•A 40-year-old male presented to the clinic with severe acute shoulder pain. The patient is a healthy avid runner who described his shoulder pain as spontaneously beginning before bed the previous evening. The patient described no associated trauma to the affected shoulder, no change in exercise regimen, or any recent illness or vaccination. Severe guarding of the joint was initially observed with limited to no movement of the shoulder joint. Initial inspection of the joint revealed a depressed right shoulder followed by winging of the right scapula upon flexion and protraction of the shoulder [Figure 3]. Palpation revealed extreme tenderness to the infraspinatus, teres minor, teres major, and thoracic paraspinals. Exacerbation of pain limited any active range of motion (ROM) with limited passive abduction, adduction, external and internal rotation. Sensation was intact bilaterally with normal active reflexes. Muscle strength testing revealed 4/5 strength for flexion, extension, abduction, adduction, internal and external rotation of the right shoulder with pain noted to be the limiting factor. The patients pain was a 10/10.

•Trigger point injections were given within the thoracic paraspinal musculature, infraspinatus muscle, and subscapular bursa.

•Osteopathic Manipulative Medicine was performed and aimed at decreasing swelling, analgesia, and improving range of motion.

•Medrol-dose pack was prescribed and  X-ray imaging performed, which ultimately was unremarkable. 

•Pain had decreased from a 10/10 to a 4/10, however, guarding of the shoulder joint was still noted and exacerbation of pain still limited any active movement. Ecchymosis and bruising was now observed along the posterior shoulder [Figure 4]. No atrophy was observed but the right posterior shoulder girdle did show decreased bulk and tone. Pain still limited active ROM, however, passive ROM was now equal bilaterally. Strength showed no improvement with pain still noted to be a limiting factor.

•MRI of the shoulder was ordered and revealed intramuscular edema within the supraspinatus, infraspinatus, teres minor, subscapularis, and teres major [Figures 5 and 6]. The teres minor and teres major were noted to display muscle fiber disruption. Cervical MRI revealed mild degenerative changes with mild neural foraminal narrowing at C5-C6 on the right.

•A cervical interlaminar epidural steroid injection with a right paramedian approach was performed at the levels of T1-T2. The patient was locally anesthetized with Xylocaine 1% 9ml and Sodium Bicarbonate 1 ml with 10mg of dexamethasone then injected into the epidural space. Under fluoroscopy guidance the patient did not show an ideal approach at the C7-T1 level, therefore, the injection was given at the T1-T2 level with the thought of cranial spread allowing the steroid to reach the desired C5, C6, and C7 spinal levels. Via the use of contrast, however, it was observed that the spread may have made it to C7 , but not as cranially as C5 [figure 7].

•Following the cervical epidural steroid injection, the patient reported an immediate improvement of a resting pain scale from a 4/10 to a 0/10. The patient regained full active ROM with moderate pain observed at both 90 degrees of flexion and abduction. Prior to injection the patient had 0 degrees of pain free active ROM. Strength improved to a 5/5 in all ranges of motion of the shoulder joint and the patient was able to resume their exercise regimen and begin strength rehabilitation.