Case Study: Evaluation of Shoulder Pain in a 45-Year-Old Male

Patient Profile:

• Name: Mr. David Harris
• Age: 45 years
• Occupation: Carpenter
• Past Medical History: Generally healthy, no prior surgeries
• Family History: Father has a history of osteoarthritis, no history of rheumatologic or orthopedic conditions
• Medications: None
• Social History: Non-smoker, occasional alcohol use, physically active due to occupation

Chief Complaint: Mr. Harris presents with a 6-month history of intermittent right shoulder pain. The pain has progressively worsened, especially when lifting objects overhead or reaching behind his back. He denies any specific trauma or injury to the shoulder but notes that his work often involves heavy lifting and repetitive overhead motion.

History of Present Illness:

• The pain is primarily located in the anterior and lateral aspects of the shoulder and worsens with activity.
• He reports some mild weakness when lifting heavy objects and difficulty sleeping due to pain when lying on the affected shoulder.
• He has tried over-the-counter NSAIDs, which provide some relief, but the pain persists.
• No numbness, tingling, or radiation of pain down the arm.

Physical Examination:

• BMI: 26 kg/m² (normal weight)
• Vital Signs: BP 128/82 mmHg, HR 72 bpm, RR 16/min
• Right shoulder exam:
  • Tenderness over the bicipital groove and supraspinatus tendon
  • Positive Neer’s impingement sign and Hawkins-Kennedy test
  • Pain and weakness with shoulder abduction and external rotation
  • Full range of motion, though limited by pain
  • No signs of instability or deformity

Imaging Considerations: Given Mr. Harris’s clinical presentation, the next step in evaluation may involve imaging to confirm the diagnosis and rule out more serious underlying conditions.

Questions for Case Assessment:

1. Based on Mr. Harris’s clinical presentation, what is your differential diagnosis, and what key features lead you to consider these potential conditions?

2. What initial imaging modality would you recommend for Mr. Harris’s shoulder pain, and what specific findings would you expect to see based on your differential diagnosis?

3. If Mr. Harris’s symptoms were not improving after initial treatment, what advanced imaging modalities could you consider, and what conditions would these tests help to diagnose?

4. Discuss the principles behind selecting different imaging modalities (e.g., X-ray, MRI, ultrasound) for evaluating orthopedic injuries and conditions. How do the indications for each modality vary based on the suspected diagnosis and clinical scenario?

5. What factors would lead you to consider referring Mr. Harris to an orthopedic specialist for further evaluation, and how would imaging results influence your decision to refer?