Mr.

KUNCUNG
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

X ray

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.