Differential Diagnosis of a Patient with Shoulder Pain 1 Sara - - PowerPoint PPT Presentation

Differential Diagnosis

• f a Patient with

Shoulder Pain1

Sara Galante, SPT UNC Division of Physical Therapy

Tell me what’s going on today?

– 40 yof – R shoulder pain

– Onset 1 mon ago – “Grinding quality” – Sensation of joint ”displacement” with lean to R side

– Chronic joint pain

PMH

– Chronic Joint pain at 12 yo

– Injury-Prone Child

– Orthostatic hypotension

– TMJ Dysfunction – Chronic Headache – Chronic Joint Pain & Fatigue – Daughter tested for POTS Review of Systems – GI Problems (IBS) – Type 2 Diabetes – Hyperlipidemia – Vitamin D Deficiency – Sensitive, Itchy Skin

Objective Exam

– Normal Strength Throughout – Pain with palpation to R Rotator Cuff – Integumentary

– Abnormally soft skin

– Flexible and Hypermobile

– Outcome Measure? The Beighton Scoring 1. 5th digit ext to dorsum of hand 2. Thumb to forearm 3. Elbow hyper- extension 4. Knee hyper- extension 5. Palms flat on floor

B L B ! !

Total = 5/9

Diagnosis?

– 5/9 Beighton Score – Hx of widespread joint pain – Spontaneous joint injury – Fatigue – TMJ dysfunction – Soft skin – Postural hypotension – IBS – Chronic Headache – Family hx?

Ehlers- Danlos Syndrome

(Hypermobility Type)

Ehlers-Danlos Syndrome (EDS)

– Group of heritable connective tissue disorders, caused by abnormal collagen formation1 – 2017 criteria divided EDS into 13 types2 – Substantial overlap between EDS types and other CT disorders3 – Prevalence: 1 : 5,000 people2,4 – RF: non-white, female, family hx2

Zhou et al. 2018

hEDS

– Disagreement in the literature regarding difference between Joint Hypermobility Syndrome (JHS) and hEDS

– Joint hypermobility is a symptom (Marfan, Loey-Dietz)5

– Consider a continuum of hypermobility3-5

Increasing severity of s/s

Asymptomatic Joint Hypermobility Symptomatic Joint Hypermobility

hEDS

– Functional defect in collagen affects all organs with presence of collagen2

– Joints, ligaments, skin, tendons, blood vessels, GI tract, etc.

– Individual manifestations will vary2

Diagnostic Criteria for hEDS

2017 Clinical Diagnosis Tool3,5

– (presence of 3 criteria)

• 1. Generalized Joint Hypermobility

– Beighton Score

• 2. At least 2 of the following:

– Systemic Manifestations of CT disorders – Positive Family Hx – MSK Complications

• 3. Absence of excessive skin fragility, exclusion of other CT

disorders or other causes of hypermobility

*Unlike the other 12 types

• f EDS, there is no known

genetic marker to diagnose hEDS.

S/S & Comorbidities

– Pain (B, Chronic) – Kinesiophobia – Soft, ”velvety” skin – Fatigue – POTS – Orthostatic Intolerance – GI Disorders – Hx of dislocations – OA – Headache – TMJ Dysfunction – Sleep Disturbances – Depression – Anxiety – Pelvic Floor Dysfunction – Proprioception & Balance Problems

Zhou et al. 2018

S/S & Comorbidities

– Pain (B, Chronic) – Kinesiophobia – Soft, ”velvety” skin – Fatigue – POTS – Orthostatic Intolerance – GI Disorders – Hx of dislocations – OA – Headache – TMJ Dysfunction – Sleep Disturbances – Depression – Anxiety – Pelvic Floor Dysfunction – Proprioception & Balance Problems

Zhou et al. 2018

S/S & Comorbidities

– Pain (B, Chronic) – Kinesiophobia – Soft, ”velvety” skin – Fatigue – POTS – Orthostatic Intolerance – GI Disorders – Hx of dislocations – OA – Headache – TMJ Dysfunction – Sleep Disturbances – Depression – Anxiety – Pelvic Floor Dysfunction – Proprioception & Balance Problems

Zhou et al. 2018

Revisiting

• ur

Patient1

Cardiology à rule out

vascular involvement (aortic root dilation)

Pain clinic à

pharmacotherapy

Rheumatologist à

screening for arthritis

PT à pain management &

pt education

Finally having a diagnosis changed everything!

EDS is often unrecognized for years, making the pt feel discredited and isolated

Referrals & Treatment

Most undiagnosed cases of hEDS will warrant a non- immediate physician referral. Pt presents with s/s that would require emergent management in the general population (dislocated shoulder, syncope) make an immediate medical referral.

PT Treatment2,6

– Pt education – Pain management – Lifestyle Modifications – Low-impact resistance training – Proprioception training – Bracing, Splinting **PT should be aware of potential complications and monitor patient closely

Article Review1

Strengths

• Good case overview &

pathology description

• Pt presentation

matches s/s & comorbidities

• Fantastic clinical

reasoning

• Includes treatment

and psychosocial impacts of disease Weaknesses

• No PT perspective
• Old EDS Classification

System

• Did not use specific

EDS Diagnostic Criteria

• No Differential Dx List
• Level 5 Evidence

–Questions?

Bibliography

1. Cohen S, Markham F. Ehlers-Danlos hypermobility type in an adult with chronic pain and fatigue: a case study.

• Clin. Case Rep. 2017;5(8):1248-1251. doi:10.1002/ccr3.1046.

2. Zhou Z, Rewari A, Shanthanna H. Management of chronic pain in Ehlers-Danlos syndrome: Two case reports and a review of literature. Medicine 2018;97(45):e13115. doi:10.1097/MD.0000000000013115. 3. What are the Ehlers-Danlos Syndromes? | The Ehlers Danlos Society : The Ehlers Danlos Society. Available at: https://www.ehlers-danlos.com/what-is-eds/. Accessed February 8, 2019. 4. Tinkle B, Castori M, Berglund B, et al. Hypermobile Ehlers-Danlos syndrome (a.k.a. Ehlers-Danlos syndrome Type III and Ehlers-Danlos syndrome hypermobility type): Clinical description and natural history. Am. J. Med. Genet. C,

• Semin. Med. Genet. 2017;175(1):48-69. doi:10.1002/ajmg.c.31538.

5. Brody L, Thein-Nissenbaum J. How Loose is TOO Loose? The Female Athlete and Hypermobility. APTA Combined Sections Meeting 2019. 6. Engelbert RHH, Juul-Kristensen B, Pacey V, et al. The evidence-based rationale for physical therapy treatment of children, adolescents, and adults diagnosed with joint hypermobility syndrome/hypermobile Ehlers Danlos

• syndrome. Am. J. Med. Genet. C, Semin. Med. Genet. 2017;175(1):158-167. doi:10.1002/ajmg.c.31545.