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Patient case: Impingement Syndrome

Patient case: Impingement Syndrome

Discussion

A 42-year-old man presents to the orthopedic clinic with a six-month history of persistent pain in his right shoulder. He describes the pain as deep and aching, worsening with movement, particularly when reaching overhead or behind his back. He denies any history of trauma but recalls that the pain gradually started after increasing his workload at his job, which involves repetitive lifting. He also reports mild morning stiffness that improves after some movement.

On examination, there is tenderness over the anterolateral shoulder, pain on active abduction beyond 60 degrees, and a positive Neer’s impingement test. Passive range of motion is preserved, but resisting abduction is painful. There is no significant swelling or warmth, and neurological examination is normal.

A shoulder X-ray is unremarkable, but ultrasound reveals subacromial bursitis with mild rotator cuff tendinosis. He is diagnosed with subacromial impingement syndrome, a common regional pain disorder. Treatment includes activity modification, physical therapy focusing on rotator cuff strengthening, and a short course of NSAIDs. A corticosteroid injection is offered for symptom relief if conservative measures fail.

Questions
1. What is the most likely diagnosis in this patient with shoulder pain aggravated by overhead movement?

A) Adhesive capsulitis

B) Rotator cuff tear

C) Subacromial impingement syndrome

D) Glenohumeral osteoarthritis

2. Which clinical test is most suggestive of the suspected diagnosis?

A) Neer’s impingement test

B) Empty can test

C) Apprehension test

D) Spurling’s test

3. What is the initial management approach for this condition?

A) Immediate corticosteroid injection

B) Surgical decompression

C) Physical therapy and NSAIDs

D) Immobilization with a sling

4. What imaging modality is most useful for confirming the suspected diagnosis?

A) Plain X-ray

B) CT scan

C) MRI

D) Ultrasound

Reveal answers

Answers

1 - C) Subacromial impingement syndrome

This condition is characterized by shoulder pain that worsens with overhead activity due to compression of the rotator cuff tendons and subacromial bursa. The preserved passive range of motion helps distinguish it from adhesive capsulitis.

2 - A) Neer’s impingement test

This test involves passive forward flexion of the arm while stabilizing the scapula. Pain suggests impingement of the rotator cuff under the acromion. Other tests, like the empty can test, assess for specific rotator cuff muscle involvement.

3 - C) Physical therapy and NSAIDs

Initial treatment includes NSAIDs for pain relief and physical therapy to strengthen the rotator cuff and improve scapular mechanics. Corticosteroid injections may be used if symptoms persist.

4 - D) Ultrasound

Ultrasound is useful for detecting soft tissue abnormalities like bursitis and tendinosis. X-rays may rule out bony abnormalities but do not show soft tissue changes.