Supplemental Material
Pain in a Patient with Metastatic Cancer Supplemental
Shoulder Examination
Developed by Adam Popchak, DPT, PhD, SCS.
Summary of Physical Exam Findings
Here are some key points you should take away from Mary’s shoulder examination:
- Upon initial observation and inspection, Mary presented with no obvious deformities or posturing that may have provided insight into the underlying pathology of her pain or toward a diagnosis.
- Based on the location of Mary’s symptoms, an upper quarter screen was warranted to determine the origin of her symptoms. This screen was negative for findings, which helps to rule out the cervical and thoracic spine as the origin of the pathology
- The active range of motion examination revealed limited active elevation—or, flexion and abduction—horizontal adduction, and internal rotation. Mary exhibited significant limitations in all planes, and all motions were painful for her. These findings indicate an impairment in either the muscle-tendon unit or a possible physical block to the range of motion.
- The passive range of motion examination revealed limited passive elevation, external rotation, and slight internal rotation. During this examination, Mary exhibited limitation in most planes, but once again all motions were painful. These findings indicate possible involvement of non-contractile elements, such as the bursa, capsule, and so forth.
Observation and Inspection
- No obvious deformities or posturing
- No insight into diagnosis
Upper Quarter Screen
- Negative screen
- Helps rule out cervical and thoracic spine as origin
Active Range of Motion
- Limited active elevation, horizontal adduction, internal rotation
- Significant limitations and pain in all planes
- Impairment in muscle-tendon unit or possible physical block
Passive Range of Motion (PROM)
- Limited passive elevation, external rotation, slight internal rotation
- Limited in most planes and painful
- Possible involvement of non-contractile elements
Scapular Function
- No obvious dyskinesis or abnormality of the scapular function was noted with her movements.
- Scapular dyskinesis most likely NOT a significant contributor
Resisted Tests
- Painful, especially abduction and external rotation
- Weakness in all positions
- Further implicates muscle-tendon units
Palpation
- Tender to palpation:
- Rotator cuff tendons
- Subacromial bursa
- These tendons likely account for at least some of Mary’s pain
Additional important information obtained from Mary’s shoulder exam includes the following:
- Mary’s movement was not impaired by poor mechanics at her scapulae, thus indicating that scapular dyskinesis is most likely NOT a significant contributor to the dysfunction.
- Resisted testing was painful for Mary, especially during abduction and external rotation; and her weakness in all positions was greater than the opposite side. These findings further implicate the muscle-tendon units as a possible contributor to pain and pathology.
- Finally, Mary’s rotator cuff tendons and subacromial bursa were tender to palpation. This information suggests that these two structures may be involved in the pathology and may be the source of the pain that Mary is feeling. Being tender to palpation likely signifies that at least some of her pain is coming from these tendons. However, while this finding does tell us that the tendons might be a source of the pain, it does not not provide us with insight into “why” they are painful.
Differential Diagnosis
Primary
Rotator cuff tendinopathy
Secondary
Dynamic sub-acromial impingement
Tertiary
Partial thickness rotator cuff tear
Evidence to support these diagnoses may be obtained by performing special tests for pathology.
The physical therapy diagnosis is that the patient presents with pain, limited and painful active and passive range of motion, and weakness of the rotator cuff resulting in limited activities of daily living, overhead tasks, and recreational activities.
Physical Therapy Approach
The physical therapy approach to treating Mary includes the following interventions:
- Educating Mary about activity modification, or what positions and activities she should avoid;
- Progressive joint mobilizations and passive range of motion to increase Mary’s available, pain-free range of motion;
- Active range of motion within pain-free ranges to establish proper kinematics and recruit rotator cuff and scapular stabilizing muscles;
- Progressive resistive exercises for the rotator cuff and scapular stabilizers to enhance scapula-humeral rhythm and function with movement;
- And functional activities once Mary is pain-free with basic range of motion, strengthening, and mobility exercises.
