1) The correct answer is C.

In the evaluation of shoulder pain, it is important to remember that the majority of etiologies arise from periarticular structures rather than intracapsular disease. Pain that is worsened with active (rather than passive) range of motion testing is suggestive of a muscle or tendon source of pain. Having the patient identify the location of maximal pain, along with provocation testing, can often localize the site of pathology.

Yergason testing is performed in the evaluation of suspected biceps tendonitis. It is not designed to identify pathology arising from the subacromial space (supraspinatus tendinitis or tear, subacromial bursitis, impingement syndrome). Patients with biceps tendonitis often localize discomfort to the anterior aspect of the shoulder, rather than the lateral aspect as in this case. Biceps tendonitis should not cause significant pain with overhead activity.

Hawkins testing, Neer sign, and painful arc testing all evaluate for pathology in the subacromial space. The description of pain with overhead activity raises suspicion of a disorder in this region and should prompt further evaluation with these tests.

Hawkins testing and Neer sign are very sensitive tests to localize injury to the subacroimial space (roughly 80%), but specificity can be poor (30%). As such, a negative test is helpful in ruling out disease in this area.

Painful arc testing is performed by the examiner stabilizing the shoulder with one hand while passively abducting the arm. A positive report of pain between 60 to 120 degrees is consistent with disease in the subacromial space (specificity 80%). Pain during the arc beyond 120 degrees may be a sign of acromioclavicular disease.

2) The correction answer C.

Subacromial bursitis and rotator cuff tendinitis (often supraspinatus tendinitis when referring to conditions localized to the subacromial space) often result from impingement of those structures between the undersurface of the acromion and the humeral head. This occurs when the interval between the acromion and humeral head is narrowed.

The deltoid is the major abductor of the arm, and also serves to pull the humeral head superiorly. The rotator cuff muscles are involved with internal and external rotation at the shoulder, as well as shoulder abduction. In addition, they exert a downward pull on the humeral head, acting as stabilizer to keep the humeral head down in the glenoid fossa as the arm is abducted. Exercises to strengthen the rotator cuff will help ‘open’ the space between the acromion and humeral head in individuals with weak rotator cuff muscles who have an imbalance between the deltoid and rotator cuff muscles.

The trapezius muscle elevates the scapula, while the biceps radialis serves to flex the arm at the elbow and supinate the arm. Strengthening of these muscles would not serve to relieve impingement in the subacromial space.

3) The correct answer is D.

A humeral head fracture can cause significant shoulder pain, but the absence of trauma and lack of evidence for an occult fracture on plain films rule out this etiology.

Calcific tendinitis and chronic rotator cuff tear (with subsequent weakening of the rotator cuff and development of the so-called ‘high riding shoulder’) are both conditions which can lead to recurrent or prolonged symptoms stemming from subacromial bursitis. The radiograph from this patient does not show evidence of either of these conditions (1, 2).

The radiograph shows evidence of a large osteophyte on the undersurface of the acromion. This decreases the space which the supraspinatus and subacromial bursae occupy. Despite adequate exercises to strengthen the rotator cuff, the interval may still be narrowed secondary to the presence of a large bone spur; referral to orthopedics should be discussed with the patient.

4) The correct answer is C.

Serotonin-syndrome results from excessive serotonergic activity in the central nervous system, and commonly is the result of medication use/medication interaction. Clinicians who manage depression and other mood disorders, as well as fibromyalgia, need to be aware of this syndrome given that many of the medications used to treat these conditions can raise levels of serotonin. Selective serotonin reuptake inhibitors (SSRIs) are well known to increase serotonin levels, but many other medications can be culprits as well, including trazodone, amitriptyline, and tramadol. Concurrent use of multiple medications may elevate the risk for development of serotonin syndrome.

The syndrome classically consists of changes in mental status (anxiety, delirium, restlessness), autonomic hyperactivity (increased heart rate, increased temperature, sweating, elevation in blood pressure, diarrhea), and neuromuscular hyperactivity (tremor, increased deep tendon reflexes, myoclonus and muscle rigidity). The syndrome represents a clinical spectrum spanning from milder to more severe presentations, with more severe forms thought to be reflective of the degree of serotonergic activity. Treatment consists of stoppage of the medications that are increasing serotonin levels. Whether all such medications need to be stopped simultaneously and immediately depends on the severity of the presentation. Additional intervention such as temporary use of benzodiazepines has been described, and more severe cases may require hospital admission for monitoring and additional management.

Brain MRI and EMG/NCV are not immediately necessary in this case. Hyperreflexia is present diffusely, with no localizing disease, which is reassuring that a focal lesion is not driving current symptomatology. As such a search for a more generalized process should begin first. CSF culture is not likely necessary at this time given lack of signs of infection (no symptoms of headache, neck stiffness, or mention on exam of neck stiffness).

Close monitoring during withdrawal of medications will be necessary; if symptoms persist then consideration should be given to these and other diagnostic tests.

5) The correct answer is C.

While prior classification criteria for fibromyalgia included reliance upon specific tender points on exam, more recent understanding of the syndrome places an emphasis on widespread pain and presence of associated symptoms such as sleep disturbance, mood disorder, bowel and bladder irritability, and multiple somatic complaints. As such, the failure to reach > 11/18 tender points is not thought to rule out the diagnosis of fibromyalgia.

Additional testing for an inflammatory rheumatic disease is not likely necessary based upon the clinical symptoms and work-up to date. The lack of joint swelling, muscle weakness or other objective exam findings, coupled with lack of end-organ disease by lab testing only 1 month prior, suggest a diagnosis other than a systemic inflammatory process. In general, the absence of clinical, radiographic and laboratory evidence of an inflammatory process after > 2 years of symptoms suggests a non-inflammatory etiology.

Research has identified objective abnormalities on functional brain MRI and in CSF neurotransmitter levels in patients with fibromyalgia. While providing valuable insight in to the pathophysiology of pain processing, they are considered a research tool and are not used in the clinical evaluation of suspected fibromyalgia.

6) The correct answer is A.

The clinical history and appearance on examination of the right hand are consistent with a diagnosis of complex regional pain syndrome (CRPS). This syndrome may follow a precipitating event, and an association with surgical procedures such as carpal tunnel release has been seen. A bone scan can be helpful in CRPS to help confirm the diagnosis, and it may help in predicting response to prednisone as well. Early in disease, diffuse uptake is seen across the finger and wrist joints. Later in disease, the sensitivity of bone scan drops significantly. As such, a negative study does not rule out disease, but may suggest a low likelihood of response to prednisone.

Nailfold capillaroscopy can be a useful tool to aid in the diagnosis of systemic sclerosis and other rheumatic conditions. Early onset systemic sclerosis may present with bilateral finger puffiness. The unilateral swelling in this case would be highly atypical of systemic sclerosis. In addition, the brisk capillary refill is also not consistent with the vasculopathy seen in scleroderma, and is suggestive of a hyperemic state.

Rheumatoid factor, anti-CCP, and ANA testing are unlikely to help direct medical therapy based upon lack of clinical or exam evidence of rheumatoid arthritis or another rheumatic condition at this time.