Mr.

Kuncung, 45 years old, presents to your outpatient department with pain on his left
shoulder since 3 days before, after painting his house. The pain is felt when he has to lift
his arm, but disappear at rest. It is on the front of his shoulder, radiating down to the left
arm. He wakes up several times at night because of pain especially when he sleeps on
his left shoulder. He has difficulties in dressing and comb his hair. He says that the same
condition in milder forms happened last year but disappear by itself.
He had hospitalized 4 years before due to chest pain, and the doctor said he has
coronary arterial disease and put one stent on it. He also has chronic paresthesia on his
left thumb, index, and middle finger especially when he has to hold on some things for
prolong period. No history of neck pain. He feels otherwise healthy.

On physical examinations you find no deformity and both of the shoulder looks the
same. On the left shoulder, the skin color and temperature are normal, no scar or
swelling is found. There is tenderness on the anterior side of his shoulder. He has full
passive movement of his shoulder but painful active abduction along the mid of the
arch and on forward flexion. No sensation deficit and regular palpable radial pulse.
 
Investigation findings
Laboratory examination
            Hb 13 g/dl
            Ht 36%
            WBC 10.000/mm3
            ESR 20mm/2 hour
ECG normal

You give Mr. Kuncung short term NSAID, and send him to physioteraphy where he get
ultrasound treatment and muscle exercise. You advise him to avoid painfull shoulder
activity.

Next 3 months, Mr. Kuncung visits you with stiff shoulder. His pain has reduced
significantly but he cannot actively abduct his arm. On physical examination you find
limited internal rotation of the shoulder, loss of active abduction, and positive drop arm
test. He still has paresthesia problem with his thumb, index and middle fingers. The
laboratory result is in normal limit.

You decide to send him to MRI department and plan to discuss the case with
orthopaedist and neurologist.