Manila Adventist College

Department of Physical Therapy

PT SEMINAR 1
PHYSICAL THERAPY INITIAL EVALUATION
Name W.D. Medical Diagnosis 1deg (L) Frozen shoulder
stage 2

Age/Sex 40/M Referring Doctor Dr. C.H.

Handedness (R) Date of Referral October 4, 2018

Civil Status Married Date of Initial Evaluation October 4, 2018

Occupation Front desk clerk Date of Treatment Session October 4, 2018

Address MAKATI Precautions Avoid any activity or

exercise that reproduces
radicular symptoms

Informant/Reliabilit Patient/Good Type of Patient Out-patient (OPD)

y

S:
C/C: W.D. Pt c/o diffuse aching pain (PS: 4/10) on (L) sh aggravated by elevation which caused difficulty in
performing her ADLs and job as a clerk

Goal: W.D. wants to relieve the pain and move her (L) sh smoothly to enable her to perform ADLs and
work c ease

HPI:

~4mos PTIE, pt noticed a diffuse, dull, aching pain (PS:3/10) on (L) sh when pt tries to put files on a high
shelf at work but did not pay attention to it. A few days later, pain became constant on (L) sh & began to
be evident at night, thus disrupting pt’s sleep especially when lying on the affected side. Pt did not seek for
any medical attention, and just opted to apply “katinko” for temporary pain relief. Pt continued applying
“katinko” whenever felt pain.

~2mos PTIE, pt noticed that the diffused, dull, aching pain (PS: 3/10) on (L) sh started to aggravate (PS:
5/10) upon reaching overhead, trying to clasp her bra strap and driving her car. Pt decided to buy an
OTC medicine (see drug hx) which, c katinko, provided pain relief. Pt still did not consult her physician and
continued taking meds & applying “katinko” whenever sx occur.

~1wk PTIE, the pain on (L) sh got worse (PS: 7/10) at rest and aggravated (PS: 10/10) when pt tried to
wash her hair. Also, pain (PS: 4/10) extended to the neck. According to the pt, the ointment and OTC
meds no longer relieved the pain. Pt finally sought for medical attention. Pt’s physician ordered to run
some tests )see ancillary procedures) which then led to the dx of idiopathic adhesive capsuilitis on (L) sh. Pt
was prescribed c meds (See drug hx) at rest but still aggravated c movement and was then referred for PT.

1| C e r v i c a l S p i n e ( G r o u p 2 : C a l a ro, D i m aya c ya c a n d Ta g n i p e z )
 Manila Adventist College
Department of Physical Therapy
PT SEMINAR 1
~At present, pt c/o diffuse, aching pain (PS: 4/10) and stiffness on (L) sh that limited her sh motions
especially during elevation, thus causing difficulty in performing her job as a clerk which requires putting
files on high shelves and in ADLs such as washing her hair.

PMHx
 (-) Previously dx adcap on ® sh
 (-) DM
 (-) HTN
 (-) heart dse

FMHx
Condition Maternal Paternal
HTN (-) (-)
DM (-) (-)
Cardiovascular condition/s (-) (-)

Medications
Medication Dosage Indication Significance to PT

250 mg q 5hrs Pain reliever Drowsiness, slight incoordination

Ibuprofen (Advil)
or as needed and stomach problems

Ancillary Procedures
Radiographic Examination Date Findings

(L) sh x-ray October 1, 2018 (N) radiographic appearance

P/S/E Hx
 Sedentary lifestyle
 Non-alcoholic drinker
 Non-smoker
 Hobbies: solving cross words and sudoku
 Financially stable
 Lives c husband

Home Situation:
 Light switches (from floor to switch): ~1 m
 Cabinets (from floor to handle): ~1m
 Room closet (from floor to handle): ~1m
 Personal computer table: ~5m from the floor

Work Situation:
 Front desk clerk (works 8 hrs/ day during weekdays): Sitting most of the day; Typing, reaching and
filing paper work

2| C e r v i c a l S p i n e ( G r o u p 2 : C a l a ro, D i m aya c ya c a n d Ta g n i p e z )
 Manila Adventist College
Department of Physical Therapy
PT SEMINAR 1
 Office: Writing and computer desk – Ht (floor to desk) ~.5m; High shelves – Ht (floor to handle):
~1.5m
 Mode of transportation: Drives a car (~20mins travel time)
O:
VS>
Before During After

BP (mmHg) 100/70 120/80 110/70

PR (bpm) 88 99 90

RR (cpm) 16 20 18

Temp (C) 36.5

Findings: Vital Signs are WNL

Significance: VS will serve as baseline purposes for future interventions

OI>
 Endomorph
 Amb s AD
 Postural deviatin (see postural ax)
 (-) Swelling on (B) UE
 (-) mm atrophy on (B) UE

Palp>
 Normothermic on (B) UE
 (+) mm tightness on (L) trapezius & levator scapulae
 (+) Gr. II tenderness near deltoid tuberosity on (L) ant & post capsule
 (+) Mm spasm on neck & (L) sh
 (+) Mm guarding on neck & (L) sh
 (-) edema on (B) UE
 (-) contractures on (B) UE

ROM>
All major joints of (B) UE and LE were grossly assessed and were found to be within functional limits and
with (N) end-feels, except for the following:
Difference from
Joint Motion AROM PROM Normal Normal End-Feel
Range
AROM PROM

Cervical Flexion 0-25° 0-25° 0-45° 20 20 “Mushy”

tissue
stretch

® cervical lat. flexion 0-25° 0-25° 0-45° 20 20 “Mushy”

tissue

3| C e r v i c a l S p i n e ( G r o u p 2 : C a l a ro, D i m aya c ya c a n d Ta g n i p e z )
 Manila Adventist College
Department of Physical Therapy
PT SEMINAR 1
stretch

(L) sh flex 0-120° 0-120° 0-45° 75 50 Capsular

(L) sh abd. 0-110° 0-110° 0-60° 50 50 capsular

(L) sh ext. rot. 0-20° 0-20° 0-60° 40 40 capsular

Findings: pt has a 20 difference c a “mushy” end feel on AROM and PROM of cervical flex and ® lat flex
and 40-70 difference c a capsular end feel on AROM ad PROM of (L) sh flex, abd ER AND IR. Also, pt has
(+) shrug sign upon elevation of (L) sh.
Sig.: tx. Should include stretching of cervical neck in all planes to increase ROM and AROME and grade III
jt mobilization of (L) sh in all planes to reduce capsular tightness.

MMT>
All major mm groups of (B) UE were grossly graded 5/5, except for the following:
 (L) shoulder flexors: 3/5
 (L) shoulder abductors: 3/5
 (L) shoulder external rotators: 3/5
 (L) shoulder internal rotators: 3/5

Superficial sensation examination

Pt’s superficial sensation is affected within light touch and pinprick were tested using pointed and dull ends
of the neurohammer

Area Tested Results

(L) sh 3/3 (100% intact)
Post neck 3/3 (100% intact)
Findings: Pt has 100% intact superficial sensation on neck and (L) sh
Significance: use of rESWT and US on neck and (L) sh is indicated to reduce pain and mm spasm

POSTURAL Ax
All major landmarks of posture were assessed in standing position and were found to WNL except:
Body Part A/P view Lateral View
Shoulders (L) is higher than ® (L) is slightly fixed
(L) slightly abducted
Findings: Pt. has elevated slightly fixed and abducted (L) sh
Significance: Guarded posturing of (L) sh is may be d/t pain. Tx should include use of rESWT and US to
reduce pain on (L) sh.

A:
PT Impression
Pt. is unable to do her work as a front desk clerk which involves putting papers on high shelves further
defined by pain at rest which is aggravated c movement, dec mm strength & LOM on (L) sh, And difficulty
in ADLs such as washing of hair & back assoc c 1° (L) Frozen shoulder stage 2

Problem list

4| C e r v i c a l S p i n e ( G r o u p 2 : C a l a ro, D i m aya c ya c a n d Ta g n i p e z )
 Manila Adventist College
Department of Physical Therapy
PT SEMINAR 1
1. Dull aching pain, (VRS4/10) and mm spasm and guarding on neck and (L) sh.
2. Dec ROM of:
a. Active and passive (L) sh flex flex by 60°
b. Active and passive (L) sh abd by 70°
c. Active and passive (L) sh IR by 40°
d. Active and passive (L) sh ER by 70°
3. Dec mm strength of (L) flexors, abductors, external and internal rotators c a mm grade 3-/5
4. Postural deviation manifested by elevated, slightly flexed and abducted (L) sh
LTG (3x/wk for 6mos.)
1. To restore previous function of (L) sh to enable pt to perform ind ADLs and to work as a front desk
clerk c ease
2. To minimize the possible complications caused by the natural course of the dse.

STG (3x/wk for 2 mos.)

1. Relieve pain , mm spasm and mm guarding on (L) sh and neck after 12 tx sessions
2. Increase ROM of cervical flex and ® lat flex, sh flex, abd, IR and ER by 20-50 after 12 tx sessions.
3. Increase mm strength of sh flexors, abd, IR and ER from 3/5 to 4/5 after 12 tx sessions

PLAN:
1. Continuous US on neck and (L) sh 1.5W/cm2, 1MHz x 5 mins to reduce mm spasm and pain and
facilitate sh jt capsule remodeling.
2. GPS on (L) upper trapezius and levator capulae x 15 SH x 5 reps x 1 set to increase ROM and
flexibility
3. End range grade III jt mobilization of (L) GH jt in all planes for 3 mins to stretch th jt capsule
4. AROMEs with pain-free range of cervical spine, scapulae and (B) UE in all planes x 10 SH x10 reps
x 3 sets to maintain physiological elasticity and contractility of mm.
5. Gentle mm setting to all mm groups of the sh, elbow and cervical region in all planes x 7 secs hold
x 10 reps x 1 set to help stimulate blood flow
6. Codman’s exercise x 10 reps x 2 sets to relieve pain through gentle traction and oscillating
movements.

Patient education:
1. Avoidance of any activity that will cause and/or aggravate pain

Home instructions:
1. Self stretching of (L) upper trapezius and levator scapulae x 15 secs hold x 2 sets to inc mm
extensibility

Prepared by:

MAC Group 2 PT Batch 2020

5| C e r v i c a l S p i n e ( G r o u p 2 : C a l a ro, D i m aya c ya c a n d Ta g n i p e z )
 Manila Adventist College
Department of Physical Therapy
PT SEMINAR 1

_______________ ___________________ ___________________

Calaro, Katrina Vea Dimayacyac, Romeo Lizandro Tagnipez, Sheena Mae

Gardoce, Eric Christian Nicole Gatbonton

6| C e r v i c a l S p i n e ( G r o u p 2 : C a l a ro, D i m aya c ya c a n d Ta g n i p e z )