozen shoulder is a clinical diagnosis often occurring in the elderly. It is caused by prolonged immobility, trauma and inflammation. The limitation of movement cannot be reduced by injecting 1% lidocaine into the subacromial space. The treatment is physical therapy and steroid injections.
Septic arthritis of the shoulder- is more common in children than adults. Those adults with artificial shoulder joints are prone to infection with Cutibacterium acnes unlike children who are more likely to have staph or strep infections.
erosion of the humerus can occur with septic arthritis.
Our patient was given stretching exercises and with physical therapy her symptoms resolved. Remember to ask about occupational injuries.
Garofalo R, Flanagin B, Cesari E, et al. destructive septic arthritis of shoulder in adults. Musculoskelet Surg 2014 98 suppl 1 S35-S39.
Huddleston C. Cymbal-player’s shoulder. NEJM 1983. Vol 309:1462. Doi: 10.1056/NEJM 1983l309:1462.
Li D, St.Angelo J, Taqi M. Adhesive Capsulitis(Frozen shoulder). StatPearls.
Faria G, Flood C, Muhammed A, et al. Prosthetic joint infections of the shoulder: a review of the recent literature. J Orthop. 2022. Dec 21;36:106-113.
Burner T, Abbott D, Huber K, et al. shoulder symptoms and function in geriatric patients. J Geriatr Phy Ther. 2014 Oct-Dec;37(4):154-158.