The patient
This 39-year-old man presented rather sheepishly with his wife. He described a vague discomfort in his upper back on the right side, radiating to his shoulder.
He thought his right arm might be a bit weak in the shoulder area, and he felt uncomfortable in the right thoracic region when he sat back in a chair. ‘As though my back's rubbing on it,' he said.
These symptoms had been present, and more or less stable, for about a month. A few weeks before, he'd suffered a flu-type illness, from which he'd made a full recovery. A month prior to this, he had – for the first time in years – started playing tennis again. Otherwise, there were no real clues in the history.
He had no relevant previous medical problems and just took a salbutamol inhaler as necessary for exercise-induced asthma.
There were no other specific symptoms, and he otherwise felt well. ‘I think it's probably the tennis, doc,' he said. ‘I must have pulled something.'
First instinct
I was tempted to agree with his diagnosis, and a cursory examination didn't change my mind. He had a good range of movement at his shoulder and neck.
His right arm, he said, just didn't ‘feel right' when I assessed its power, though there was no obvious motor deficit – and his reflexes and sensation were normal.
His upper back looked slightly asymmetrical, but there was no obvious scoliosis. With firm palpation, he could be persuaded that the scapula area was a little tender.
Differential diagnosis
• Muscular strain
• Rotator cuff syndrome
• Referred pain from neck
• Neuropathy/nerve entrapment.
Muscular strains are common, the symptoms were a bit vague but probably compatible and it was the patient's own diagnosis – so this was definitely the front runner.
Rotator cuff syndrome is another familiar primary care presentation, but the good range of movement at his shoulder made this diagnosis unlikely. Similarly, his neck movements were full and pain free, making it unlikely that this was the source of his problem.
Nerve involvement remained a possibility given the subjective weakness, but the normal reflexes and lack of any other objective signs put this differential very much on the back burner.
The hidden clue
It was as I was starting my ‘muscle strain' spiel that his wife finally piped up.
‘I knew he wouldn't tell you if I didn't come, doctor,' she said. ‘His back sticks out really oddly when he stands a certain way.'
Cue a re-examination, and a beautiful demonstration of a right winged scapula when he extended his arms against resistance.
Getting on the right track
Suddenly his vague presentation became clear, even if the underlying cause wasn't.
I referred him to the local orthopaedic department, where the consultant confirmed a winged scapula and arranged muscle-strengthening physiotherapy.
It was postulated that the problem was either post-viral or the result of his tennis – but this soon because academic, as his symptoms resolved with treatment.
Dr Keith Hopcroft is a GP in Laindon, Essex
Upper back pain Upper back pain
