Jenna Faiella

MSE Assignment

Problem I:

N.J. was born in 1993 and is currently in her first semester of graduate school. Her chief complaint consists of intermittent right shoulder pain. She attributes this onset of pain after having a partial labral tear in her right shoulder. This injury occurred two years ago after falling onto an outstretched hand while playing soccer. After receiving an X-Ray and MRI, it was confirmed that she had a partial posterior tear of her labrum and was advised to receive physical therapy for her injury. While receiving rehabilitation, she started to experience pain in the anterior region of her shoulder, as well as the scapular region, while she was doing various strengthening exercises. Due to insurance reasons, she decided to forego physical therapy after experiencing this new pain and did not go back for further treatment of her partial labral tear.

II. Subjective:

Current condition/chief complaint(s): The patient reports that her R shoulder pain began 2 years ago. This pain occurred while receiving physical therapy for a partial posterior labral tear, as the exercises she was performing started to cause a new pain in the anterior region of her shoulder and R shoulder blade. She stated that exercises performed at or above her shoulder level seemed to aggravate the pain the most and caused her to stop participating in therapy, as well as because of insurance reasons. This was the first time she had experienced anterior and scapular shoulder pain and had no similar problems related to her shoulder, besides the labral tear. Currently, she experiences pain at night and in the morning when she wakes up after sleeping in certain positions. Pain also occurs when she reaches above shoulder level or holds positions for a sustained amount of time. She rated the pain as an 8/10 on the Numeric Rating Scale (NRS) at worst and her current pain while sitting at a 1/10. The patient describes the pain as mostly dull and achy, but sometimes is a quick sharp pain that occurs in an instant and will go away when her shoulder is at rest. She states that resting and holding her arm in the position such as if she were to have a sling on (at her side, supporting her forearm across her chest) relieves the pain. Since she is currently in graduate school, she is sitting as her computer for long hours in a static position and notices that the she will gradually experience pain in the anterior part and scapular region of her R shoulder after sitting for a long time typing on the computer. She copes with the problem by finding ways to relieve the pain and not putting her shoulder in positions that will further aggravate it, especially overhead movements.

Current Functional status/Activity level: As a result of the patients pain, she is no longer able to perform upper extremity exercises that she used to do such as lifting weights because of the pain that it has caused her. She has a part-time job as a waitress and can no longer hold the tray with her right upper arm because her shoulder becomes weak and tired so she has adapted to holding the tray with her left hand instead. Other than that, no adaptive/assistive devices are needed during physical activities and she is independent with mobility, gait, and other activities.

Social history: There are no cultural/religious beliefs affecting patient care. Patient lives with her aunt and says she has a strong support system if she ever needed help.

Employment status: As stated above, patient works part-time as a waitress and has switched to holding the tray when carrying food out to the unaffected side instead. She is also a full-time student and experiences pain while working at her computer for long hours, holding her book bag on the right shoulder, as well as reaching down to pick up the book bag.

Living environment: There are no environmental obstacles that the patient must overcome or accomplish due to her condition/injury.

General health status: N.J. considers her health status as good, but would like it to be better. She attributed not being able to exercise as much as she wants to due to having a busy schedule with school and work. During the past year, she moved from living at home with her parents to living with her aunt because it was closer to attend school.

Social/health habits: Occasionally will have 1-2 drinks on the weekend, does not smoke, exercises 2x/week doing abdominal and lower body strength training such as planks, squats, lunges, and various other lower body strengthening machines at her local gym.

Family health history: Heart disease, pancreatic cancer, asthma

Patients Medical/Surgical history: X-ray and MRI for posterior labral tear: May 2013

Spinal Fusion from C7-L5 for Scoliosis: 1996

Medications: None

Other clinical tests: Nerve Conduction Testing for Brachial Plexus: Negative (June 2014)

Patient goals (for PT):

Short Term Goal (STG)

1. Decrease pain in R shoulder

2. Increase strength in shoulder and back muscles

Long Term Goal (LTG)

3. Eliminate pain completely in order to be able to perform upper body strengthening exercises at the gym

III. PHYSICAL EXAMINATION:

Objective

Review of Systems

System:

Results:

Impaired/Not Impaired

Cardiovascular/Pulmonary

HR: 62 bpm

RR: 14 breaths/minute

BP: 110/78 mmHg

Edema: Not present

Not Impaired

Integumentary

Not applicable

Not Impaired

Musculoskeletal

Gait

Locomotion

Balance

Motor Function

Not Impaired

Communication Ability

Affect

Not impaired

Not impaired

Cognition

Oriented to person, place, time: oriented x 3

Not impaired

Learning Barriers, Learning Style, Educational Needs

-Patient wears contacts daily

-Learns best with pictures, visual information, hands on demonstration

-Would like to more information on healing process/exercises she can perform safely and without pain

Postural Assessment:

Observations:

Static Sitting

Slouched in chair

Forward Head

Posterior Pelvic tilt

Static Standing

Left shoulder lower than Right (Due to corrective surgery for scoliosis, patient stated that after surgery, shoulder height was still not able to be completely aligned in a horizontal fashion and right shoulder was still a little higher than left)

Scapular Winging bilateral (upward rotation and anterior tilt of scapula- R scapula winging more than left)

Normal spinal curvatures (Due to fused vertebrae after corrective surgery for scoliosis)

Observations:

Results

Palpation

Increased tenderness when palpation to R anterior acromion region

Scapular Assistance Test

Positive- N.J. experienced decreased pain with assistance

Modified Scapular Test

Positive Patients pain was reduced when given assistance with scapular upward rotation/tilt

Scapular Retraction Test

Positive N.J. demonstrated increased strength when resistance was added to static position and less pain was noted

Upper Quarter Screen:

Impaired/Not Impaired

Dermatomes

Not impaired

Myotomes

Not impaired

Deep Tendon Reflexes

Biceps Brachii (C5): 2+

Brachioradialis (C6): 3+

Triceps Brachii (C7): 2+

[Not Impaired]

Range of Motion

AROM vs. PROM

Shoulder Movements

Left

Right

AROM (all)

Flexion

Extension

Horizontal Adduction

Horizontal Abduction

Abduction (Scapular Plane)

Internal Rotation

External Rotation

L shoulder AROM normal

R shoulder AROM normal

EXCEPT:

R Internal Rotation: 50 due to pain

Manual Muscle Testing: Isometric Break-Test

Manual Muscle Testing

Motion/Muscle Tested

Left

Right

(Isometric Break Test for all)

Flexion

5/5

3+/5 Pain

Extension

5/5

5/5

Abduction

4/5

3+/5 Pain

IR

5/5

5/5

ER

5/5

3+/5 Pain

Serratus Anterior

5/5

5/5

Upper Trap

4+/5

4/5

Middle Trap

4/5

3/5 pain

Lower Trap

4/5

3/5 pain

Rhomboids

4/5

3/5 pain

Flexibility testing2

Muscle tested:

Patient Position

Results:

Pectoralis Minor Muscle Length

-Patient supine, arms at side, shoulders laterally rotated

-Forearms supinated

-Measurement taken from posterior border of acromion process to table

L: 2 inches 6.35 cm

R: 3 inches 7.62 cm

[When compared to the gold standard of 2.6 cm (about 1 inch) for pec. Minor length, patient has significant pectoralis minor tightness bilaterally]

Special Test:

Testing for:

Results: Positive/Negative

Hawkins-Kennedy

Subacromial Impingement

Positive on R shoulder

Similar pain was reciprocated when test performed on R UE

Drop Arm Test

Rotator Cuff Tear (Supraspinatus)

Negative

ER Lag Sign

Rotator Cuff Tear (Infraspinatus)

Negative

Yergasons Test

Bicipital Tendinopathy

Negative

Assessment:

1. Possible hypothesized diagnoses that my patient presents with include:

Subacromial (anterior) impingement syndrome (SIS)

Rotator cuff tear