Free Physician Assistant Board Review Question

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Free PA Board Review Question

A 58-year-old retired construction worker presents to your clinic complaining of right shoulder pain. He states that he noticed the pain several months ago and thinks it is progressing. The pain is 6/10, is worst when reaching over his head and better with rest. Physical exam shows no visible deformities, full active and passive range of motion, strong pulses and 5/5 MMS throughout the extremity. The most tender spot on physical exam is on the anterior aspect of the shoulder. The patient’s pain is exacerbated when you have him supinate his forearm against resistance. What is the most likely diagnosis?

• A. Bicipital tendonitis
• B. Rotator cuff tear
• C. Subacromial bursitis
• D. Labral tear
• E. Osteoarthritis

Answer and Explanation

Bicipital tendonitis presents with anterior shoulder pain, worst near the bicipital groove. Pain may be exacerbated with supination and/or flexion of the elbow. Yergason’s and Speed’s tests may be positive. It is initially treated with conservative treatment including rest, activity modification, physical therapy and oral NSAID’s. When conservative treatments fail to relieve the patients pain, corticosteroid injection into the bicipital groove is indicated. When all previous treatments fail a biceps tenodesis or biceps tenotomy is indicated.

Did you get it right? The correct answer is: A

Incorrect Answer Explanations

Answer B: Rotator cuff tears are a common cause of shoulder pain that is exacerbated with overhead activities. Patients may awaken from sleep secondary to the pain. Rotator cuff tears present with decreased active range of motion secondary to loss of muscle strength. Physical exam can help determine which tendon of the cuff is torn.

Answer C: Subacromial bursitis is a common cause of shoulder pain. It presents with shoulder pain that is often poorly localized however it is sometimes present around the acromion. Patients complain of shoulder pain that is worst when doing overhead activities such as combing one’s hair and may awaken the patient at night. Physical exam is usually benign but may show a positive Neer’s impingement test. Neer’s impingement test is performed with the patient in the sitting position. The patient’s arm is forward flexed while the scapula is stabilized. Pain near the acromion is considered a positive test. Hawkin’s test is also sensitive for detecting subacromial impingement and is elicited by abducting the shoulder to ninety degrees and internally rotating the arm. Pain near the acromion is considered a positive test.

Answer D: Labral tears commonly present with poorly localized shoulder pain. Physical exam may show a positive O’Briens test. MRI is used to confirm the diagnosis.

Answer E: Osteoarthritis presents with shoulder pain worse with activity and better with rest. Physical exam usually shows decreased active and passive range of motion with crepitus throughout the range of motion. X-rays will show osteophyte formation, joint space narrowing and bony sclerosis.

Bottom Line

Bicipital tendonitis presents with anterior shoulder pain, worst near the bicipital groove. Pain may be exacerbated with supination and/or flexion of the elbow. Yergason’s and Speed’s tests may be positive. Make sure you can diagnose and treat bicipital tendonitis, subacromial bursitis, rotator cuff tears and epicondylitis.

For more information, see:

Biceps tendinopathy and tendon rupture. UpToDate.

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