Clinical presentation

(Musculoskeletal)

Anatomy
The shoulder joint is a ball and socket
synovial joint compromised out of 3 bones.
The scapula , the humerus and the
clavicle.
The head of humerus fits into the glenoid
fossa , and the joint is covered by a
capsule.
To ensure smooth shoulder movements,
synovial fluid lubricates the capsule and
the joints

Adhesive capsulitis
Better known as a Frozen shoulder
Causes pain and stiffness in the shoulder.
Capsular tightening at the glenohumeral
joint
A condition that involves the spontaneous,
gradual onset of shoulder stiffness and
pain caused tightening of the joint
capsule.(jonathan cluett,M.D.,December
16,2014)

Pathology

Clinical presentation
Painful stage
Pain with movement
Generalized ache that is difficult to pinpoint
Muscle spasm
Increasing pain at night and at rest
Adhesive stage
Less pain
Increasing stiffness and restriction of movement
Decreasing pain at night and at rest
Discomfort felt at extreme ranges of movement
Recovery stage
Decreased pain
Marked restriction with slow, gradual increase in range of
motion
Recovery is spontaneous but frequently incomplete

Demographics

Name: Lok Mei Chew

Age:59
Sex : Female
Date of assessment : 5-1-16
Dr. Diagnosis : Left Frozen Shoulder
(adhesive capsulitis)
Dr. Management : Conservative MX

Subjective Assessment
Chief Complaint:
Patient complained of left shoulder pain
around the shoulder joint when moving
arm forward,side
ways,backwards,inwards and
outwards above the avalible range

Pain Assessment
Scale :0/10 at rest and 6/10 when aggrevated
Type : Intermittent (At extreme range of
limitation)
Characteristic/nature of pain: Stabbing pain
Aggravating factor: Moving shoulder beyond
available range
Easing factor : Bringing back shoulder within
available range/rest
Severity: High
Irritability: Low

Current History
Pain gradually onset over than a month
ago, Patient could not recall any
particular triggering event .
Patient applied for Physiotherapy via
form when she was on her follow up
session with her Dr. for OA knee

Past history
Patient claimed that she had frozen
shoulder on the same side (left) a
few years ago , making this the 2nd
episode
No other history of other shoulder
pathology

Medical history
Controlled hypertension for over 10
years
No DM
No existent heart conditions

Past medical history / surgical

history
Undergone appendectomy when she
was younger , patient unable to recall
when

Social history
Occupation: Nurse (Not involved in
heavy lifting)
Currently living with family(husband
and child)
Driving to work

Special questions

General health: patient is healthy

Pacemaker/hearing aids: none
Tobacco use : none
Alcohol use: none

Objective Assessment
Observation:
General :
59 year old Chinese lady
Rounded shoulders and a khyphotic thoracic spine
No gait abnormalities
Local :
No signs of inflammation
No discoloration
No redness

Palpation
Grade I tenderness on anterior aspect
of shoulder joint
No temperature changes
No muscle spasm around shoulder joint
musculature

Physical Examination
Range of Motion of left shoulder
(Affected)
Movemen
t

Active
ROM

Passive
ROM

End Feel

Flexion

140

145

Firm

Extension

30

35

Firm

Abduction

85

90

Firm

Internal
rotation

35

35

Firm

External
rotation

65

65

Firm

Interpretation
The firm end feel felt at the end of
the movement suggests joint
stiffness which is a common clinical
presentation of adhesive capsulitis

 Range of motion of Right

shoulder
Movemen
t

Active
ROM

Passive
ROM

Flexion

165

165

Extension

60

Abduction

175

180

Internal
rotation

65

75

External
rotation

90

90

End Feel

Manual Muscle Testing

left shoulder
Muscle

Grade

Anterior Deltoid

3/5

Posterior Deltoid

3/5

Middle Deltoid

3/5

Infraspinatus

3/5

Subscapularis

3/5

 right shoulder
Muscle

grade

Anterior deltoid

5/5

Posterior deltoid

5/5

Middle deltoid

5/5

Infraspinatus

5/5

Subscapularis

5/5

Interpretation
Failure to test for MMT grade 5
indicates that she has muscle
weakness

Clearing test
Elbow: No abnormalities
Neck: No abnormalities

Accessory movement
assessment
Posterior GH glide: Joint hypomobility
Inferior GH glide: Joint hypomobility
Anterior GH glide: joint hypomobility

Special test
Patient tested negative for empty
can test for supraspinatus tendinitis ,
speeds test for bicep tendinitis and
drop arm test for rotator cuff injury

Analysis
Pain at extreme range due to joint
stiffness
Restricted range of motion due to
joint stiffness
Muscle weakness due to pain

Plan of treatment

Pain relief
Joint mobilization
Mobilizing exercise
Strengthening exercise
Home education program
Patient education

Short term goal

Reduce pain within 3 weeks
Increase range of motion within
every consecutive appointment
Increase muscle strength within 6
weeks

Long term goal

For the patient to be able to resume
her job as a nurse pain free and with
a fully functional shoulder within 6
weeks

Intervention
Hydrocollator pack:
Position: Sitting on chair
Duration: 15minutes
Benefits: pain relief, increase soft tissue
extensibility.

Ultrasound therapy
Position: sitting
Duration: 5 minutes
Mode :continuous
Intensity: 0.5 W/CM(2)

Peripheral Joint Mobilization:

Posterior Glenohumeral glide:
Position: supine lying
Dose:10-15 repetition
Use: to increase range of shoulder flexion
Inferior Glenohumeral glide
Position: supine lying
Dose 10-15 repetition
Use: to increase range of shoulder abduction

Anterior Glenohumeral glide

Position : prone lying
Dose: 10-15 repetition
Use: to increase range of shoulder
extension

Stick exercise:
Position: sitting
Dose: 30 repetition for 1 set
Starting position: shoulder neutral
Ending position: shoulder flexed

Postural correction:
Postural awareness

Evaluation
Pain scale reduced from VAS 6/10 to
VAS 5/10
ROM
after treatment
(Left
shoulder)
Movement
Active ROM
Passive
ROM
flexion

150

155

extension

45

45

abduction

105

110

Internal
rotation

45

50

External
rotation

75

75

Review

Pain scale
ROM
Muscle strength
Posture
Home exercise given

Follow up(6/1/16)
Subjective assessment:
Patient complained of left shoulder
pain around the shoulder joint when
moving arm forward,side
ways,backwards,inwards and outwards
above the avalible range

Pain Assessment
Scale :0/10 at rest and 5/10 when aggravated
Type : Intermittent (At extreme range of
limitation)
Characteristic/nature of pain: Stabbing pain
Aggravating factor: Moving shoulder beyond
available range
Easing factor : Bringing back shoulder within
available range/rest
Severity: High
Irritability: Low

Observation
Observation:
General :
59 year old Chinese lady
Rounded shoulders and a khyphotic thoracic
spine
No gait abnormalities
Local :
No signs of inflammation
No discoloration
No redness

palpation
Tenderness grade I on anterior aspect
of shoulder joint
No temperature changes
No swelling
No muscle spasm

Physical Examination
Range of Motion of left shoulder
(Affected)
Movemen
t

Active
ROM

Passive
ROM

End Feel

Flexion

150

155

Firm

Extension

45

50

Firm

Abduction

110

115

Firm

Internal
rotation

45

50

Firm

External
rotation

75

75

Firm

 Range of motion of Right

shoulder
Movemen
t

Active
ROM

Passive
ROM

End Feel

Flexion

165

165

Extension

60

Abduction

175

180

Internal
rotation

65

75

External
rotation

90

90

Manual Muscle Testing

Left shoulder
Muscle

Grade

Anterior Deltoid

3/5

Posterior Deltoid

3/5

Middle Deltoid

3/5

Infraspinatus

3/5

Subscapularis

3/5

 Right shoulder
Muscle

grade

Anterior deltoid

5/5

Posterior deltoid

5/5

Middle deltoid

5/5

Infraspinatus

5/5

Subscapularis

5/5

Accessory movement
assessment
Posterior GH glide: Joint hypomobility
Inferior GH glide: Joint hypomobility
Anterior GH glide: joint hypomobility

Analysis
Pain at extreme range due to joint
stiffness
Restricted range of motion due to
joint stiffness
Muscle weakness due to pain

Plan of treatment

Pain relief
Joint mobilization
Mobilizing exercise
Strengthening exercise
Home education program
Patient education

Short term goal

Reduce pain within 3 weeks
Increase range of motion within
every consecutive appointment
Increase muscle strength within 6
weeks

Long term goal

For the patient to be able to resume
her job as a nurse pain free and with
a fully functional shoulder within 6
weeks

Intervention
Hydrocollator pack:
Position: Sitting on chair
Duration: 15minutes
Benefits: pain relief, increase soft tissue
extensibility.

Ultrasound therapy
Position: sitting
Duration: 5 minutes
Mode :continuous
Intensity: 0.5 W/CM(2)

Peripheral Joint Mobilization:

Posterior Glenohumeral glide:
Position: supine lying
Dose:10-15 repetition
Use: to increase range of shoulder flexion
Inferior Glenohumeral glide
Position: supine lying
Dose 10-15 repetition
Use: to increase range of shoulder abduction

Anterior Glenohumeral glide

Position : prone lying
Dose: 10-15 repetition
Use: to increase range of shoulder
extension

Wall ladder(flexion):
Position: standing
Dose: 30 repetition for 1 set
Starting position: shoulder flexed,fingers
rested on wall ladder
Ending position: shoulder flexed to
limitation level,fingers rested on wall
ladder

Wall ladder(abduction):
Position: standing
Dose: 30 repetition for 1 set
Starting position: shoulder abducted,
fingers on wall ladder
Ending position: shoulder abducted to
limitation level, fingers on wall ladder

Postural correction:
Postural awareness

Evaluation
Pain scale remain the same at VAS 5/10
ROM after treatment (Left shoulder)
Movement

Active ROM

Passive ROM

flexion

160

160

extension

50

55

abduction

115

120

Internal
rotation

50

60

External
rotation

75

80

Review

Pain scale
ROM
Muscle strength
Posture
Home exercise given

Evidence base
Years

Author

Conclusion

2010

Rookmoneea M et
al.

Recent evidence has not been able to conclude

which treatment technique, whether physical
therapy, home exercise program, cortisone
injection, manipulation, or surgery, is most
effective.

2009

Kelley MJ, McClure

PW, Leggin BG.

Therefore the decision to begin and continue with

formal physical therapy should involve input from
the physician, the patient preference, and physical
therapist after initial evaluation. Patients who may
benefit more from formal physical therapy include
those with higher disability levels , higher anxiety
levels, lower educational levels, and those who
have less social support.

Years

Author

conclusion

2005

Ryans I,
Montogmery A,
Galway R,
Kernohan WG,
McKane R.

While evidence regarding the use of intraarticular cortisone injections is conflicting as

well, some studies do indicate they provide
better short-term (4-6 week) pain reduction than
other forms of treatment.

2009

(Kelley MJ,
McClure PW,
Leggin BG.

Given this information, if this is not offered to

patients before referral to physical therapy and
they do not demonstrate progress within 3-6
weeks, referral for evaluation for an injection
should be considered

2010

Harvard medical
skill uviversity

Always warm up shoulder before performing

your exercises. The best way to do that is to
take a warm shower or bath for 10 to 15
minutes. You can also use a moist heating pad
or damp towel heated in the microwave

Year

Tittle / author

Conclusion

2010

Journal 7 step
rotator cuff
treatment system

Massage is one of the best ways to increase

blood flow to an injured area, and of course the
oxygen and nutrients that go with it. The other
benefit of massage is that it helps to reduce
the amount of scar tissue which is associated
with all muscle, tendon and joint injuries.

2010

Adhesive
The effectiveness of joint mobilization in
capsulitis :
adhesive capsulitis will increases range of
Use the evidence to motion in patients with adhesive capsulitis.
integrate
intervention.

2010

Adhesive
capsulitis :
Use the evidence to
integrate
intervention.

Active-assisted range of motion (AAROM)

exercises. These typically involve the patient
using the uninvolved arm, or using equipment
such as rope-and-pulley and These patients
significantly improved in pain, range of motion,
and shoulder function

conclusion
In a nutshell , Mrs. Lok Mei Chew is a
really cooperative patient who is
motivated to return to her premorbid state, making it a pleasure to
treat her. Her ROM of her left
shoulder significantly increased
within a short period of time. Her
pain score did reduce slightly.