You are examining a 20-year-old male who complains of pain when elevating his right shoulder and when carrying a briefcase in either hand to and from work. The patient also reports a slight crunching or grinding sensation went actively elevating his right shoulder. The patient appears in excellent physical condition, swims approximately 200 laps daily, and works weekends as a lifeguard.

Upon observation, there is no muscular wasting, but there are prominent pectoralis and anterior deltoid muscles because of hypertrophy. The range of motion of both upper extremities is within functional limits, but the right upper extremity has a positive upward painful arc at 80° to 115°. Both strength and flexibility are normal. There is a mild posterior capsular tightness of the right glenohumeral joint, and with the resisted testing, there is pain with resisted external rotation and abduction, as well as during passive internal rotation when the shoulder is elevated to 80°. The selected special tests have a negative drop arm test, positive impingement sign, negative Speed’s test, and negative Adson’s maneuver. Based on the findings thus far, what is the most likely working hypothesis?

1. A SLAP (superior labrum, anterior to posterior) tear
2. Impingement syndrome involving the supraspinatus
3. Bicipital tendinopathy
4. Thoracic outlet syndrome (TOS)

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