Insight for patient with severe shoulder and arm pain

[ReinField]

Had a new patient come in yesterday complaining of intense shoulder and upper arm pain, mostly localized to the anterior deltoid and radiating slightly down the bicep, says the pain has been getting worse over the past couple of weeks, its sharp with movement, dull and persistent at rest. ROM is limited too, especially with abduction and external rotation.
Ortho already cleared for major red flags, and imaging showed nothing acute. I'm leaning toward subacromial bursitis or possible long head biceps involvement, but the severity of the pain is making me second guess a simple mechanical origin
Need help diagnosing this please, thanks in advance

 

[DiscoPickle]

Had a new patient come in yesterday complaining of intense shoulder and upper arm pain, mostly localized to the anterior deltoid and radiating slightly down the bicep, says the pain has been getting worse over the past couple of weeks, its sharp with movement, dull and persistent at rest. ROM is limited too, especially with abduction and external rotation.
Ortho already cleared for major red flags, and imaging showed nothing acute. I'm leaning toward subacromial bursitis or possible long head biceps involvement, but the severity of the pain is making me second guess a simple mechanical origin
Need help diagnosing this please, thanks in advance

Given the symptoms and imaging, your initial thoughts of subacromial bursitis or long head biceps involvement are solid candidates. The severity can be a hallmark of a very irritated bursa or tendon
Have you tried any specific tests that differentiate between the two? (e.g., Speed's and Yergason's for biceps, Neer/Hawkins for impingement/bursitis).
It's also worth seeing how they respond to a very gentle palpation of the bicipital groove vs. the subacromial space.

 

[Averagejoe80]

I don't want to sound like a smartass, but wouldn't an ultrasound confirm any of the potential diagnosis?

 

[New Yorker]

Had a new patient come in yesterday complaining of intense shoulder and upper arm pain, mostly localized to the anterior deltoid and radiating slightly down the bicep, says the pain has been getting worse over the past couple of weeks, its sharp with movement, dull and persistent at rest. ROM is limited too, especially with abduction and external rotation.
Ortho already cleared for major red flags, and imaging showed nothing acute. I'm leaning toward subacromial bursitis or possible long head biceps involvement, but the severity of the pain is making me second guess a simple mechanical origin
Need help diagnosing this please, thanks in advance

Ok it might be worth doing an ultrasound if you haven't yet. I agree with them... especially with pain that sharp and lingering. Ultrasound could help rule in or out a sneaky biceps tendinopathy or inflamed bursa.