Case
- 65 y.o., university administrator (P/T)
- Shoulder pain & stiffness
- Entire shoulder girdle (bilateral)
- Sx started about 4-5 weeks ago
- She cannot recall any specific injury leading Sx
- Feels generally less well
- Noticed some pain in her fingers
- Developed jaw pain & left sided headaches (over last 2 days, not normally headache sufferer) |
Shoulder girdle
- Stiff & achy
- 8/10
- Worse in the morning
- Needs approx 1hr before she can shower & dress herself |
Fingers: achy pain
- Headache: 8-9/10
- Jaw pain: comes on when chewing |
AA: Getting up & dressed; combing hair (difficulty to lift hand), sleeping (turning in bed painful) |
Extras
- Paracetamol & ibuprofen last two weeks (didn't help)
- Headache doesn't ease w/ medication
- Discectomy L4-5 @ 35 y.o.
- Full hysterectomy @ 42 y.o. due to fibroids
- Getting more tired & Sx affect her mood
- Very concerned shimmy have toggle up job
- Husband passed 2 years ago from MI
- Mother: RA; died @ 65 y.o. from stroke
- Father: passed from aortic aneurysm @ 64 y.o.
- Lost 2.5kg over last 2 months for no specific reason
- Recently more night sweating which wakes her up |
Physical Examination Findings
General observations
- Mild kyphosis |
Head, eyes, ears, nose
- Very tender to palpation over the temporal area on L |
Clinical tests
- Full AROM & PROM shoulders: w/ moderate pain & stiffness in the shoulder girdle
- AROM Cx: some tenderness & stiffness on R rotation
- Full AROM & PROM fingers: although some pain in all directions |
Discussion
Working diagnosis
- Polymyalgia Rheumatica (PMR) - fits well w/ presentation including red flag features |
- Bilateral shoulder pain & stiffness: appears MSK & inflammatory
Differentials (based on age):
- Polymyalgia rheumatica (PMR): fits well w/ presentation, including red flag features
- Rheumatoid arthritis (RA): doesn't normally present in the shoulders |
- Temporal pain presentations: pathognomonic of temporal arteritis
Differentials:
- Giant cell arteritis (GCA) affecting temporal arteries: pain location, pain severity, very tender scalp & presence of jaw claudication
→ Urgent referral needed due to risk of blindness |
Clinical guidance
- Specialised (normally rheumatologist) evaluation take place same day (but in all cases within 3 days)
- GP will refer to secondary care via the local fast track GCA pathway
- We need to get the pt to see their GP (or nurse practitioner) urgently on the same day |
PMR & GCA are related conditions: around 10% of PMR pts have HCA & about 50% of those w/ GCA have PMR
- PMR-like Sx: been linked to cancer related to a paraneoplasic syndrome leading some to suggest that pts w/ PMR-like Sx should be screened for occult cancer |
Learning Outcomes
Differentials for inflammatory shoulder pain
- Rotator cuff tendinitis or tear: inflammation or tear of rotator cuff tendons that attach the muscles of the shoulder to the bone
- Adhesive capsulitis (frozen shoulder): condition in which the shoulder joint becomes stiff & painful, often following a period of immobility
- Bursitis: inflammation of bursa, commonly seen in the subacromial bursa
- Shoulder arthritis: inflammation of the shoulder joint, commonly due to OA or RA
- Polymyalgia rheumatica (PMR): systemic inflammatory disorder that causes muscle pain & stiffness, commonly affecting the shoulders, hips, & neck
- Gout: type of arthritis caused by the build-up of uric acid crystals in the joints, which can cause sudden & severe pain in the shoulder
- Lupus: chronic autoimmune disorder that can cause joint pain & inflammation, including in the shoulders |
Causes of referred pain in the shoulder
- Pancreatitis: upper abdomen, radiating to back & L shoulder
- Angina, heart attack, pericarditis: L shoulder or arm pain
- Gallbladder disease: R shoulder blade
- Liver disease: R shoulder
- Cx disc herniation: sharp/shock-like pain
- Pneumonia or pleurisy: sharp/stabbing pain
- Cx/upper Tx musculature |
Causes of jaw claudication (Jaw pian, often when chewing)
- Giant cell arteritis (temporal arteritis)
- Atherosclerosis in jaw vasculature: affecting blood flow
- Fibromuscular dysplasia: artery walls thicken, narrowing lumen
- TMJ disorders: dysfunction or inflammation that can be mistake for claudication pain
- Tx outlet syndrome |
PMR & temporal arteritis
- Related inflammatory conditions: can both present w/ fever, fatigue, depressed effect, malaise, weight loss
⏺ Polymyalgia rheumatica (PMR):
- Non-specific pain, stiffness in shoulder & pelvic girdles
- Increased ESR rate
- Morning stiffness lasts 30-60 min
- Stiffnessafter prolonged sitting
- Severe pain in neck, shoulders & buttocks
- Can find it difficult to do ADL, overhead work, brush hair, walk stairs, etc
- Muscle tender to palpate
- NO weakness (unless muscles are atrophying)
⏺ Temporal arteritis (giant cell arteritis):
- Can lead to sudden blindness if left untreated
- Unilateral eye Sx: double vision, vision loss
- PMR Sx + headaches, tenderness of affected area of scalp
- Burning, stabbing sensation of Ha
- Jaw claudication is associated Sx, pain when chewing |
Myofascial trigger points
- Nodules in muscle tissue associated w/ localised pain, tenderness, referred pain
- Can be caused by injury, overuse, stress, or poor posture
2 types:
- Active: TTP, causing pain & discomfort locally or referred
- Latent: nodules present but not painful/uncomfortable unless pressure is applied |
Which muscles can refer pain to temporal area?
⏺ Primary:
- Trapezius
- Sternocleidomastoid (SCM)
⏺ Secondary:
- Temporalis
- Splenius cervicis
- Suboccipital group
- Semispinalis capitis |
Health implications for a pt who's had a full hysterectomy
- Menopause: if ovaries removed too, pts will go into menopause if they have not already done so; can lead to Sx: hot flashes, mood changes, & vaginal dryness
- Infertility: no longer fertile
- Sexual function: decreased sex drive; vaginal dryness &/or discomfort during intercouse
- Urinary problems: incontinence; UTIs
- Increased risk of heart CV disease: due to change in hormone levels
- Increased risk of certain cancers: (e.g. ovarian cancer) due to the removal of the ovaries |
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