It is important to consider all of the structures that are in the region and related regions.

Functional testing on the shoulder will discern which soft tissue structures are injured. Passive examination will evaluate the bursa and joints, active examination will evaluate the muscles.

Observation of the shoulder in comparison to the other side will determine any muscle contractures. Look for a forward rounding of the humerus on the anterior rib cage, this will indicate any contractions of the anterior muscles and possible impingement syndromes. This patient had forward rounding of the left shoulder in comparison to the right.

Palpation of soft tissue structures will determine inflammation and swelling as well as contractures and trigger points. This patient had pain, inflammation and contractures of the pectoralis minor, coracobrachialis, biceps and anterior deltoid. There was pain over the acromioclavicular joint and sternoclavicular joint.

Quality, timing and patterns of pain will determine which soft tissues are involved. There are 4 types of pain:

• Dermatomal pain is sharp, shooting and indicates nerve involvement.
• Capsular pain is local, achy, pain can be elicited on movement and there are specific limitations of movement; for the shoulder, the limitations are external rotation, abduction and internal rotation.
• Scleratomal pain is from bursa, tendon and periosteum, it is achy and diffuse.
• Myofascial pain is achy, elicited on movement and can radiate distant from the lesion.

Quality of the pain for this patient has been described as local, achy, sharp exacerbations and limitation of movement in raising his arm overhead as in external rotation with abduction.

Site of the pain is the anterior shoulder.

Timing is intermittent with acute exacerbations.

Question: Based on the information from your examination, what soft tissue structures are you considering as the cause of this patient’s condition?