MUSCULOSKELETAL PRESENTATION PRESENTATION BY: Samruddhi Borade and Sadhana chouguleName: Mr. Sharan Gowda Muthkhod Age: 57 years old Gender: Male Address : Nerul Dominance: Right hand Occupation: Chemical engineer DOA: 15/04/2021 DOE: 19/04/2021 Chief complaints: Difficulty and pain while performing all activities involving left shoulder like weering shirt, pain during overhead activities, lifting objects,taking hand behing, buttoning shirtHOPI: 4 months back when patient was at his work place while getting up from his chair he hit a box on the lateral aspect of his left shoulder at a perpendicular angle due to which he witnessed pain at his left shoulder for 2 to 4 minutes, the pain later subsided with rest and he got back with his work, he could also use his left hand normally after this, the patient use to lift heavy objects during grocery shopping using his left hand and sleep on his left(affected ) shoulder, sometimes he used to experience slight pain at his left shoulder while lifting weight but he ignored it believing that eventually it will get reduced only to know that the pain aggregated insidiously in a span of 1 month to the point that the patient started experiencing pain even while performing activities of daily living and joint stiffness resulting in reduced range of motion at his left shoulder joint for which he went to a MBBS doctor and was suggested for an X ray and MRI. The x-ray findings were normal and MRI suggested Adhesive Capsulitis. He was then suggested for physiotherapy for 10 days.Current status : Pain while performing overhead activities, wearing and taking off the shirt, taking hand behind his back. But the pain has reduced about 15-20% with physiotherapy treatment since 5 days. Pain history: Intensity -At rest 0/10 (_)—_|__1 On activity 6/10 lL \ Site anterior and lateral aspect | __{ ++ Of shoulder Onset - sudden Type - dull aching pain Duration- Intermittent (on activity only) Aggregating factor- Any overhead activities of shoulder Relieving factor - restPast history- Medical - nothing significant Surgical nothing significant Personal history: Sleep: normal Bowel and bladder: normal Appetite: normal Addi ns: Absent Family history: not significant Socio economic: No. Of family members: 6 No. Of earning family members- 2 Status- Upper middle class. Environmental history- At job- desk at the level of chest, chair comfortable, hand rested, At home- lives in building, with good electricity and water supply, and Indian toilet Drug history: Toplenac SPC( relieves pain and swelling) Banoflam(pain relief) Supplements-Nerviday vitamin B12 and Vitamin D3Provisional Diagnosis: 1 = adhesive Capsulitis 2= shoulder istability 3= impingementAssessment * General Examination: * Vitals: stable * Built: medium built (mesomorph) * Nutrition : healthyOn observation: + Posture : In standing * Anterior view: left shoulder slightly elevated B/L round shoulders , Pectus excavatum(funnel chest seen) since birth* Lateral view: forward head posture. Slight increase in thoracic kyphosis. Increased lumbar lordosis. Anterior pelvic tilt. Knee hyperexten sion.+ Posterior view: scapula is elevated and outward positioned at left side* Trophic changes: nothing significant * Swelling : nothing significant 5 Agophy: fuser of deltoid and supraspinatus(left) in palpation: Temparature : Afebrile Tenderness : Grade 1 tenderness present on anterior aspect of shoulder stoid Ti ments Left Right Trapezius Mild Mild Sternocleidoma | Mild Mild Pectoralis minor Moderate Mild+ Range of motion assessment: * [Soint Movement [Right Endfeel_ [Left Endfeel Shoulder [Flexion [0-180" | Firm 0110" [Empty Extension | 0-60" Fim’ 030° Empty ‘Abduction [0-180° | Firm O45" Empty Medial [90° Emoty | 20° Empty rotation Lateral [85° Empty | 15° Empty rotationCervical |Leftsidelateral [25° Firm endfeel aa flexion Joint Fight side lateral | 25° Firm endfeel flexion Flexion or Firm endfeel Extension 50° Firm endfeel Right side 60" Firm endfeel rotation Left side os Firm endfeel rotationElbow Left Endfeel | Right Endfeel Flexion 0135" | Soft 0135" | Soft Extension [Relative | Bony BonyWrist Left Endfeel | Right Endfeel Flexion 0-75" Firm o7s | Firm Extension | 0-70" Firm’ 070" Firm Radial [020° Bony (020° Bony deviation Uinar 030" Firm’ 030° Firm deviation+ Joint play: Posterior and inferior glide reduced on left side + Capsular tightness: Posterior and inferior capsule tightness + Shoulder joint GMT Shoulder | Movement | Left Right Flexors | 4at 5 available ROM Extensors | 4 5 Abductors | Bat 5 available ROM+ Elbow and wrist GMT: Elbow Movement [Left Right [Flexors 3 5 TExtensors [5 5 Wrist Flexors 5 5 Extensors [5 5 Radial 5 5 deviators Unnar deviators | 5 5IMT. LEFT. Right. PECTORALIS. (pain) Normal (BOTH STERNAL AND CLAVICULAR) RHOMBOIDS (pain) Normal SeRRATUS Present Womal ANTERIOR DELTOID Coed Nomal UPPER TRAPEZIUS | Good Womal TOWER TRAPEZIUS | (pain) Womal MIDDLE TRAPEZIUS | (pain) Normal TERESWAJOR | Flcker of Nomal TATISIMUS DORST | Ficker of Nomeal contraction+ Limb girth measurement + Left: Arm- 11 inches; Forearm- 8 inches + Right : Arm- 11.3 inches; Forearm- 8 inches + Difference between limb girth of arm is 0.3inches + Resting Position of scapula: * While performing flexion: the patient elevates the arm with scapular retraction in the initial range of flexion there is also elevation of the shoulder in order to take the arm up. * While performing abduction: there is scapular retractionResting position of scapula: LEFT RIGHT Upper [2sinches 2.Sinches Middle |S2inches 3.2inches Lower ‘inches 3.6 inches* Scpulohumeral rhythm- During bilateral flexion of arm the position of scapula Right Left Inferior binches S.inches Middle 3.Sinches a.Binches Upper 33inches 2.7inches* Bilateral Abduction: Right | Left Lower | S.Sinches ‘inches Middle [3.5inches 25 inches Upper 27inches 23 inchesSpecial tests- + Empty can test-negative + Yergason test-negative + Dugas test- negative + Scale (outcome measure) * SPADI SCALE(SHOULDER PAIN AND DISABILITY SCALE) is 76.15% * Total pain score = 39/50*100=78% * Total disability score= 60/80*100=75% * Total SPADI score= 99/130*100=76%ICF: HEALTH CONDITION: ADHESIVE CAPSULITIS Impairment of body functions: Impairment Supportive Clinical findings resoning it Onhistor Pain on activity can be 1)Pain(left — oanes” Because ct ackot shoulder on —ATREST-0/10 synovial uid which Si ATACTIVITY-6/10 —_helpsin lubricating the activity) gap between humerus. and glenoid fossa while doing movement2) Reduced range of motion left shoulder joint Flesion, abduction, medial iateral rotation With reduced joint play(posterior and inferior glide) ‘On ROM assessment 3)Reduced muscle strength ‘On mmt and IMT ‘Asa result of which the ‘capsule of shoulder thickens ewells and becomes tight, Results in pain ‘Capsular tightness and restriction leading to reduced ROM and joint play. Also the patient is apprehensive due to pain. Disuse of muscles due topain Due to faulty posture Results in weakness of muscles Strenght of muscle is reduced‘4) Altered scapulahumeral rhythm ‘On observation Due to restrictionof lenohumeral motion there is compensation of arm elevation, Movement by upward rotation of scapulaStructural impairment: Tightness of On tightness pectoralis minor, assessment trapezius and sternocleidomas toid Disuse of muscles due to pain and faulty posture. Results in adaptive shortening of muscles. Results in tightness of muscles.Posterior and On examination inferior capsule stiffness Inability because of pain Posture(rounde On observation d shoulder, forward head, ‘thoracic kyphosis, lumbar lordosis, left evevation scapula) Disuse ofActivity limitation and participation restriction: * Activities limited + Reason * General tasks and + As these activities cause demands involving stress over the shoulder movements at shoulder _joints and also there is joint like putting and pain on movement as taking off the shirt, these activities will be washing his back over limited to prevent pain head activities, hair washing and combing etc.Contextual factors: + Facilitators * Barriers + Patient is cooperative, + Age motivated, willing to take physiotherapy treatment * Good socio economic status