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Pain in the left shoulder muscle when raising the arm. A month doesn't pass. Male, 50 years old.
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### **FINAL CONCLUSION OF THE CONSILIUM**
**1. PRELIMINARY CONCLUSION**
The most likely cause of pain in the left shoulder when raising the arm in a 50-year-old man is **pathology of the rotator cuff**, in particular, **tendinopathy or partial rupture of the supraspinatus tendon (impingement syndrome)**. This is supported by the characteristic mechanism of pain (with active abduction), the duration of symptoms (1 month) and the age of the patient, which corresponds to the peak of degenerative changes in the tendons. Cervical radiculopathy and cardiac pathology require exclusion, but are considered less likely in the absence of corresponding neurological symptoms and “red flags” from the heart.
**2. RECOMMENDATIONS**
* **Mode:** Temporary restriction of movements that provoke pain (raising the arm above shoulder level, sudden swings, lifting weights). Complete immobilization is not recommended.
* **Drug therapy:** A short course (5-7 days) of NSAIDs (for example, nimesulide, celecoxib) orally to relieve pain and inflammation, taking into account the condition of the gastrointestinal tract and kidneys. It is preferable to use local forms (gels, creams) based on NSAIDs.
* **Physical rehabilitation:** Prescription of a course of physical therapy (physical therapy) under the supervision of a rehabilitation physician or instructor with an emphasis on isometric exercises for the rotator cuff muscles, stretching exercises for the joint capsule. As the pain subsides, move on to strengthening exercises with an expander.
* **Interventional methods:** If severe pain persists after 2-3 weeks of conservative therapy, consider conducting a therapeutic and diagnostic blockade (injection of a corticosteroid with an anesthetic) into the subacromial space under ultrasound guidance.
**3. REQUIRED INVESTIGATIONS**
1. **Ultrasound of the shoulder joint** is a priority method for visualizing the condition of the rotator cuff, the tendon of the long head of the biceps, the subacromial bursa and identifying signs of impingement.
2. **X-ray of the shoulder joint** in standard projections - to assess bone structures, the width of the subacromial space, to exclude arthrosis and calcifications.
3. **Laboratory tests:** Complete blood count, C-reactive protein (CRP), fasting blood glucose (or glycated hemoglobin HbA1c).
4. **ECG (electrocardiogram)** - as a screening method to exclude cardiac pathology, especially in the presence of risk factors for coronary artery disease.
**4. WHAT SPECIALISTS TO CONTACT**
* **Orthopedic traumatologist** - to conduct an in-depth orthopedic examination, interpret ultrasound/X-ray results, determine treatment tactics (physical therapy, blockade) and decide whether an MRI is necessary.
* **Physiotherapist/rehabilitologist** - to draw up and monitor an individual exercise therapy program.
* **Consultation with a neurologist** - indicated if numbness, weakness in the arm, or neck pain appears or worsens.
* **Consultation with a cardiologist** is mandatory if you experience chest pain, shortness of breath, or a connection between shoulder pain and physical activity on your legs (walking).
**5. SPECIALIST POSITIONS**
* **Orthopedic traumatologist:** The main diagnosis is impingement syndrome/tendinopathy of the rotator cuff. Examination (Neer, Hawkins, Jobe tests) and ultrasound are key. Recommends starting with exercise therapy and limiting provoking movements.
* **Neurologist:** Cervical radiculopathy (C5-C6) is possible, but less likely with isolated shoulder pain without radicular radiation, numbness or weakness. Recommends neurological examination and observation; MRI of the cervical spine - only if a neurological deficit appears.
* **Cardiologist:** A cardiac cause is unlikely given the typical association of pain only with arm movement. However, given the age and gender of the patient, minimal screening (ECG, risk factor assessment) is necessary. We strongly recommend that you contact us immediately if you have any chest pain.
* **Therapist:** Focuses on excluding systemic inflammatory and metabolic causes (diabetes). Recommends basic tests (CBC, CRP, glucose) for general assessment of the condition and safe prescription of NSAIDs.
**6. ⚠️ IMPORTANT**
This opinion is based on the information provided as part of the consultation using the AI model and is preliminary. **It cannot replace a face-to-face consultation with a doctor.** To make an accurate diagnosis and prescribe treatment, you must contact a qualified specialist (orthopedic traumatologist, therapist) and undergo the recommended examinations. If “red flags” appear (chest pain, shortness of breath, increasing arm weakness, fever), **immediate medical attention is required.**
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Раунд 1 5 реплик
Главный врач 🏥 **Chief Doctor | Round 1/3** | Pattern: `round_robin` | 2 rounds left Round 1: initial …
🏥 **Chief Doctor | Round 1/3** | Pattern: `round_robin` | 2 rounds left
Round 1: initial assessment of the likely causes of pain in the left shoulder with arm elevation for 1 month and determination of priorities for evaluation/exclusion of dangerous conditions.
Therapist: collect medical history and “red flags” (fever, weight loss, injury, night pain, oncology), assess systemic causes and propose a basic examination plan | Orthopedic traumatologist: differential diagnosis of the shoulder joint (impingement, tendinopathy/tear of the rotator cuff, adhesive capsulitis, bursitis, arthrosis), what tests/examination and what studies (ultrasound/MRI/X-ray) are needed | Neurologist: exclude cervicoradiculopathy/plexopathy and neuropathies (C5-C6, n. suprascapularis), what are the neurological signs and when is ENMG/MRI of the neck needed | Cardiologist: assess the likelihood of a cardiac cause of pain (atypical angina/ischemic heart disease), what questions/symptoms are alarming and what minimum cardiac screening is indicated
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Терапевт Thank you, chief doctor, for the task. When collecting anamnesis, it is important to cla…
Thank you, chief doctor, for the task.
When collecting anamnesis, it is important to clarify the following points. First, the nature of the pain: is it sharp or aching? What is the exact location - anterior, lateral or posterior of the shoulder? It is important to know whether pain occurs with certain movements or loads, especially when lifting your arm. Night pain can also be a significant sign, especially if systemic inflammatory processes or cancer are suspected.
The next step is to assess whether there are any red flags. It is necessary to clarify whether there have been recent injuries, weight loss for no apparent reason, fever or other systemic symptoms such as night sweats. These data may indicate more serious conditions such as cancer or infection. It is also important to find out if there are comorbidities, such as diabetes or rheumatoid arthritis, that may affect the clinical picture.
In terms of screening, I would suggest starting with basic tests: complete blood count, C-reactive protein (CRP) to assess inflammation, and perhaps glucose levels to rule out metabolic disorders. After this, depending on the results obtained and the clinical picture, it will be possible to consider referral for ultrasound of the shoulder joint and radiography to assess the condition of the joints and soft tissues.
Next, turning to the rest of the discussion, what additional examinations do you think would be warranted at this stage? Orthopedic traumatologist, what are your thoughts on tests and examination of the shoulder joint?
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Травматолог-ортопед Thank you, fellow therapist, for your detailed history taking and emphasis on systemic “re…
Thank you, fellow therapist, for your detailed history taking and emphasis on systemic “red flags.” Your initiative with OAC and SRP is logical, but as an orthopedic traumatologist, I insist: the key to diagnosis is a **specific examination of the shoulder**, and not just the laboratory. A 50-year-old patient has had pain when raising his arm for a month - this is a classic **impingement syndrome** or **supraspinatus tendinopathy**. I'll check this with tests:
- **Hawkins-Kennedy** (forced internal rotator test) will reveal compression of the tendon under the acromion;
- **Jobe** (“empty glass”) will put a load on the supraspinatus muscle - pain in the arc of 60–120° of movement will confirm the pathology of the rotator cuff;
- **Speed/Yergason** will assess biceps tendon involvement.
According to the consultation, **Ultrasound of the rotator cuff and subacromial bursa is a mandatory start**, not an option. An X-ray of the shoulder is needed if post-traumatic arthrosis or calcifications are suspected (for example, if the pain is localized strictly under the acromion). Important: if the pain persists during passive movements (I help the patient raise his arm), this is **adhesive capsulitis**, but if you are 50 years old and do not have diabetes (it was checked by a therapist!) the likelihood is lower. Let me remind you: a complete tear of the cuff is manifested by **weakness in abduction** - if the patient cannot raise the arm above 70° without assistance, this is an indication for an MRI now, and not in a month.
Case study: a 52-year-old truck driver has a similar complaint. Ultrasound showed a partial tear of the supraspinatus muscle (defect width 5 mm), but thanks to early physical therapy with an emphasis on isometric exercises and subacromial steroid injection, surgery was not necessary.
Neurologist colleague, your move: If a patient complains of numbness in the deltoid muscle or anterior shoulder, what tests would you perform to rule out compression of the **suprascapularis nerve**? Without duplicating Spurling, how do you differentiate nerve damage from tendinopathy?
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Невролог Thank you, colleagues, for the detailed description of diagnostic approaches. As a neurolo…
Thank you, colleagues, for the detailed description of diagnostic approaches. As a neurologist, I would begin by ruling out neurological causes of pain and numbness that may mimic or accompany orthopedic problems.
The first thing I would do is take a medical history, paying particular attention to any numbness, tingling, or weakness in the deltoid area, anterior shoulder, or arms. Important symptoms are: the presence of pain radiating to the neck, arms, sensory disturbances or muscle weakness, especially with movement or stress. In case of complaints of numbness or weakness, it is necessary to conduct sensitivity tests (tactile and vibration sensitivity tests) and muscle strength. To avoid compression **n. suprascapularis** it is important to assess the sensitivity and strength of the deltoid muscle.
I will pay particular attention to features that indicate the cervicogenic nature of the symptoms: the presence of pain starting in the neck, radiating to the shoulder or arm, aggravation with neck movements, positive Spurling tests, as well as the presence of limitations in neck movements. If neurological pathology is suspected, I will order EMG/ENMG to evaluate the function of the C5-C6 nerve roots and the condition of the peripheral nerves, especially the suprascapularis nerve.
It is also important to exclude neuropathy associated with diabetes or other systemic diseases. If there are progressive symptoms of weakness or deterioration in sensitivity, an MRI of the neck is indicated to diagnose radiculopathy or other structural changes.
My questions to my colleagues: if you have muscle weakness and numbness, what standards or clinical tests do you use to assess the degree and location of the neurological deficit? And what level of electromyography is considered sufficient to confirm or exclude nerve compression?
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Врач-кардиолог As a Cardiologist, I must admit that an initial cardiac cause for left shoulder pain may s…
As a Cardiologist, I must admit that an initial cardiac cause for left shoulder pain may seem less likely given the location of the pain and the movement that triggers it. However, an important aspect in diagnosis is the exclusion of cardiac causes of pain, especially in patients with cardiovascular risk factors such as age, hypertension, diabetes, hyperlipidemia, or a family history of cardiovascular disease.
In a 50-year-old patient complaining of left shoulder pain when raising his arm, I would ask about signs that may indicate a cardiac cause, such as shortness of breath, chest pain or discomfort, especially with exercise or emotional stress. It is also important to ask about the presence of risk factors for cardiovascular disease.
Minimum cardiac screening should include measuring blood pressure, assessing heart rhythm, and listening to heart sounds. Among laboratory tests, it is important to perform blood tests for cholesterol, glucose, and markers of heart damage if clinically warranted.
Given the patient's background and the nature of the complaint, I would recommend an ECG to evaluate the heart rhythm and identify potential changes that may indicate ischemia or other cardiac problems. If the history or physical examination reveals signs suggestive of a cardiac cause of pain, additional studies such as stress echocardiography or coronary angiography may be indicated.
It is important to note that although a cardiac cause of left shoulder pain is less likely than an orthopedic or neurological cause, it should not be ruled out without proper evaluation. Therefore, I would recommend a comprehensive evaluation including both cardiac and orthopedic/neurological aspects for accurate diagnosis and effective treatment.
My question to the next panelist: What specific neurological tests and investigations would you recommend to rule out cervicoradiculopathy or plexopathy, and how might these results impact the patient's overall treatment plan?
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Раунд 2 5 реплик
Главный врач 🏥 **Chief Doctor | Round 2/3** | Pattern: `consensus_building` | 1 round left Round 2/3: …
🏥 **Chief Doctor | Round 2/3** | Pattern: `consensus_building` | 1 round left
Round 2/3: formulate a coordinated tactics and set of examinations for pain in the left shoulder, which intensifies when raising the arm and persists for 1 month in a 50-year-old man.
Therapist: take anamnesis and red flags, form a preliminary differential diagnosis and plan for initial examinations | Orthopedic traumatologist: assess the likelihood of rotator cuff/impingement/adhesive capsulitis, suggest clinical tests and tactics (physical therapy, NSAIDs, indications for ultrasound/MRI) | Neurologist: assess the likelihood of cervical radiculopathy/plexopathy/tunnel syndromes, suggest a neuroexamination and indications for ENMG/MRI of the neck | Cardiologist: assess the need to exclude myocardial ischemia/angina with irradiation, list cardiac red flags and minimum examinations (ECG, acute troponin, stress tests if indicated)
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Терапевт I RECOMMEND: Conduct a comprehensive examination of the patient with an emphasis on medica…
I RECOMMEND: Conduct a comprehensive examination of the patient with an emphasis on medical history, red flags and differential diagnosis.
To begin, I will take a history, paying attention to the nature and location of the pain, whether it radiates, factors that precipitate or alleviate symptoms, and associated symptoms such as weakness, numbness, or tingling. Red flags include: the presence of chest pain, shortness of breath, sudden deterioration of the condition, or the presence of risk factors for cardiovascular disease.
Preliminary differential diagnosis includes:
1. Orthopedic causes: tendinopathy, impingement syndrome, adhesive capsulitis.
2. Neurological causes: cervical radiculopathy, plexopathy.
3. Cardiac causes: angina pectoris, coronary heart disease.
The initial examination plan consists of:
- general blood test,
- assessment of the level of CRP,
- conducting an ECG,
- Ultrasound of the shoulder joint to assess the condition of the rotator cuff,
- neurological examination to identify signs of nerve compression.
Further, based on the data obtained, we can determine the necessary treatment tactics and additional research.
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Травматолог-ортопед I RECOMMEND: Immediate ultrasound of the rotator cuff and subacromial bursa followed by st…
I RECOMMEND: Immediate ultrasound of the rotator cuff and subacromial bursa followed by staged treatment: conservative (physical therapy, subacromial injection) for partial rupture or tendinitis, surgical for complete rupture or ineffective therapy after 3 months.
The patient has a typical picture of impingement syndrome: pain in an arc of 60–120° when raising the arm, persistent for more than a month. To confirm, I will perform the Hawkins-Kennedy and Jobe tests - their positive result will indicate compression/pathology of the supraspinatus muscle. An ultrasound will determine the depth of the injury: if the defect is less than 50% of the tendon thickness (partial tear), I will prescribe a 6-week exercise program with an emphasis on isometric exercises for the supraspinatus muscle and one subacromial injection of dexamethasone. Surgery (arthroscopic repair) is indicated for complete rupture (impossibility of abducting the arm above 70° without assistance) or no dynamics after 3 months of conservative treatment. I will perform an X-ray of the shoulder only if calcifications or post-traumatic changes are suspected.
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Невролог I RECOMMEND: Conduct a neurological examination, including tests of sensitivity, muscle st…
I RECOMMEND: Conduct a neurological examination, including tests of sensitivity, muscle strength and reflexes, as well as assess for symptoms of cervical radiculopathy or tunnel syndromes, and, if necessary, order ENMG/MRI of the neck.
Rationale: Neurologic status will help determine the location and nature of neurologic abnormalities, such as weakness, numbness, or hyperesthesia, that may indicate compression of the neural structures of the cervical spine. Positive tests (eg, Sprowling's test, Guyon's sign, or Lassegue's sign) will indicate a cervicogenic nature of the symptoms. ENMG will help differentiate radiculopathy and plexopathies, and MRI of the neck will help visualize structural changes. This will allow planning further treatment, including possible neurosurgical correction.
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Врач-кардиолог I RECOMMEND: Perform a comprehensive cardiac evaluation to rule out myocardial ischemia or…
I RECOMMEND: Perform a comprehensive cardiac evaluation to rule out myocardial ischemia or angina radiating to the left shoulder.
Rationale: Given the patient's age and nature of pain, it is important to rule out cardiac causes that may mimic orthopedic or neurologic pathology. Red flags for cardiac disease include chest pain or discomfort, shortness of breath, sudden deterioration of the condition, or the presence of cardiovascular risk factors. Minimum testing should include an ECG, troponin blood test (if symptoms are severe), and exercise testing as indicated. If the history or physical examination reveals signs suggestive of a cardiac cause of pain, additional studies such as stress echocardiography or coronary angiography may be indicated. Only after cardiac pathology has been excluded can one focus on orthopedic or neurological causes of pain.
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Раунд 3 5 реплик
Главный врач 🏥 **Chief Doctor | Round 3/3** | Pattern: `voting` | 0 rounds left Final round: voting on…
🏥 **Chief Doctor | Round 3/3** | Pattern: `voting` | 0 rounds left
Final round: voting on the leading cause of left shoulder pain and the minimum necessary examinations to exclude dangerous conditions.
Therapist: collate data, assess red flags, formulate final plan and need for urgent referral/testing | Orthopedic traumatologist: vote for/against the primary orthopedic diagnosis (rotator cuff/impingement/adhesive capsulitis) and suggest initial tactics and shoulder examinations | Neurologist: vote for/against the leading neurological cause (cervical radiculopathy/tunnel syndromes), indicate criteria and required tests/ENMG/MRI | Cardiologist: vote for/against the mandatory exclusion of a cardiac cause (ischemia/angina with irradiation), determine the minimum set of examinations and urgency criteria
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Терапевт VOICE: FOR Rationale: Given the patient's age, nature of pain, and duration of pain, a ca…
VOICE: FOR
Rationale: Given the patient's age, nature of pain, and duration of pain, a cardiac cause should not be excluded without proper evaluation. Red flags, such as the presence of shortness of breath, chest pain, or sudden deterioration of the condition, require immediate exclusion of cardiac diseases. The minimum set of examinations includes an ECG, a blood test for troponin and stress tests if clinically indicated. After ruling out cardiac pathology, I recommend proceeding with an orthopedic and neurological examination.
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Травматолог-ортопед VOICE: FOR Pain when raising the arm in a “pain arc” of 60–120° in a 50-year-old patient…
VOICE: FOR
Pain when raising the arm in a “pain arc” of 60–120° in a 50-year-old patient is typical of impingement syndrome or partial rupture of the supraspinatus tendon. Positive Hawkins-Kennedy and Jobe tests in combination with ultrasound of the rotator cuff will confirm the diagnosis: for a defect <50% of the tendon thickness, I start with 6 weeks of exercise therapy and subacromial injection; surgery is indicated only if there is a complete rupture or no dynamics after 3 months of conservative therapy.
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Невролог VOICE: FOR Rationale: Given the duration of symptoms, sensitivity, and the presence of po…
VOICE: FOR
Rationale: Given the duration of symptoms, sensitivity, and the presence of possible neurological manifestations (numbness, weakness, reflex changes), the leading cause is cervical radiculopathy or tunnel syndromes. A neurological examination, tests of sensitivity, muscle strength, reflexes, as well as ENMG and MRI of the cervical spine are necessary to confirm the diagnosis and determine the degree of compression or damage to the nerve structures.
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Врач-кардиолог VOICE: FOR Rationale: I believe that it is imperative to rule out a cardiac cause of left …
VOICE: FOR
Rationale: I believe that it is imperative to rule out a cardiac cause of left shoulder pain, especially given the patient's age and the potential for myocardial ischemia or angina radiating to the left shoulder. The minimum set of examinations should include an ECG, a blood test for troponin and, if necessary, stress tests to exclude cardiac diseases.
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