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Mike Jones, PT, MHS, OCS, MTC Board Certified in Orthopaedic Physical Therapy

Mike Jones, PT, MHS, OCS, MTC Board Certified in Orthopaedic Physical Therapy Fellow-in-Training, EIM Orthopaedic Manual Physical Therapy Fellowship Program. EIM -105 Management of Upper Extremity Disorders Section 2 Week 2 Case-based Discussion: Subjective Examination.

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Mike Jones, PT, MHS, OCS, MTC Board Certified in Orthopaedic Physical Therapy

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  1. Mike Jones, PT, MHS, OCS, MTC Board Certified in Orthopaedic Physical Therapy Fellow-in-Training, EIM Orthopaedic Manual Physical Therapy Fellowship Program EIM -105Management of Upper Extremity DisordersSection 2Week 2Case-based Discussion: Subjective Examination

  2. Rationale for Case Selection • Presentation of concurrent neck, shoulder, wrist and hand symptoms requiring differential diagnosis

  3. Subjective Examination • Description of Referral • Referral Source • Orthopaedic surgeon specializing in management of shoulder disorders • Referring Diagnoses • Cervical radiculopathy • Right shoulder adhesive capsulitis

  4. Subjective Examination • Patient Profile • Age • 69 • Gender • Male • Occupation • Retired from electronic manufacturing • Recreation • Travelling via motorcycle, camping

  5. Subjective Examination • Chief Complaints • Primary complaint of right shoulder pain and stiffness • Complaints of periodic neck pain • Complaints of occasional dull, non-specific pain in dorsal right wrist and hand • Denies upper extremity parasthesias

  6. Subjective Examination P2 P2 P1 • Body Diagram • P1 • Intermittent • Frequent • Variable • Ache • P2 • Intermittent • Variable • Ache • P3 • Intermittent • Rare • Variable • Ache P1 P1 P3 P3 P2

  7. Subjective Examination • Pain Scale • P1 • Average 5/10, Worst 8/10, Best 0/10 • P2 • Average 1/10, Worst 5/10, Best 0/10 • P3 • Average 1/10, Worst 2/10, Best 0/10

  8. Subjective Examination • Aggravating Factors • P1 • Reaching with right arm overhead, out to side, and behind back • Lifting with right arm away from body or above shoulder height • P2 • Looking up • Turning head right or left • P3 • Unknown

  9. Subjective Examination • Easing Factors • P1 • Resting with arm at side immediately eliminates severe pain although full alleviation may take several minutes to hours following exacerbation occurring with aggravating activities • P2 • Resting with neck in neutral position immediate alleviation • P3 • Unknown

  10. Subjective Examination • Relationship between symptoms • P1 and P3 occur independently from P2 • P3 seems to occur after P1 is quite aggravated

  11. Subjective Examination • 24-hour Behavior • P1 • Stiff and sore at waking in a.m. • Sore at the end of day • P2 • Stiff at waking in a.m. • P3 • No specific pattern over 24-hour period

  12. Subjective Examination • History of Current Episode • Long-standing history of intermittent neck pain for years with insidious, idiopathic onset • Right shoulder symptoms began 3 months prior to initial visit in physical therapy • Patient was using a motorized tiller in his garden and hit a rock, which caused the tiller to veer sharply straining his right shoulder • There was some soreness later that day, but pain and shoulder mobility worsened over the next several weeks • No specific injury to wrist or hand described with insidious, idiopathic onset of these symptoms occurring after onset of shoulder symptoms

  13. Subjective Examination • History of Past Episodes • Long-standing neck pain with no prior complaints of shoulder, wrist or hand pain

  14. Subjective Examination • Previous Treatment • Received an injection of his right shoulder by the referring physician with significant improvements in resting pain of the right shoulder and some improvements in right shoulder mobility following, but with pain and mobility now staying consistent at these improved levels • Also taking gabapentin for pain as prescribed by the referring physician

  15. Subjective Examination • Medical History/Review of Systems • Medical history of hypertension and hypercholesterolemia, which patient reports are well controlled with medication, psoriasis and gastroesophageal reflux disease • Surgical history significant for right MTP-1 joint arthroplasty and prostatectomy for benign prostate hypertrophy

  16. Subjective Examination • Medications • Moexipril • Lipitor • Soriatane • Omeprazole • Gabapentin

  17. Subjective Examination • Red Flag Screening1-3 • Denies the following • History of cancer • Weight loss • General constitutional symptoms • Recent illness or infection • Bowel or bladder dysfunction • Saddle anesthesias • Balance difficulties • Dizziness • Drop attacks • Left upper extremity pain or parasthesias • Association of symptoms with physical exertion not involving upper quarter • Association of symptoms with eating

  18. Subjective Examination • Yellow Flag Screening • Depression screen4-6 • Negative • Elevated fear avoidance beliefs screen7 • Negative

  19. Subjective Examination • Diagnostic Imaging • Radiographs • Right shoulder • Unknown • Cervical spine • Multi-level DJD and DDD

  20. Subjective Examination • Patient Goals • Improve shoulder mobility • Reduce shoulder pain • Eliminate contribution of cervical dysfunction to shoulder pain

  21. Clinical Reasoning • Potential Structural Involvement1-3,8,9 • Joints • Cervical spine • Throracic spine • Right acromioclavicular joint • Right glenohumeral joint • Right wrist

  22. Clinical Reasoning • Potential Structural Involvement1-3,8,9 • Muscles • Cervicothoracicparaspinals • Scalenes • Upper trapezius • Levator scapulae • Deltoid • Subscapularis • Supraspinatus • Infraspinatus • Teres minor • Wrist and finger extensors • Supinator

  23. Clinical Reasoning • Potential Structural Involvement1-3,8,9 • Referring structures • Cervical nerve roots • Upper thoracic nerve roots • Cervical arteries • Myocardium • Gallbladder • Liver • Ipsilateral lung • Ipsilateral kidney

  24. Clinical Reasoning • Potential Structural Involvement1-3,8,9 • Other • Cervical myelopathy • Tumor • Abscess

  25. Clinical Reasoning • Subjective Asterisk Signs10 • P1 • Reaching with right arm overhead, out to side, and behind back • Lifting with right arm away from body or above shoulder height • P2 • Looking up • Turning head right or left

  26. Clinical Reasoning • SINSS Presentation10-13 • P1 • Severity: Moderate • Irritability: Moderate • Nature: Mechanical shoulder pain • Stage: Chronic • Stability: Stable

  27. Clinical Reasoning • SINSS Presentation10-13 • P2 • Severity: Minimal • Irritability: Minimal • Nature: Mechanical neck pain • Stage: Chronic • Stability: Stable

  28. Clinical Reasoning • SINSS Presentation10-13 • P3 • Severity: Minimal • Irritability: Minimal • Nature: Somatic referred pain • Stage: Chronic • Stability: Stable

  29. Clinical Reasoning • Hypotheses • Primary • Right shoulder adhesive capsulitis14 • Relatively minor traumatic event leading to initial onset • Insidious progression of shoulder pain and motion loss • Secondary • Mechanical neck pain • Occurs with at end range of cervical movement with no direct subjective association of cervical and upper extremity symptoms • Somatic referred wrist and hand pain1 • Described as dull, poorly-localized ache occurring periodically following aggravation of shoulder symptoms

  30. Clinical Reasoning • Hypotheses • Differential diagnosis • Cervical radiculopathy15 • May occur with or without upper extremity pain or parasthesias • Right rotator cuff tear16,17 • A frequent cause of shoulder pain in patients of similar age

  31. Clinical Reasoning • Objective Examination Planning • Symptoms should not limit examination • Expect comparable signs for P1 and P2 to be easy to reproduce • Comparable signs for P3 may be difficult to reproduce • Based on red flag screening questions, it is considered highly unlikely that visceral structures or other pathological conditions serve as the origin of the patient’s symptoms

  32. References • Yung E, Asavasopon S, Godges JJ. Screening for head, neck, and shoulder pathology in patients with upper extremity signs and symptoms. J Hand Ther. 2010 Apr-Jun;23(2):173-85. • Goodman CC. Screening for gastrointestinal, hepatic/biliary, and renal/urologic disease. J Hand Ther. 2010 Apr-Jun;23(2):140-56. • Goodman CC, Snyder TE. Differential Diagnosis for Physical Therapists: Screening for Referral. 5th ed. St. Louis, Mo: Elsevier Saunders; 2012 • Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression. Two questions are as good as many. J Gen Intern Med. 1997 Jul;12(7):439-45. • Arroll B, Khin N, Kerse N. Screening for depression in primary care with two verbally asked questions: cross sectional study. BMJ. 2003 Nov 15;327(7424):1144-6. • Haggman S, Maher CG, Refshauge KM. Screening for symptoms of depression by physical therapists managing low back pain. Phys Ther. 2004 Dec;84(12):1157-66.

  33. References • Hart DL, Werneke MW, George SZ, Matheson JW, Wang YC, Cook KF, Mioduski JE, Choi SW. Screening for elevated levels of fear-avoidance beliefs regarding work or physical activities in people receiving outpatient therapy. Phys Ther. 2009 Aug;89(8):770-85. • Feinstein B, Langton JN, Jameson RM, Schiller F. Experiments on pain referred from deep somatic tissues. J Bone Joint Surg Am. 1954 Oct;36-A(5):981-97. • Cooper G, Bailey B, Bogduk N. Cervical zygapophysial joint pain maps. Pain Med. 2007 May-Jun;8(4):344-53. • Maitland GD, Hengeveld E, Banks K, English K, eds. Vertebral Manipulation, 7th ed. Edinburgh, UK: Elsevier Butterworth-Heinemann; 2005. • Farrell JP, Jensen GM. Manual therapy: a critical assessment of role in the profession of physical therapy. Phys Ther. 1992 Dec;72(12):843-52. • Koury MJ, Scarpelli E. A manual therapy approach to evaluation and treatment of a patient with a chronic lumbar nerve root irritation. Phys Ther. 1994 Jun;74(6):548-60.

  34. References • Barakatt ET, Romano PS, Riddle DL, Beckett LA, Kravitz R. An Exploration of Maitland's Concept of Pain Irritability in Patients with Low Back Pain. J Man ManipTher. 2009;17(4):196-205. • Kelley MJ, McClure PW, Leggin BG. Frozen shoulder: evidence and a proposed model guiding rehabilitation. J Orthop Sports Phys Ther. 2009 Feb;39(2):135-48. • Wainner RS, Gill H. Diagnosis and nonoperative management of cervical radiculopathy. J Orthop Sports Phys Ther. 2000 Dec;30(12):728-44. • Norwood LA, Barrack R, Jacobson KE. Clinical presentation of complete tears of the rotator cuff. J Bone Joint Surg Am. 1989 Apr;71(4):499-505. • Murrell GA, Walton JR. Diagnosis of rotator cuff tears. Lancet. 2001 Mar 10;357(9258):769-70.

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