SHOULDER CASE STUDY 1
Task1
Site
Stage
Severity
Stability
Nature
Irritability
Progression / Rate
Regular / Irregular Pattern
Diagnosis
Hypothesis
1. RC Tendonopathy
P R Ant Shoulder
Chronic 8/12
VAS 2/10 best 4/10 worst
Hypermobile but normal endfeel
Mechanical
Possibly chemical component-pain 2/10 @ best
Low-mid. Easily provoked, but P eases w rest, if she rolls off
shoulder
Stable last 6/12
Regular
Impingement syndrome:
RC Tendinopathy/Rupture
Subacromial bursitis
Compounding factors: Hypermobility, weakness/Decr NMC
Positive Evidence
+ Impingement tests:
(Hawkins/Kennedy,
Neer/Welsh)
+ Empty can
Decr. Ms definition/tone
Mechanical P
Weak, P on ext rot
Nature of injury
Location of P
+ Impingement tests:
(Hawkins/Kennedy,
Neer/Welsh)
+ Empty can
Decr. Ms definition/tone
Mechanical P
Weak, P on ext rot
Nature of injury
Location of P
Steroid injection
Chemical P
+ Impingement tests
Location of P
2. RC Ruture
3. Bursitis
Negative Evidence
Too young?
Too young?
Weakness
Task 2
Contraindications
(Gibbons 2000)
Absolute
Relative
Articular factors
Instability ie. Spondylolithesis,
degeneration, general hypermobility
Spinal deformity: ie. Scoliosis, Kyphosis
Foraminal Encroachment:
Hx of recurrent trauma
Bone
Circulatory disorder
Drugs
Neurological
Unclassified
Infections: Osteomyelitis, Septic
arthritis, Tb
Inflammatory Conditions ie. Pagets
disease (enlarged, weakened bones),
inflammatory Arthritis
Neoplastic disease (tumour)
Vertebrobasilir insufficiency i.e
dizziness, drop attacks, nausea
Haemophilia (severe)
Alcohol
Anticoagulents
Strong Analgesics
Cord/ Cauda Equina symptoms:
dysreflexia, altered power, sensation
>1 Cx N root
>2 Adj Lx N roots
Severe joint P
Undiagnosed P
Advanced diabetes
No consent
Shoulder Specific Red Flags (ACC Guidelines 2004)
Fracture/dislocation:
Unexplained deformity/swelling
Infection: Fever/chill/malaise
Suspected malignancy
Significant/unexplained sensory/motor deficit
Pulmonary or vascular compromise
Significant weakness not due to P
Steroids (long term)
Antidepressants
Cx/Tx referred symptoms to LL
Acute N root irritation/ compression
Adverse reactions to previous MT
Disc herniation/prolapse
P w psychological overlay
Children/teenagers
Ms spasm
Pregnancy (last 3 months)
Spinal mvmnt/palpation causing distal
symptom
Irritable conditions
Worsening condition
Structures to be examined and tests to be performed on that structure
Structure Priority
1. RC
Muscle
Neural
Observation
Palpation
Function
AROM
PROM
Resisted
Special:
Hawkins/Kennedy
Neer/Welsh
Painful Arc
2. Subacromial
bursitis
Joint
Other Problems
Observation
Palpation
Function
AROM
PROM
Resisted
Special:
Hawkins/Kennedy
Neer/Welsh
Painful Arc
3.
Objective Assesssment and Expected Outcome
Observation






Skin
Alignment of Cx/Tx spine, scapula-Superior angle at T2, Root at T3, Inf angle at T7,
Olecranon facing posterierly?
Symmetry
Medial borders vertical, and four pt finger widths from spine?
Muscle bulk: Atrophy/ Hypertrophy?
Humeral head position: 1/3 of HOH ant to ant. Margin of acromion?
 +ve: Decr. Ms tone/definition –ve: normal tone, allignment
Palpation



Bone: SCJ, clavicles, ACJ, Acrominon, HOH, Bicipital groove, Spine of scapulae
Ms: Supraspinatus, Long tendon of Biceps, MTPs,
Bursa
 +ve: P over bursa area -ve: Painless
Function


Scaption: Symmetry, Painful arc?
Hands behind back, neck
 +ve: Painful arc, poor scapula control/giving way. –ve: full, painless,
symmetrical movement
Neural Screening (weakness)
Sensation:C4
Strength
AROM-3 reps per set

Shoulder flexion/ext, int/ ext rot, abd/add, horiz abd/add
 +ve: P on ext rot
-ve: full, painless, symmetrical ROM without
compensation.
PROM: Qulaity (resistance), P, End feel

End feel: flexion/ext, int/ ext rot, abd/add, horiz abd/add
 +ve: normal, slightly hypermobile. –ve: Painless, symmetrical ROM, normal
end feel
Resisted

Flexion/ext, int/ ext rot, Abd 10* /add, horiz abd/add
 +ve: Abd 10*: R >50% weaker than left ( McCabe 2005)
 –ve: Symmetrical Grade 5 all movements
Special
Impingement
Assessment Type
Neer/ Welsh
Hawkins/Kennedy
Painful arc
Validity
Reliability
Sn (%)
79
79
32-73
Sp (%)
53
59
80-81
Reference
(Hegedus et al, 2008)
(Hegedus et al, 2008)
(Kessel & Watson, 1977)
Lewis, (2009): “No tests can specify whether problem is RC, SAB, or ACJ. Therefore specific
diagnosis requires MRI, ultrasound”.
 +ve: Neer/Welsh, Hawkins/Kennedy. Perform painful arc also.
 -ve: - to all tests above
“Rotator Cuff”
Assessment Type
Validity
Reliability
Sn (%)
Sp (%)
Reference
Resisted Abd @ 10*
Empty can & Full can (+ indic.
by P, weakness,compensation)
Lift off-Subscap tear
IRLS
Belly Press
ERLS
79
53
(McCabe 2007)
(Hegedus et al, 2008)
89
100
98
84
46
94
(Gerber & Krushnall 1991)
(Gerber & Krushnall 1991)
(Gerber 1996)
(Miler, 2008)
Hughes, (2008): Results of specific tests can’t be recommended for clinical use due to inconsistencies
across studies. Rather
“suspicion” incr if +
Palpation
Combined Hawkins/Kennedy/ Painful arc/
infraspinatus
Lift off
Belly press
Drop arm
 +ve: Empty can
Diagnosis
RC tear
Task 3-Rx
Short-term Rx goals:
“suspicion” decr if -:
Hawkins/Kennedy
Empty can
Palpation