Virtual Rounds Shoulder Case

1. Virtual Rounds Shoulder Case NAME: Matt Anderson, DPT, OCS, CSCSDATE:3/15/2013 BODY REGION: Shoulder

2. Case Rationale • I chose this case because it is a slightly different presentation than I usually see, and the patient’s values are forcing me to take a different approach to his care. I also want to improve on my prescription of exercises for shoulder problems.

3. PATIENT PROFILE Patient Profile:Patient is a 32 y/o caucasian male who self-referred to PT for shoulder stiffness and limitation with overhead movements. The shoulder problem started >10 years ago, but the patient reports it as more of an annoyance than a painful condition. He currently works as a physical therapist, and enjoys all forms of exercise. His current goal is to successfully train for and complete a Mud Run in late April. Chief complaint: Left shoulder stiffness during overhead activity. Stiffness in L shoulder during functional ER and IR movements. Weakness during pullup movements. Tightness and fatigue in the L shoulder during higher rep pushup workouts. Achiness and stiffness after propping on the L arm in prone or L sidelying Self Reported Scores / Outcome Tools: (ODI, NDI, LEFS, DASH, etc) PSFS Items: Overhead press: 6/10; Pullups: 4/10; Rope climbing: 4/10; Putting L arm around wife while sitting on couch: 7/10 Fear = low

4. BODY DIAGRAM • Primary complaint (s) in depth: • P1: Intermittent achy shoulder stiffness, Pain now 0/10, at best 0/10, worst 3/10; Stiffness/achiness felt at end ranges of shoulder flexion, abduction, IR and ER; no increase in pain with repetitive movement into end ranges; 3/10 soreness present the day after a workout involving overhead movements • P2: intermittent medial L scapula stiffness and CT junction and thoracic stiffness- present after sitting for >30 minutes; present in am • P3: Intermittent R sternal / rib stiffness Numbness and or Tingling: denies • Relationship between symptom areas: Can occur separately, or concurrently P1 P3 P2 C

5. PE Planning I. What areas/structures must be considered a source of symptoms?

6. Symptom Behavior • Aggravating and Easing Factors: • P1 Aggravating Factors: • 1: Flexion and combined end range shoulder movements- 0-3/10; more stiffness than pain • 2. Prone or sidelying on elbows- 0-3/10 • 3. Pullups- feels very weak- can perform only 2-3 at a time • P1 Easing Factors: • 1: Immediately eases out of position • 2. OOP- takes ~5 minutes to loosen back up to baseline • 3. Horizontal pulls feel better than vertical pulls • P2 Aggravating Factors: • 1: Sitting for >30 minutes increases stiffness to moderate • P2 Easing Factors: • 1: Foam rolling, manipulation, yoga movements (Downward dog, cobra, spine rotations)- reduces feeling of stiffness to mild

7. History • Sleep and 24 hour pattern: • Sleep: no trouble falling asleep/staying asleep. • Morning: Pt reports AM worse than PM- more stiffness • Evening/night: Feels best when active/ moving • Duration of current symptoms: Intermittent for 10 years • Mechanism of injury / current history: No specific trauma- pt reports that he did a lot of overhead lifting (press, jerks, snatch) in college and noticed that when he was performing dumbbell bench press with heavier weights- sometimes the L arm would just “give out” when moving into elbow extension. He also began having difficulty with any overhead lift- stopped heavy overhead and benching movements and focused on running/ LE strength

8. PATIENT INTAKE • Medical History / Co-Morbidities / Review of Symptoms (ROS): • Borderline high cholesterol • Red Flag Screen: no numbness/tingling, no falls, no gait dysfunction, no bowel/bladder changes, no saddle anesthesia, no trauma, no headaches, no visual changes • Yellow Flag Screen: (-) depression screen • Special Questions: • Diagnostic tests / Imaging : No imaging • Medications : NSAIDS PRN

9. Clinical Reasoning • (S) What is the severity of the condition (min, mod, severe)? • Min- no work duties effected, can still work out, ADL’s not effected •  (I) What is the irritability of the condition (min, mod, severe)? • Min- Symptoms only at end range, ease almost immediately out of position, repetitive movement into end range does not progressively increase pain • (N) What is your primary nature statement of the problem - The report of a feeling of weakness and giving out during horizontal pressing points towards an instability or possibly labrum problem. Current report of stiffness and weakness could be compensation over many years for the original problem • (S) What is the stage of the disorder: Chronic (10 years) • (S) What is the current stability of the disorder • Stable: reports no progressive weakness or numbness- just stiffness

10. Planning the PE • What will you include to rule in/out your hypotheses? • 1: ROM testing with OP (shoulder) • 2: Muscle strength testing • 3: AROM testing w/ OP (cervical) • 4: Functional movements: Apley’s scratch test, overhead squat, pullup, pushup • 5: Palpation of shoulder musculature • 6: Prone cervical and thoracic spine PAIVM • 7: Supine shoulder PROM/ joint mobiiltytesting • 8: Supine AC joint and anterior rib A/P assessment 9 . Special tests when in relevant position (stand, supine, prone) 10. Muscle length testing

11. Physical Exam • Precautions and or Contraindications: None • Postural Observation: Slight trunk rotation to the R; R shoulder lower than L, no visible atrophy present • Shoulder ROM: • Flexion: R WNL, L 165 in scapular plane- OP firm end feel-familiar stiffness • Extension: Full bilateral, no symptom reproduction • External rotation: R WNL, L 15 degrees (neutral); L 60 degrees at 45 degrees abduction; L 60 degrees at 90 degrees abduction • Internal rotation: R WNL, L WNL at neutral; L 50 degrees at 45 degrees abduction; L 0 degrees at 90 degrees abduction (produced familiar stiffness/ achiness at posterior and superior shoulder • Thoracic spine: Low to mid-lumbar spine hypomobile; no comparable pain observed

12. Physical Exam • Muscle strength: • Scapular elevation: 5/5 B; Shoulder abduction: R 5/5, L 4+/5; Bicep: 5/5 B; Tricep: 5/5 B; Shoulder Internal rotation: 5/5 B; Shoulder external rotation: R 5/5, L 4/5 with comparable posterior shoulder stiffness; Scapular retraction: 5/5 B; Grip strength: R 120#, L 110# • Cervical ROM testing: Extension full w/ OP; Flexion full w/ upper thoracic stiffness felt w/ OP; Cervical rotation: 60 degrees bilateral with feeling of upper thoracic stiffness with OP; Lateral flexion: L 60 degrees with OP; R 40 degrees- OP produced L anterior and lateral neck stretch and R lateral t-spine compression/stiffness feeling • Functional Movement Tests: • Apley’s Scratch Test: Fxnl ER:R to T4, L to T2; Fxnl IR: R to T8, L to TL junction with tightness felt at anterior shoulder/pec

13. Physical Exam • Functional Tests: Pullup: Difficulty with full ROM at top; L shoulder moved into IR during concentric phase; Pushup- posterior shoulder pressure on L side; L shoulder moved into IR during concentric and eccentric portion; Overhead squat holding PVC pipe: Unable to fully flex L shoulder- resulted in rotation of the trunk to the right • Spinal Segmental and or Joint Restrictions: C2/3 hypomobile with grade IV PA and UPA pressure B- no pain; C4-6 normal with Grade IV; CT junction stiff w/ CPA grade IV- no pain produced; thoracic spine- hypomobile CPA and UPA with grade IV with comparable stiffness- no pain • Supine Shoulder PROM: R WNL; L flexion: 165, L ER at 90: 65 degrees, L IR at 90: 25 degrees; Supine GH A/P (various angles of shoulder flexion) hypomobile with boggy end-feel- familiar stiffness and achiness produced- Grade IV; P/A glide normal motion; Lateral distraction: hypomobile w/ familiar stiffness reproduced (P1) • Supine R rib assessment: 1st rib stiffness (CRLF + L), ribs 2-4 hypomobile with complaint of comparable stiffness (P2) • Special Tests: Hawkins-Kenedy: + on L, Bicep load II: - on L

14. Physical Exam • Muscle length testing: • Moderate restriction found in left levator scapula, pec major, pec minor, subscapularis and latissimusdorsi

15. Assessment & Plan • What is your primary hypothesis following the PE: • The patient presents with posterior shoulder hypomobility, with regional musculature and joint compensatory changes. • The patient is very active, and prefers to be given a HEP, with follow up every 3-4 weeks for progression. His main goals with PT are to be able to progress the number and load of pullups and pushups he can perform, manage the stiffness that he feels, and move in a more symmetric manner. He is motivated, and states that he will be diligent with any HEP he is given.

16. Day 1 Treatment Treatment provided today and the patient’s response to each intervention.   TREATMENTS Rx 1: Grade IV GH A/P mobilization 5 x 1:00, in various degrees of shoulder flexion Rx 2: L 1st rib manipulation in sitting RESPONSES TO… Rx 1: Improvement of shoulder ROM to 173 degrees; ability to keep elbow in neutral during 10 pushups Rx 2: Simulated “arm around wife” position produced no pain/stiffness

17. Response & Assessment at Day 1 • Other treatment provided today and the patient’s response: • Manual Therapy: None • Exercise: Self-mobilization of 1st rib with towel and laeral flexion of neck; Posterior GH joint mobilization with various angles of shoulder flexion and ER (using 1” resistance band); foam rolling for mid-thoracic spine, lats and medial scapula; Self posterior GH joint sustained mobilization (supine w/ shoulder at 90 degrees- hold 53# kettlebell-1 to 2 minutes prior to workout • Education: Interdependence of thoracic spine, ribs, scapula and GH joint • What changes did you note in your asterisks (test/retest)? • Report of medial scapula and anterior rib stiffness reduction by ~60%; Improved shoulder flexion , improvement in ability to perform pushup with good form. • Prognosis (note timeframe of expected level of recovery): • Due to chronicity of the problem, PT expects timeframe to be in the 8-12 week range to reach the goals the patient wishes to achieve. He is very motivated, and has low severity and irritability;

18. Response & Assessment at Day 1 • Plan of care (including plan for assessment on day 2): • Better: Progress self-mobilization of GH joint, progress thoracic mobility activity, progress specific RTC strengthening • Worse: low grade mobilizations of the GH joint in end range positions • Same: Sustained GH joint mobilization, CT junction and thoracic spine manipulation, PNF D2 and D1 patterns (passive >active>resisted) and contract-relax