A journey of a middle-aged man with Shoulder pain, followed by physical assault. Lastly diagnosed by Musculoskeletal Ultrasound.

1. A MIDDLE-AGED MAN
WITH
LEFT SHOULDER PAIN
Dr. Md. Mamunul ABEDIN
Assistant Registrar
Dept. Of Physical Medicine & Rehabilitation
Shaheed Suhrawardy Medical College Hospital

2. PARTICULARS OF THE PATIENT
▪ Name : Mr. Nur Hossen
▪ Age : 38 years
▪ Sex : Male
▪ Marital status : Married
▪ Occupation : Day Laborer
▪ Religion : Islam
▪ Address : Sadar, Chandpur
▪ Date of Admission : 01.12.2021
▪ Date of Examination : 01.12.2021
▪ Ward: 101, Bed: 102

3. PRESENTING COMPLAINTS
1. H/o Physical assault followed by
generalized body-ache 4 months back
2. Severe pain in left shoulder joint with
loss of movement for 2 months
3. Pain in right thigh for same duration

4. H/O PRESENT ILLNESS
Patient states that he is a victim of physical
assault which occurred 4 months back. Since
then, he is suffering from neck, back &
generalized bodily pain. For these pain, he took
several medications (both oral & injection) those
gave temporary & incomplete relief. Then he
develops sudden severe pain in the left shoulder

5. H/O PRESENT ILLNESS (CONTD.)
joint 2 months back which is continuous,
throbbing in character, non-radiating, associated
with fever & skin discoloration of left upper arm.
The pain exacerbates while trying to move the
joint & lying on that side but not relieved by any
means. The pain is so severe & distressing that
he have difficulties moving left upper arm and

6. H/O PRESENT ILLNESS (CONTD.)
performing various ADL activities. The Fever is
undocumented, low grade, continuous, not
associated with any chills, rigor or sweating. He
also complaints of pain in the right thigh for the
same duration, which is dull in character, non-
radiating, continuous, moderate in severity,
exacerbated while walking and mildly relieved by

7. H/O PRESENT ILLNESS (CONTD.)
hot compression & painkillers. He also noticed
wasting of left upper arm for last 15 days. He
gave no history of weight loss, anorexia, night
sweat, rash or nail changes, hand joint pain,
muscle twitching, sexual exposure, painful red
eye, oral ulcer, cough, breathlessness, chest pain
or bowel-bladder problems. He is non-diabetic,
normotensive & non-asthmatic.

8. H/O PAST ILLNESS
• Nothing significant

9. SOCIO-ECONOMIC CONDITION
 Patient belongs to lower socio-economic status
 Monthly income is average 15,000 BDT
 Lives in Tin-shade house & uses sanitary latrine
 Drinks boiled water & takes usual Bangladeshi
diet

10. PERSONAL HISTORY
 He is a day laborer
 Non - smoker, non-alcoholic
 No habit of chewing betel leaf, Jarda or Gul

11. PSYCHOSOCIAL HISTORY
• He is a practicing Muslim
• Meerly satisfied with his way of living and
quality of life
• Not involved in any kind of litigation

12. FAMILY HISTORY
 He is married for 5 years with 1 son
 Has 3 brothers and 1 sister
 Elder brother was treated for pulmonary
tuberculosis 10 years back
 All other family members are in good health
 No h/o consanguinity of marriage

13. IMMUNIZATION HISTORY
Patient is immunized as per EPI schedule
including BCG vaccination.

14. DRUG HISTORY
He had taken both oral & injectable painkillers of
several doses for these symptoms.

15. CLINICAL EXAMINATION

16. GENERAL EXAMINATION
▪ Appearance : Ill looking, anxious
▪ Body build : Below average
▪ Co-operation : Co-operative
▪ Decubitus : On choice
▪ Anaemia : Absent
▪ Jaundice : Absent
▪ Cyanosis : Absent
▪ Oedema : Absent
▪ Dehydration : Absent

17. GENERAL EXAM (CONTD.)
▪ Clubbing : Absent
▪ Koilonychias : Absent
▪ Leukonychia : Absent
▪ Lymph nodes : Not Palpable
▪ Neck vein : Not engorged
▪ Thyroid gland : Not enlarged
▪ Nail changes : Absent
▪ Skin : Dark coloration of left
upper limb

18. GENERAL EXAM (CONTD.)
 Pulse rate : 78 bpm
 Blood pressure : 110/70 mm Hg
 Temperature : 99.0° F
 Respiratory rate : 12/min
 Height : 1.67 m
 Weight : 48 Kg
 BMI : 17.2 Kg/m²

19. SYSTEMIC EXAMINATION

20. LOCOMOTOR SYSTEM
Gait: Antalgic
Arms (Upper limb):
Left Shoulder Joint
 No deformity or swelling
 Wasting of shoulder girdle muscles: Seen
 Temperature: Warm
 Tenderness: Grade-3 tenderness at periarticular
area

21. LOCOMOTOR SYSTEM (CONTD.)
Left Shoulder Joint
 ROM (Active & Passive)
Movement Right Left
Flexion 160° 10°
Extension 75° 20°
Abduction 170° 10°
Adduction 35° 10°
Ext Rotation 50° 5°
Internal rotation 40° 7°

22. Deltoid
Biceps
Supraspinatous
Infraspinatous

23. Cervical Spine
ROM: Flexion
Shoulder Joint ROM:
Extension
Shoulder Joint
ROM: Abduction

24. LOCOMOTOR SYSTEM (CONTD.)
Arms (Upper limbs):
All other joints of upper limbs are normal.

25. LOCOMOTOR SYSTEM (CONTD.)
Legs (Lower Limbs)
-Mild localized swelling of right distal thigh
-No deformity
-Temperature: Normal
-Grade-2 tenderness in Right distal
Quadriceps with firm consistency
- ROM: Normal

26. LOCOMOTOR SYSTEM (CONTD.)
Spine:
Look:
-Cervical & Lumbar lordosis: Normal
-Wasting: Left para-spinal muscles are wasted
-No deformity, Gibbus or swelling

27. LOCOMOTOR SYSTEM (CONTD.)
Spine:
Feel:
Tenderness : Absent
Temperature : Normal
Step sign : Negative
Move:
All the ROM of spine are within normal range.

28. LOCOMOTOR SYSTEM (CONTD.)
Examination of Sacro-Iliac joints:
Right Left
Tenderness - -
Compression test - -
Distraction test - -
Pump Handle test - -
Gaenslen test - -

29. LOCOMOTOR SYSTEM (CONTD.)
Special Tests
▪ Straight leg raising (SLR): Right : 80°
Left : 80°
▪ FABER test : Negative
▪ Spurling Test : Negative

30. NERVOUS SYSTEM
EXAMINATION :
Higher psychic function : Normal
Gait : Antalgic
Speech : Normal
Signs of Meningeal Irritation: Absent
Cranial nerves : Intact

31. EXAMINATION OF MOTOR SYSTEM :
Bulk of Muscle : Left shoulder girdle &
cervico-thoracic paraspinal muscles are
wasted.
Tone of Muscle : Normal

32. EXAMINATION OF MOTOR SYSTEM
(CONTD.):
Power of muscles :
Upper Limbs :
Right Left
Shoulder
Abductors 5/5
N/A
Adductors 5/5
Flexors 5/5
Extensors 5/5
Elbow
Flexors 5/5 5/5
Extensors 5/5 5/5
Wrist
Flexors 5/5 5/5
Extensors 5/5 5/5

33. EXAMINATION OF MOTOR SYSTEM
(CONTD.):
Power of muscles :
Lower Limbs :
Right Left
Hip
Abductors 5/5 5/5
Adductors 5/5 5/5
Flexors 5/5 5/5
Extensors 5/5 5/5
Knee
Flexors 5/5 5/5
Extensors 5/5 5/5
Ankle
Dorsiflexors 5/5 5/5
Planterflexors 5/5 5/5

34. EXAMINATION OF MOTOR SYSTEM
(CONTD.):
Deep Tendon Reflexes :
Biceps Triceps Supinator Knee Ankle
Right 2+ 2+ 2+ 2+ 2+
Left 2+ 2+ 2+ 2+ 2+

35. EXAMINATION OF MOTOR SYSTEM
(CONTD.):
Plantar Reflex : Bilaterally Flexor
Hoffmann’s reflex : Bilaterally Negative
Clonus : Absent
Coordination :
Romberg’s sign : (-)
Finger-nose test : normal
Heel-shin test : normal
Rapid alternating movements : normal

36. EXAMINATION OF SENSORY SYSTEM:
 Pain : Normal
 Touch : Normal
 Temperature : Normal
 Vibration : Normal
 Joint position sense : Normal
 Two point discrimination : Normal
 Point localization : Normal

37. EXAMINATION OF OTHER SYSTEMS:
 Respiratory system
 Alimentary system
 Cardiovascular system
 Genitourinary system
Examination of these systems revealed no
apparent abnormality

38. FUNCTIONAL EXAMINATION:
Ambulation He faces difficulty in walking, stair
climbing etc.
Transfer No difficulties
Dressing Skill Difficult, often needs assistance;
both for upper & lower body
Eating Skill No difficulties
Personal Hygiene Can not use left hand after toileting
Communication No difficulties
Pain Score (Visual Analogue Scale): 10/10

39. SALIENT FEATURES
Mr. Nur Hossen, 38 yrs, male, Day laborer,
normotensive, non-diabetic, non-asthmatic
hailing from Sadar, Chandpur presents with
h/o physical assault 4 months back followed
by generalized body-ache including neck &
back area. For these pain, he took multiple
doses of oral & injectable medications without

40. SALIENT FEATURES (CONTD.)
any satisfactory result. Then he develops sudden
severe throbbing pain in the left shoulder for last
2 months which is continuous, non-radiating,
associated with fever & skin discoloration of left
upper arm. The pain exacerbates during
initiating the joint movement & lying on that side
but not relieved by any means. The Fever is

41. SALIENT FEATURES (CONTD.)
undocumented, low grade, continuous, not
associated with any chills, rigor or sweating. He
also complaints of pain in the right distal thigh
which is mechanical in character for the same
duration. He noticed wasting of left upper arm for
last 15 days. He gave no history of weight loss,
anorexia, cough, hand joint pain, muscle twitching,

42. SALIENT FEATURES (CONTD.)
rash or nail changes, sexual exposure, oral ulcer,
or bowel-bladder problems. He is a day laborer of
poor socio-economic condition. His elder brother
was treated for pulmonary tuberculosis 10 years
back. Rest of the family members are in good
health.

43. SALIENT FEATURES (CONTD.)
On examination, Patient is ill looking, anxious,
underweight, body temp 99°F with other stable
vital signs. His gait is antalgic; Muscle wasting is
noted at left shoulder girdle & left cervico-
thoracic paraspinal area; Left shoulder is mildly
warm with Grade-3 tenderness. Right quadriceps
is firm in consistency with Grade-2 tenderness.

44. SALIENT FEATURES (CONTD.)
He has both active & passive painful restricted
movement of left upper arm in all direction.
Other ROM are normal. Muscle powers is 5/5
except in left shoulder which could not be
evaluated due to severe pain. Deep tendon
reflexes are normal with negative Hoffman’s
reflex and flexor plantar responses. All sensory

45. SALIENT FEATURES (CONTD.)
modalities are intact. Other systemic
examinations reveal no abnormality. His Pain
Score in VAS is 10/10. Due to these conditions,
he faces difficulties in various ADL activities.

46. ?
PROVISIONAL
DIAGNOSIS

47. PROVISIONAL DIAGNOSIS
Post-Traumatic Stiffness of Left Shoulder
with Chronic Regional Pain Syndrome
with Right Quadriceps Strain

48. DIFFERENTIAL DIAGNOSIS
 Septic Arthritis (Pyogenic/ Tubercular)
 Rotator Cuff Tear with Adhesive Capsulitis
 Fracture of Left Shoulder Girdle with
Osteomyelitis
- with Right Quadriceps Strain

49. INVESTIGATIONS:
Investigation Result
CBC
Hb% 9.6 gm/dl
ESR 130 mm
TC 8,000/cmm
PMN 54%
Lympho 37%
PCV 30%
MCV 88 fL
MCHC 32 gm/dL
TRBC count 3.0 m/uL
As on 04.12.2021

50. INVESTIGATIONS:
Investigation Result
S. Creatinine 0.8 mg/dL
Blood sugar (Random) 5.56 mmol/L
CRP Positive, (6-12) mg/L
S. CPK 29 u/L
MT 3 mm between 48 & 72 hours

51. CXR P/A VIEW

52. PLAIN X-RAY LEFT SHOULDER JOINT
(BOTH/VIEW)

53. PLAIN X-RAY L/S SPINE (B/VIEW)
Before Admission
Normal Findings

54. MRI OF L/S
SPINE
Before Admission
Normal Findings

55. NCS & EMG OF LEFT UPPER LIMB
NCS
Ulnar, Median NCS are normal
Radial sensory NCS is normal
EMG
Normal except reduced recruitment of
some sampled muscles
Impression: NORMAL STUDY
Before Admission

56. USG OF LEFT SHOULDER JOINT
Deltoid
IS
Capsule
HH
HH
Labrum
Affected side Normal
G

57. USG OF LEFT SHOULDER JOINT

58. USG OF LEFT SHOULDER JOINT
Needle Tip

59. USG OF THIGH (LONG AXIS)
Left side
Right side

60. USG OF THIGH (SHORT AXIS)
Left side
Right side

61. WORKING DIAGNOSIS
Septic Arthritis with Rotator
Cuff Tear of Left Shoulder
with
Right Quadriceps Strain

62. MANAGEMENT
Objectives:
 To control infection
 To relieve pain
 To mobilize the affected joints

63. MANAGEMENT (CONTD.)
 Pharmacological
 Non-Pharmacological

64. PHARMACOLOGICAL
MANAGEMENT
 Inj. Ceftriaxone
 Inj. Flucloxacillin
 Tab. Indomethacin
 Cap. Omeprazole
 Tab. Tolperisone

65. NON-PHARMACOLOGICAL
 Patient education
 Exercises

66. PATIENT EDUCATION
 Nature of the disease
 Prognosis
 Treatment options
 Importance of exercises

67. EXERCISES
 Pain-free PROM & A-AROM exercises of left
shoulder joint with very gentle stretching of
muscles
 Shoulder mobilization exercises in Shoulder
Wheel
 Deep breathing exercise

69. FOLLOW-UP
3 weeks later

70. LEFT SHOULDER JOINT
ROM
Movement Previous After
Flexion 10° 80°
Extension 20° 50°
Abduction 10° 65°
Adduction 10° 25°
Ext Rotation 5° 15°
Internal rotation 7° 22°
As on 22.12.2021

71. FUNCTIONAL EXAMINATION:
Ambulation No difficulties
Transfer No difficulties
Dressing Skill Difficult both for upper & lower
body but does not need assistance
Eating Skill No difficulties
Personal Hygiene Difficult to use left hand after
toileting
Communication No difficulties
Pain Score (Visual Analogue Scale): 4/10
As on 22.12.2021

72. FUNCTIONAL EXAMINATION:
Ambulation He faces difficulty in walking, stair
climbing etc.
Transfer No difficulties
Dressing Skill Difficult, often needs assistance;
both for upper & lower body
Eating Skill No difficulties
Personal Hygiene Can not use left hand after toileting
Communication No difficulties
Pain Score (Visual Analogue Scale): 10/10
As on 01.12.2021

73. INVESTIGATIONS:
Investigation Result
CBC
Hb% 10.3 gm/dl
ESR 39 mm
TC 5,500/cmm
PMN 46%
PCV 30.7%
MCV 86.2 fL
MCHC 33.6 gm/dL
TRBC count 3.56 m/uL
CRP Negative, (0-6) mg/L
As on 22.12.2021