Subjective

Pain and Discomfort

 Site: right anterolateral shoulder

 Onset: gradual, intermittent
 Character: dull
 Radiation: remains local
 Associations: generalized fatigue
 Timing: worsens throughout the day
 Exacerbating/Relieving Factors: worsens with activity, particularly with
elevation of the right arm and improves with rest
 Severity: VAS = 6/10 (average), 7/10 (worst), 0/10 (best)

Objective

Observation

POSTURE:

 Upper Extremity Alignment (standing) = landmarks are level

 Pelvic Alignment (standing) = ASIS/PSIS level, Right iliac crest slightly
higher vs Left
 Lower Extremity Alignment (standing) = Right greater trochanter, tibial
tuberosity, fibula, lateral malleolus are slightly higher vs Left
 Spinal Alignment (standing) = slight left lumbar curve
 Tone: Mild atrophy noted in right lower extremity compared to left
lower extremity

GAIT ANALYSIS:
Overall the patient exhibits a reduced gait speed with a short step length on
the right side. It is accompanied by a right foot drop during left leg single limb
support, particularly evident from initial swing to the loading response of the
right limb. It is followed by a slight compensatory left-sided trunk lean, right
pelvic hiking, and circumduction gait of the right hip in order to assist with
foot clearance. There is an occasional but infrequent foot slap observed in the
right foot between initial contact and loading response. The patient is
cognizant of the abnormalities in his gait and the compensatory strategies that
he is employing.

RESPIRATORY ASSESSMENT:
The patient exhibits a largely normal diaphragmatic breathing pattern with
some recruitment of apical muscles noted. Auscultation was unremarkable
with some reduced breath sounds and fine inspiratory crackles in the lower
lobes.

Neurological Testing

 Dermatomes and sensory testing (superficial and cortical) normal

bilaterally
 Myotomes
 C4 Shoulder Elevation: Left 5/5, Right 3/5
 C5 Shoulder Abduction: Left 5/5, Right 2+/5
 L3 Knee Extension: Left 5/5, Right 3+/5
 L4 Ankle Dorsiflexion: Left 5/5, Right 3/5
 All other myotomes normal
 Reflexes:
 U/E LMN reflexes: All 2 (normal)
 L/E LMN (Left): All 2(normal)
 L/E LMN (Right): Patellar and Achilles Hyporeflexia 1
 UMN: Negative Babinski and Hoffman's sign

 Cranial Nerve Testing:

 Cranial nerve testing revealed no abnormalities

Range of Motion (ROM)

 Shoulder
 Flexion = AROM: 95° on Right vs 174° on Left / PROM: 110° on
Right vs 180° on Left
 Abduction = AROM: 80° on Right vs 170° on Left / PROM: 102°
on Right vs 176° on Left
 Extension/Internal Rotation/External Rotation= WNL bilaterally
 Elbow + Wrist + Hip
 All Joint ROM = WNL bilaterally
  Knee
 Flexion = WNL bilaterally
 Extension = AROM: -10° on Right vs 0° on Left / PROM: WNL
bilaterally
 Ankle
 Dorsiflexion = AROM: 5° on Right vs 18° on Left / PROM: WNL
bilaterally
 Plantarflexion/Eversion/Inversion = WNL bilaterally

Manual Muscle Testing (MMT)

 Shoulder
 Flexion = 2+/5 on Right vs 5/5 on Left
 Abduction = 2+/5 on Right vs 5/5 on Left
 Extension/Internal Rotation/External Rotation= 5/5 bilaterally
 Elbow + Wrist + Hip
 All Joint ROM = 5/5 bilaterally
 Knee
 Flexion = 5/5 bilaterally
 Extension = 3+/5 on Right vs 5/5 on Left
 Ankle
 Dorsiflexion = 3/5 on Right vs 5/5 on Left
 Plantarflexion/Eversion/Inversion = 5/5 bilaterally

Special Tests

 Negative special tests for bilateral shoulder

impingement: Neers, Hawkins-Kennedy, Supraspinatus "Full/Empty
Can" Test
 Negative Drop Arm test bilaterally
 Positive "Hornblowers" and "Lift Off" test indicating possible
infraspinatus, teres minor and subscapularis lesion (right side)

Self-Reported Outcome Measures

 Activity-specific Balance Confidence (ABC) Scale : 40.62%

 Fatigue Severity Scale (FSS): 48/63
Functional Outcome Measures

 Timed-Up-and-Go (TUG): 18 seconds

 10 Metre Walk Test (10MWT): 13 seconds
 12 Minute Walk Test (12MWT): 504 metres
 Disability of the Arm, Shoulder, and Hand (DASH): 75