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An Unusual Case of Shoulder Pain
An Unusual Case of Shoulder Pain CASE PRESENTATION
An 11-year-old male arrived with his mother to the primary care pediatric office with a chief complaint of right shoulder weakness and tenderness for 4 days. The mother was not concerned until today when he reported that he could not complete push-ups in gym class because of the pain and weakness in his right shoulder and could not cut his food at lunch. Upon further questioning, the patient reported his 14-year-old brother tackled his right arm and side while wrestling outside together 4 days earlier. The patient denied numbness and tingling, and there was no loss of consciousness.
head to parallel to the floor (Figure 2) and with the pushing the wall test (Figure 3), there was significant medial winging of the right scapula.1 He also had decreased muscle strength to his right shoulder and arm with shoulder shrug and resistance. He had equal and bilateral hand grips and 3þ radial pulses with no pain upon internal or external rotation of his arms. He did have mild bruising and tenderness to his right lateral costal area, which correlated to the injury history, but no edema noted during physical examination. He had good aeration throughout
IMAGE OF THE MONTH
Past Medical History
The past medical history for the patient included being a full-term infant delivered via a cesarean section with no history of fractures or other skeletal injuries. He was hospitalized overnight at 3 years of age for dehydration after an outpatient umbilical hernia repair. The patient has been otherwise healthy with no daily medications and is up to date with his immunizations including this year’s influenza vaccine. His mobility and physical activity include being in the 6th grade, being right-handed, and playing ice hockey 10 months per year. PHYSICAL ASSESSMENT
His vital signs were as follows: temperature of 97.6 F, 78 lb, 58 inches tall, pulse oximetry of 99%, heart rate of 102 beats/min, and respiratory rate of 30 breaths/min. The patient was well developed, alert, and appeared in no apparent distress with a pain rating of 0 on a scale of 0 to 10 while sitting in the examination room chair, but he reported a pain level of 3 to 4 with movement of his right arm and shoulder. The patient had full range of motion with mild right shoulder laxity when his arms were raised above his head and at rest but no clunking or crepitus with movement (Figure 1). With forward lowering of his arms from above his www.npjournal.org
Renée L. Davis, DNP, CPNP-PC, and Michelle L. Papachrisanthou, DNP, CPNP-PC all lobes with no wheezing, crackles, or rubs. His heart rate was regular with a normal sinus rate and rhythm and no murmurs present. DIAGNOSTICS Right Shoulder and Right Humerus X-ray
A right shoulder and humerus x-ray was ordered at the local hospital to guide treatment and rule out any fractures or dislocation. All views of the x-rays were negative for fractures, and joint spaces appeared well spaced and intact. DIAGNOSIS Etiology of Scapular Winging
A winged scapula is caused by injury, damage, or inflammation to the long thoracic nerve from trauma, pressure lesions, or neuritis causing paralysis to the serratus anterior, trapezius, or rhomboid muscle.1-3 If the serratus anterior muscle is affected, medial scapular winging The Journal for Nurse Practitioners - JNP
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Figure 1. Posterior view at rest.
occurs.3 Lateral winging of the scapula occurs if the trapezius or rhomboid muscles are affected.3 The serratus anterior muscle is the most commonly affected.3 Initially after the injury, shoulder pain is common and can extend from the base of the neck to the deltoid.2 Within a few days to 2 weeks, scapular winging can occur and can also present with limited abduction.2 The presentation of scapular winging can also occur with loss of strength on the affected shoulder and arm or decreased ability to perform daily activities such as cutting food or brushing teeth.3 Figure 2. A lateral view of the forward lowering of arms test.
Figure 3. A posterior view of the push the wall examination.
The diagnosis includes visual inspection and assessment. The most sensitive physical examination finding to elicit scapular winging is forward lowering of arms, whereas the push the wall test is less sensitive but the best known examination.1 An electromyogram can be used to assess the degree of long thoracic nerve involvement, to differentiate between other palsy conditions, and to guide care.2 Management and treatment include rest and avoidance of overhead use of the affected extremity until the pain resolves. Then, passive range of motion exercises involving physical therapy focusing on scapular stability strengthening and/or scapular bracing are recommended, but compliance can be an issue with bracing.3 Conservative treatment for the serratus anterior muscle has good outcomes within 24 months but is not as effective if the trapezius muscle is affected.3 If it does not respond to therapy or spontaneously resolve, surgical intervention may be necessary.2,3 Outcomes
Upon consultation and evaluation with a pediatric orthopedic specialist, the initial management included rest and the use of an arm sling e2
The Journal for Nurse Practitioners - JNP
Volume
-,
Issue
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2017
for 1 week to prevent the patient from overextending the muscle resulting in further damage to the nerve. He then began physical therapy focusing on the scapular muscles, recruit
Resource Toolbox Additional Resource on Scapular Winging: Gooding BWT, Geoghegan JM, Wallace WA, Manning PA. Scapular winging. Shoulder . Elbow. 2014;6(1):4-11. Ortho Bullets: Scapular Winging- http://www .orthobullets.com/sports/3062/scapular-winging Mph SL. Scapular winging: Evaluation and treatment; AAOS Exhibit Selection. 2015:SCIENTIFIC ARTICLES; Pg. 1708-1716. Additional Resource on Shoulder Exams: Lazaro, L. E., & Cordasco, F. A. (2017). Physical exam of the adolescent shoulder: Tips for evaluating and diagnosing common shoulder disorders in the adolescent athlete. Current Opinion in Pediatrics, 29(1), 70-79. doi:10.1097/mop.0000000000000443 The Painful Shoulder, Part 1: http://www.aafp.org/ afp/2000/0515/p3079.html
www.npjournal.org
nerve involvement, and to support the stability of the shoulder to prevent further injury. He improved throughout physical therapy, and at the 4-month mark he only had small scapular winging. He was cleared to return to hockey and gym class and perform his activities of daily living and was scheduled for 6-month interval follow-up visits. References 1. Khadilkar SV, Chaudhari CR, Soni G, Bhutada A. Is pushing the wall, the best known method for scapular winging, really the best? A Comparative analysis of various methods in neuromuscular disorders. J Neurol Sci. 2015;351(1):179-183. 2. Gooding BW, Geoghegan JM, Wallace WA, Manning PA. Scapular winging. Shoulder Elbow. 2014;6(1):4-11. 3. Martin RM, Fish DE. Scapular winging: anatomical review, diagnosis, and treatments. Curr Rev Musculoskelet Med. 2008;1(1):1-11.
Renée L. Davis, DNP, DPNP-PC, and Michelle L. Papachrisanthou, DNP, CPNP-PC, are assistant professors at Saint Louis University School of Nursing in St. Louis, MO. Ms. Davis can be reached at [email protected].
1555-4155/17/$ see front matter © 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2017.05.092
The Journal for Nurse Practitioners - JNP
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An 11-year-old male arrived with his mother to the primary care pediatric office with a chief complaint of right shoulder weakness and tenderness for 4 days. The mother was not concerned until today when he reported that he could not complete push-ups in gym class because of the pain and weakness in his right shoulder and could not cut his food at lunch. Upon further questioning, the patient reported his 14-year-old brother tackled his right arm and side while wrestling outside together 4 days earlier. The patient denied numbness and tingling, and there was no loss of consciousness.
head to parallel to the floor (Figure 2) and with the pushing the wall test (Figure 3), there was significant medial winging of the right scapula.1 He also had decreased muscle strength to his right shoulder and arm with shoulder shrug and resistance. He had equal and bilateral hand grips and 3þ radial pulses with no pain upon internal or external rotation of his arms. He did have mild bruising and tenderness to his right lateral costal area, which correlated to the injury history, but no edema noted during physical examination. He had good aeration throughout
IMAGE OF THE MONTH
Past Medical History
The past medical history for the patient included being a full-term infant delivered via a cesarean section with no history of fractures or other skeletal injuries. He was hospitalized overnight at 3 years of age for dehydration after an outpatient umbilical hernia repair. The patient has been otherwise healthy with no daily medications and is up to date with his immunizations including this year’s influenza vaccine. His mobility and physical activity include being in the 6th grade, being right-handed, and playing ice hockey 10 months per year. PHYSICAL ASSESSMENT
His vital signs were as follows: temperature of 97.6 F, 78 lb, 58 inches tall, pulse oximetry of 99%, heart rate of 102 beats/min, and respiratory rate of 30 breaths/min. The patient was well developed, alert, and appeared in no apparent distress with a pain rating of 0 on a scale of 0 to 10 while sitting in the examination room chair, but he reported a pain level of 3 to 4 with movement of his right arm and shoulder. The patient had full range of motion with mild right shoulder laxity when his arms were raised above his head and at rest but no clunking or crepitus with movement (Figure 1). With forward lowering of his arms from above his www.npjournal.org
Renée L. Davis, DNP, CPNP-PC, and Michelle L. Papachrisanthou, DNP, CPNP-PC all lobes with no wheezing, crackles, or rubs. His heart rate was regular with a normal sinus rate and rhythm and no murmurs present. DIAGNOSTICS Right Shoulder and Right Humerus X-ray
A right shoulder and humerus x-ray was ordered at the local hospital to guide treatment and rule out any fractures or dislocation. All views of the x-rays were negative for fractures, and joint spaces appeared well spaced and intact. DIAGNOSIS Etiology of Scapular Winging
A winged scapula is caused by injury, damage, or inflammation to the long thoracic nerve from trauma, pressure lesions, or neuritis causing paralysis to the serratus anterior, trapezius, or rhomboid muscle.1-3 If the serratus anterior muscle is affected, medial scapular winging The Journal for Nurse Practitioners - JNP
e1
Figure 1. Posterior view at rest.
occurs.3 Lateral winging of the scapula occurs if the trapezius or rhomboid muscles are affected.3 The serratus anterior muscle is the most commonly affected.3 Initially after the injury, shoulder pain is common and can extend from the base of the neck to the deltoid.2 Within a few days to 2 weeks, scapular winging can occur and can also present with limited abduction.2 The presentation of scapular winging can also occur with loss of strength on the affected shoulder and arm or decreased ability to perform daily activities such as cutting food or brushing teeth.3 Figure 2. A lateral view of the forward lowering of arms test.
Figure 3. A posterior view of the push the wall examination.
The diagnosis includes visual inspection and assessment. The most sensitive physical examination finding to elicit scapular winging is forward lowering of arms, whereas the push the wall test is less sensitive but the best known examination.1 An electromyogram can be used to assess the degree of long thoracic nerve involvement, to differentiate between other palsy conditions, and to guide care.2 Management and treatment include rest and avoidance of overhead use of the affected extremity until the pain resolves. Then, passive range of motion exercises involving physical therapy focusing on scapular stability strengthening and/or scapular bracing are recommended, but compliance can be an issue with bracing.3 Conservative treatment for the serratus anterior muscle has good outcomes within 24 months but is not as effective if the trapezius muscle is affected.3 If it does not respond to therapy or spontaneously resolve, surgical intervention may be necessary.2,3 Outcomes
Upon consultation and evaluation with a pediatric orthopedic specialist, the initial management included rest and the use of an arm sling e2
The Journal for Nurse Practitioners - JNP
Volume
-,
Issue
-, -/-
2017
for 1 week to prevent the patient from overextending the muscle resulting in further damage to the nerve. He then began physical therapy focusing on the scapular muscles, recruit
Resource Toolbox Additional Resource on Scapular Winging: Gooding BWT, Geoghegan JM, Wallace WA, Manning PA. Scapular winging. Shoulder . Elbow. 2014;6(1):4-11. Ortho Bullets: Scapular Winging- http://www .orthobullets.com/sports/3062/scapular-winging Mph SL. Scapular winging: Evaluation and treatment; AAOS Exhibit Selection. 2015:SCIENTIFIC ARTICLES; Pg. 1708-1716. Additional Resource on Shoulder Exams: Lazaro, L. E., & Cordasco, F. A. (2017). Physical exam of the adolescent shoulder: Tips for evaluating and diagnosing common shoulder disorders in the adolescent athlete. Current Opinion in Pediatrics, 29(1), 70-79. doi:10.1097/mop.0000000000000443 The Painful Shoulder, Part 1: http://www.aafp.org/ afp/2000/0515/p3079.html
www.npjournal.org
nerve involvement, and to support the stability of the shoulder to prevent further injury. He improved throughout physical therapy, and at the 4-month mark he only had small scapular winging. He was cleared to return to hockey and gym class and perform his activities of daily living and was scheduled for 6-month interval follow-up visits. References 1. Khadilkar SV, Chaudhari CR, Soni G, Bhutada A. Is pushing the wall, the best known method for scapular winging, really the best? A Comparative analysis of various methods in neuromuscular disorders. J Neurol Sci. 2015;351(1):179-183. 2. Gooding BW, Geoghegan JM, Wallace WA, Manning PA. Scapular winging. Shoulder Elbow. 2014;6(1):4-11. 3. Martin RM, Fish DE. Scapular winging: anatomical review, diagnosis, and treatments. Curr Rev Musculoskelet Med. 2008;1(1):1-11.
Renée L. Davis, DNP, DPNP-PC, and Michelle L. Papachrisanthou, DNP, CPNP-PC, are assistant professors at Saint Louis University School of Nursing in St. Louis, MO. Ms. Davis can be reached at [email protected].
1555-4155/17/$ see front matter © 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2017.05.092
The Journal for Nurse Practitioners - JNP
e3