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Case Report: Shoulder pain differential diagnosis; infected axillary lymph nodes

Physical Therapist Diagnosis – Providing a dynamic diagnosis method


In the age of science and evidence-based healthcare, it is surprising that patients continue to think of imaging as the gold standard for diagnosis. Magnetic Resonance Imaging (MRI) and X-Ray can only provide a picture of the internal structures, while a thorough examination can reveal multiple levels of real information to diagnose pain and dysfunction, as well as identify a plan of care and prognosis that the patient can utilize to return to normal pain-free life.

A perfect example can be provided from a recent experience. A new patient called for an appointment due to the onset of shoulder pain. At the evaluation, he reported sudden onset of pain earlier in the week, a high fever, and instruction to go to the ER by his physician. At the ER the patient was left waiting for nearly 12 hours and after examination, he was prescribed pain medication and sent home. The pain did not resolve, and so he was seeking PT evaluation to identify if the cause was muscle or skeletal. As I performed my examination I observed that the pain was not typical of muscle injury or skeletal impairments. I suspected an inflamed lymph node as the cause of the pain, likely due to an infection which could explain the high fever. I recommended that the patient call his physician and ask about an antibiotic prescription.

CT Scan or MRI would be indicated if no improvements were observed within 3 days of beginning antibiotics. The patient called his MD who agreed with my assessment and he prescribed an antibiotic. The patient continued to have pain after his conversation with his primary and later that evening returned to the ER for a CT scan to rule out malignancy. The CT scan revealed an inflamed axillary lymph node and the patient recovered with treatment of antibiotics.

Dr. Abraham Lieberman is a primary care physical therapist in Houston, Texas where he provides comprehensive examinations and evaluations, and treatment for musculoskeletal and Neuromuscular pain and dysfunction for patients throughout their lifespan. 

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