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Monthly CASE PRESENTATION

Monthly CASE PRESENTATION. Ron Masri, PT, Doctor of Physical Therapy Board Certified Orthopedic Specialist Certified Athletic Trainer Fellow In Training, Evidence In Motion BODY REGION: Upper Extremity. PATIENT INTERVIEW.

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Monthly CASE PRESENTATION

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  1. Monthly CASE PRESENTATION Ron Masri, PT, Doctor of Physical Therapy Board Certified Orthopedic Specialist Certified Athletic Trainer Fellow In Training, Evidence In Motion BODY REGION: Upper Extremity

  2. PATIENT INTERVIEW • Patient Profile: Pt is a 45 year-old male, who reports injuring his L shoulder in late March of this year, associated with a backwards fall catching himself with arm stretched backwards. Patient reports anterior shoulder pain that ranges from 1- 6/10 depending on activity. He also c/o intermittent neck and UT pain on the L side too. Shoulder forward/ abduction elevation increases patient's symptoms with a painful arc of motion. Symptoms subside immediately upon lowering arm. Pt states he is limited sitting at his desk and working on his computer due to his UT / neck and shlder pain. Patient's goals include playing golf, picking up his children, and dressing without increase in shoulder symptoms. He has initiated his own referral to a physical therapist. His past medical history is unremarkable as related to this condition. He is an otherwise healthy male without any prior medical complications that would limit his full and active participation in rehabilitation. I had previously seen this pt for R shlder pain with great success 2 yrs ago. Pt seen first of April 2012 • Self Report Outcomes: FOTO score Head, Neck, Thoracic Outcome: 40%, UEFS:55/80 Chief complaints: P1 –L Anterior Shlder pain P2– L UT/ cervical pain

  3. PATIENT INTERVIEW P1: inter, variable,dull, catching Agg: overhead activity; reaching behind back and head Rel: rest, arm in neutral Pain: 1-6/10 P2 P1 P2: inter, variable, tight, stiff Agg: sitting, desk work Rel: laying down, moving around Pain: 3/10

  4. Early Hypotheses – Post Body Chart • List your primary and secondary hypotheses in prioritized order: • P1 • Biceps tendonitis • Shoulder Impingement • AC joint • P2 • Myofascial pain • Cervical facet dysfunction

  5. Symptom Behavior • Primary complaint in depth: • P1: L anterior shoulder pain that is worse with FF/ ABD, painful arc 90-160 deg FF and 60-140 deg ABD; dull, ache , “catching” • Secondary complaints • P2: L UT tightness, dull ache pain after sitting for >45 min or working at his computer • Numbness and or Tingling: No compliants • Relationship between symptom areas: • P1 happened after catching himself from falling backwards • P2 stated he was having this but was not a big deal until he hurt his L shlder and now this has intensified in nature and frequency---comes on quicker now

  6. Symptom Behavior • Activity and Participation Capabilities and Restrictions: • Activity restrictions & Aggravating/Relieveing Factors: • P1 aggravated with overhead activity; FF painful 90-160 deg; ABD pain 60-140 deg; pain reaching behind back ; no issues sitting and working below 90 deg with his UE’s excepts when reaching out to his side with his L UE like reaching for something in the passenger seat; diff reaching behind head with L UE • P2 worse sitting > 45 deg; however P1 doesn’t affect P2 besides the fact that now it just comes on a little quicker and is more intense when it comes on—in the past he would feel this UT/ neck discomfort on the L about 3-4 hrs working behind a desk • Sleep and 24 hour pattern: • Denies night pain/ NT in UE • Neck stiff in AM and times hard to turn head to R—but loosens up after shower and gets up getting ready for work (15min) • P1 just hurts with elevation; no issues just sitting –however P2 happens during first hour or so at work but been getting up and moving pretty often and that helps ease his pain—pain does not increase through out the day

  7. PATIENT INTERVIEW • Medical History / Co-Morbidities / Review of Symptoms (ROS): • Thyroid Disease, Hx of R shlder pain • Red Flag Screen: NONE • Yellow Flag Screen: NONE • BP 124/74 HR 72

  8. Clinical Reasoning Component • (S) What is the severity of the condition (min, mod, severe)? • P1=Moderate, worst pain 6/10, has not attempted recreational/vocational activity due to possibly exacerbating her symptoms, limited overhead activity, no difficulty sleeping • P2=Mild, worst pain 3/10, has not attempted recreational/vocational activity, no difficulty sleeping • (I) What is the irritability of the condition (min, mod, severe)? • P1= Min, pain is decreased immediately after provoked, pt still working • P2=Min , takes >45min for provoke, sleeping not effected, pt still working • (N) What is your primary nature statement of the problem (hypothesis). • P1= Anterior shoulder pain due to Bicep/ RC tendonitis • P2= UT/LevatorMyofascial pain

  9. Clinical Reasoning Component • (S) What is the stage of the disorder for its current episode: • P1-started in march after a fall -- subacute • P2 – had been around but now more noticeable -(subacute on chronic) • (S) What is the current stability of the disorder: • P1 stable • P2 stable but staying localized but quicker to come on • ** Discuss how the results of the SINSS will lead to planning the exam: • Pt is appropriate for PT • Will try to reproduce pain—no need for OP at shlder but will do this at C-spine

  10. Clinical Reasoning Component • What will you use as your asterisk signs from the history? (Specify for P1, P2, etc) • P1 pain FF 90-160 (painful arc); Abd 60-140 pain; pain with hand behind back and Hand behind head • P2 not sure yet maybe able to use Cervical ROM; sitting tolerance • List your primary hypotheses in prioritized order: • P1=Anterior shlder pain due biceps tendonitis • P2=Myofascial pain UT/Levator

  11. Clinical Reasoning Component • List your hypotheses and items you must rule out for each P: • P1 • Anterior Shlder pain=Rule out visceral pain-GI, Respiratory, Cervical spine • P2 • Myofascial pain UT/Levator – Cervical Spine

  12. Clinical Reasoning Component • List issues that you feel may predispose or contribute to the main problem: • NO yellow/red flags • List the non-musculoskeletal issues that you have ruled out in your history: • As noted earlier referred pain from the viscera

  13. Planning the PE • What will you include in your physical exam to rule in/out your top hypotheses? • Anterior Shoulder pain= ROM, joint mobility testing SC, AC, GH jts; impingement testing ( painful arc, Neer, Rz ER, Hawkins Kennedy, open can test) ,ScapDyskinesis, Scap assist/Reposition tests, MMT, ROM, SLAP, RC testing, palpation) • Myofascial Strain=ROM, palpation, muscle length • Treatment strategy (relate to hypotheses and SINNS) • P1= joint mobilization, Cervicoscapular. Scapulothoracicstrengthening, posture training, ergonomic evaluation • P2= Soft tissue mobilization, flexibility, joint mobs

  14. Planning the PE • What areas/structures must be considered as a possible source(s) of the patient’s symptoms? • Joints: Lower Cervical Spine, 1strib, AC joint, GH joint • Muscle/Tendon: Upper trapezius, levator scapulae, deltoid, RTC, biceps • Other: Neural C4-6, lung, diaphram, heart, GI • What will you assess Day 1, Day 2, Day 3 (prioritize), and why? • Day 1 • Phase 1 Diff Dx, clear cervical then assess shoulder • Day 2 • Thoracic

  15. Physical Exam Precautions and Contraindications: NONE Postural Observation: Moderate forward head rounded shlder posture; inc thoracic kyphosis Functional movement analysis (* sign):* (HBH)Reach behind head to occiput-pain (HBB)Hand behind back to sacrum-pain Arm to oppshlder-no issues Cervical AROM: Cervical flexion 2 fingers to manubrium tight L side of neck Extension 45 deg no pain; R Cervical Rotation 70 deg tight at end range--tightness increased with OP—when pt asked to place L UE on oppshlder and then repeat cervical rotation R that improved to 80 deg with signif decrease in tightness feeling L Cervical ROM 80 deg no issues with OP; Cervical Quadrant clear Neurological Screen: not necessary

  16. Physical Exam Shoulder Testing: AROM: L elevation painful arc 90-160, pain ABD 60-140 deg; L Scapular dumping on with decent ; Scap reposition test ABD improves to 120 deg before pain and elevation improves to 140 deg Special Tests: + Speeds, no pain with ER rz, pain with Rz ABD, slight pain open can test; + Neers and + Hawkins-Kennedy; +Crank test, +Obrien’s, +Yergason’s Winging of the scapula-type 2 (medial boardersticks out) SC and AC joint clear Palpation: Tender biceps tendon proximally, tender UT/ levator, pecs. Subscap muscles –tight, trigger points noted MMT: Goss weakness L UE 4/5—likes to shrug for stability—more related to pain AAROM supine : IR at 90-90 limited 55 deg—pain anterior shlder; ER at 90-90 75 deg Accessory Motion: Fig 8 mobs of L GH revealed restrictions at 7-8 O’clock position

  17. Assessment, Plan & Treatment • (N) What is your primary nature statement of the problem (hypothesis) following the PE findings as well as the competing hypothesis: • P1 Anterior shlder pain due to bicep tendonitis with possible SLAP lesion • P2 UT and levator strain • List your historical and physical exam ‘asterisk’ items: • Hx: P1 UE elevation; HBH pain and HBB pain; P2: sitting >45 min • PE: P1 +Special test for shlder impingement, biceps tendonitis, and SLAP, • P2 palpation and cervical ROM • Prognosis (note timeframe of expected level of recovery): • Hewill do great 6-8 visits • Precautions or Contraindications to treatment: NONE

  18. Treatment Day 1 : Treated L GH joint Fig 8 mobs in restricted area grade 2/3+ 45 sec x 5 reps; HBH improved to occiput STM pecs, subscap, cross body posteror cuff stretch x 3min; MWM with towel IR stretch x 10 reps; HBB improved to above belt line HEP: I dream of Genie posterior cuff stretch; Robbery; and shlder extension isometric with arm straight thumbs in/ thumbs out hold 6 sec for 3min- pt ed on proper posture and to avoid lifting overhead heavy objects for 2 weeks with L UE Rationale For Treatment: I wanted to address shlder since that was his primary compliant. I made good changes this first visit and put an ADL modification restriction because I did not want him aggravating that L UE with overhead activity

  19. ASSESSMENT-Day 22 Days after IE Subj: pt stated more aware of posture—been able to tuck in his shirt with ease—still has pain with elevation > 145 deg Obj: fair posture with Vcing; +impingment testing and bicep tendonitis testing; tender bicep tendon proximally; HBH to occiput and HBB to belt line—c/o tightness more than with that motion Stiff T-spine centrally T3-T8

  20. Treatment-Day 22 Days after IE STM bicep tendon instrument assisted x 5min Supine T-spine central mobs grade 3 45 sec x3-reassessed UE ROM--HBH improved to C7 and HBB above belt line (L3) Prone UE extension palm down/ palm up hold 6 sec x 3min each Prone horiz abduction hold 6 sec x 3min Sidelying ER 2# x 3min Supine SA punches 5# x 3min N ER red band x 3min Standing low rows w/ N Mini squat --25# x 3min Door way pec stretch x3min—added this to HEP

  21. ASSESSMENT-Day 37 Days after IE Subj: pt states feeling much better reached up in cupboard for glass of water with L UE with no pain; he states he still has tightness in L side of his neck but now feeling it more at end of day after work and not at the beginning like before Obj: - speeds tests; - open can test; elevation 165 deg; HBH to C7 and HBB to L3 Treatment: Scap PNF x 5min; Scap clocks; Rhythmic stabilization supine; push ups with a plus and repeated prone ex’s from previous visit

  22. Final NOTES Pt was seen for 5additional visits where his shlder ROM continued to improved to full painfree motion; he still possessed a + Hawkins-Kennedy but I told him that is just a test I use to see how he is doing –when is he ever going place his arm in that position in every day life anyway—so I was not to worried about that –all other tests cleared up Over those 5 visits we got him going on more functional ex’s emphasis GH and Scapular stability with functional task training that involved pushing/ pulling/ lifting, carrying, playing golf—his HEP emphon RC strength but more on scapular stabilization; we also did some ergonomics training too At his last visit—min to no scapular dyskinesisnoted—he said he is able to work at as computer for longer now and that he was back to playing golf with ease, was able to help his dad install ceiling fan with ease. He remains compliant with HEP where on M-W F he does band ex for shlder and T-R-Sat- he does prone ex’s

  23. Final NOTES This was just an ok case of anterior shlder pain—I think he had a SLAP just from PE and subjective hx/ mechanism of injury—I really concentrated on scapulothoracicmostability training—I did not really have to emph RC as I felt it was more of a scapular dyskinesis issue so I really wanted to get after the lower traps; SA and rhomboids. I added some RC ex’s later on and also I really did not have to do much UT/ levator stretches –when I loosened up his T-spine he came back saying he could sit longer and that his neck was tight as end of the day I welcome your thoughts!!!

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