Shoulder Injury – Certified Nursing Assistant


Romulo Vasquez, United Health Service Hospitals Sports Medicine, Binghamton, NY.

romulo_vasquez@uhs.org (Sponsors: Luis Rodriguez, Andrew Getzin)

HISTORY: 20-year-old right-handed female certified nursing assistant presented with right shoulder pain for six weeks after pulling a patient for bed transfer. Pain was sharp 7/10, constant on right neck, upper back, shoulder and arm. She complained of numbness, tingling, and weakness in right upper extremity. Pain was aggravated with movement, sleeping on right shoulder, lifting, pushing, and work related activity. Flexeril and Naproxen did not relieve symptoms. She denied similar symptoms in the past.

PHYSICAL EXAMINATION: Cervical lordosis is mildly decreased. There is mild tenderness in right lower paracervical muscles, but no tenderness in spinous processes. AROM, strength and Spurling test are normal. Right shoulder has no erythema, ecchymosis, swelling or joint deformity. There is tenderness in right upper trapezius. AROM and strength of right shoulder are limited in all planes by pain. Hawkins, Speeds, Supraspinatus, Yergason, Obrien, and Cross Arm tests are negative. Upper back exam is significant for medial scapula winging, which is worse with arm flexion to 90 degrees. Trapezius and rhomboids strength are normal, but right serratus anterior strength is decreased. Neurovascular exam is normal.

DIFFERENTIAL DIAGNOSIS: 1. Cervical strain, 2. Rotator cuff injury, 3. Rhomboid palsy, 3. Trapezius palsy, 4. Accessory nerve palsy, 5. Long thoracic nerve palsy.

TESTS AND RESULTS: Cervical spine x-ray anteroposterior and lateral views: mild loss of lordosis. Cervical spine MRI is normal. Right shoulder x-ray anteroposterior, Y-scapular and axillary views all normal. Nerve conductive study of right upper extremity is consistent with long thoracic nerve injury.

FINAL WORKING DIAGNOSIS: Right long thoracic nerve injury

TREATMENT AND OUTCOMES: 1. Pt educated on etiology, signs and symptoms, and natural course of the injury. 2. Off work for a week, then return to light duty work with no lifting over ten pounds and no right arm pushing or pulling related activities. 3. Start physical therapy program focusing on right scapular stabilization and strengthening. 4. Gabapentin. Three and a half months post injury pain has resolved and scapula winging is unchanged, still on rehabilitation program working light duty.

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