The Monday Memo
May 22, 2017 PITT DPT STUDENTS
Below is a hypothetical case study: The patient is representative of an impairment/functional deficit that is common in an outpatient physical therapy clinic. Leave a comment with the next steps that you would take if you were the primary clinician: Would you continue with the physical exam? Redirect your focus? Do you feel comfortable prescribing treatment from the given information? What other questions might you ask this patient? Is this a situation where referral may be needed? Why or why not?
Patient: 26 y.o Female Graduate Student
- Right shoulder pain with elevation affecting the ability to perform overhead activities and reach across to grab her seatbelt.
- Over 1 month ago — Occurred while performing dumbbell presses in a strength training group class. Immediate limitations included putting on a shirt and reaching across her body. Pain at the AC joint area.
- Seemed to get better on its own over the next week or two… Then got worse after a poor night’s sleep. This worsening presented as more of a “constant” pain and stiffness with the patient feeling as though she needed to pop it back into place. Reports “cracking” with movement.
- Seemed to get better again with time, but 2 days ago the patient was leaning on her elbows and pain flared back up after standing back up and unweighting the shoulder. New onset of pain is in a different place: More lateral to the AC Joint. Pain has decreased over the past 48 hours.
- Worst: 5-7/10 , Best: 1/10
- No prior history of shoulder injuries besides bilateral broken clavicles at a young age.
- Pt has been dealing with headaches since teenage years. Two main types: First is typical with a cervicogenic left-sided “Ram’s Horn” presentation and also has referral to the supraorbital area over the R. eye. She also complains of tension-type headaches that she correlates with dehydration, stress, and posture. Reports that the tension-type headaches are helped with postural exercises (chin tucks).
- Patient appears to be in good health. Slender frame with average or slightly below average muscle mass. Slight forward head posture. Depressed R shoulder relative to L.
- Full ROM with slight pain at end-range FLEX/ABD; 4/5 on MMT with most movements, but painful with resisted FLEX/ABD/ER.
- Abnormal scapular mechanics noted with ABD. R side seems to get hung up, especially on descent. Flexion mechanics appear normal, but a “click” or “pop” is felt and heard with both movements on elevation and descent.
- Special Tests:
- No signs of instability or apprehension with testing.
- Clicking felt with Load and Shift to assess anterior capsule/labrum
- (+) Neers, (+) Jerk for anterior pain, (+) Crank w/ clicking, (+) Hawkins Kennedy
- (-) RTC cluster, (-) Sulcus Sign, (-) Biceps load test