Case 6: Shoulder Pain

Chronic Recurrent Shoulder Pain

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A middle age male presents to the ED with recurrent shoulder pain for about 6 months. He has been seen before for the same and told it was tendonitis. While checking his pulse in that arm you notice his fingernails look abnormal. What is this called? What is the differential diagnosis? (his friends fingernails are shown on the top-right for comparison)

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ANSWER:

This is called clubbing. Chronic shoulder pain with recent onset of clubbing is an ominous sign that the patient has lung cancer. Lung tumors, especially Pancoast tumors, not infrequently mimic musculoskeletal conditions of the shoulder. Consider adding a chest xray to the workup in the proper clinical scenario or when there is a lack of positive findings on examination of the shoulder. Here is the chest xray for this patient.

Excerpt from “Quick Essentials“

DIFFERENTIAL DIAGNOSIS OF SHOULDER PAIN:
Posterior: neck, suprascapular nerve entrapment
Anterior: AC joint, GH joint arthritis, biceps tendonitis
Lateral: impingement, rotator cuff. (both usually aggravated by reaching overhead)
Other: Brachial plexus, vascular, TOS, pancoast tumor, MI, AAA, pericarditis, GI D

DIFFERENTIAL DIAGNOSIS OF FINGERNAIL ABNORMALITIES:
Whilte lines: Muehrcke Lines = low albumen, Mees Lines = arsenic F
Ungal ID: RF: male, tight shoes, PVD, HIV, Tob. T. rubrum=90%.
��� Rx: Lamisil (but 20-70% relapse in 3y)
Clubbing: “CLUB”: Congenital, Cor, Lung(CA), Ulcerative Colitis, Biliary.
��� Rarer: HIV, ^thyroid, cirrhosis