CASE PRESENTATION

Presented by: Sonali Joshi

Roll No. 1820720
MPT 3rd Semester (Sports
Injuries)
Demographic details

Name: Mr. Kamaljeet

Age: 30 years
Gender: Male
Occupation: Clerk
Address : Barara, Ambala
Date of assessment : 15/07/2021
Chief complaint

Patient presented with the complaint of pain and limitation in shoulder

movements since 2 weeks
History of present illness:

The patient was apparently well around 2 months back, when on 2nd of
July he suddenly met with an accident while riding a bike and fell on his
left side with the hyper-abducted shoulder leading to dislocation with
no episode of loss of consciousness
Patient was immediately taken to the emergency of Maharishi
Markandeshwar Hospital (MMH), where he was given injections for
pain relief and sedation, meanwhile the shoulder was also
conservatively reduced
During the x-ray examination the reduced shoulder again displaced
from its position and was upheld in the due position with an arm
sling. Surgical procedure was advised to the patient with which
patient was not agreeing to, therefore he took leave and went home
with the same sustained condition of the shoulder
On 5th of July due to unbearable pain in shoulder the patient again
went to the hospital in ambala cantt, where he was initially managed
for pain via analgesics followed by immediate reduction of the
shoulder conservatively within a day
On 15th of july the patient visited the Physiotherapy department of
Maharishi Markandeshwar University, MM (DU) with the primary
complaint of persistant pain and limitation in movements around the
shoulder
Pain History
• Side: Left
• Site: Localized around the shoulder joint
• Onset: Sudden
• Duration: Felt consistently since last 2 weeks
• Type: Non-radiating
• Aggravating factors: Attempting sudden movements at shoulder joint
• Relieving factors: None
• Intensity: 9/10 on NPRS
History of past illness
• Patient had no similar kind of event or injury reported in the past
Medical History
• Not relevant
Pharmacological History
• Patient was taking analgesics, antibiotic and NSAIDs for the present
condition
Surgical History
• None
Personal History
• No history of drug abuse and alcohol intake
Family History
• Not relevant
Socio-economic History
• According to Modified Kuppuswamy Socio-economic Scale (MKSS),
score is 12 which belongs to lower middle socio-economic class
 On Observation
a) General
Posture
R L L R
Anterior view Lateral view Posterior view
Eyes: Not equidistant (left eye is Lateral line running through tragus
higher than the other eye) passing anteriorly through the
humeral head
Ear: Right earlobe lower than the Shoulders: Protracted Shoulders: Asymmetrical,
other side decreased space between left
earlobe
Shoulders: Asymmetrical, Scapula: Inferior angle of scapula in
decreased space between left right side is
earlobe and shoulder than the
other side, non equidistant AC
joints
Hip: Iliac crest and ASIS of right side
lower than the other side
Body asymmetry: Asymmetrical
mid-sagittal line through nasal
septum, umblicus and symphysis
pubis
a) General
• BMI: 25.59 kg/m2

b) Local
• Swelling: Not present
• Any scar: Present (Left shoulder, around acromion process of
scapula: 5cm long and 3cm wide)
• Deformity: Not present
Scar (Left shoulder, around AC joint)
On Palpation:

• Tenderness: Grade 2 (around the glenohumeral joint)

• Edema : Not present
On Examination
Motor:
Range of Motion: (Left)

Shoulder Elbow Wrist

Flexion 0-25 degree Flexion 0-130 degree Flexion 0-70 degree
Extension 0-20 degree Extension 130-0 degree Extension 0-80 degree
Abduction 0-25 degree Pronation 0-70 degree Radial deviation 0-20 degree
(forearm)
Medial rotation 0-10 degree Supination 0-75 degree Ulnar deviation 0-35 degree
Lateral rotation 0-15 degree

Cervical
Flexion 0-40 degree
Extension 0-60 degree
Lateral flexion Right 0-25 degree Left 0-35 degree
Lateral rotation Right 0-65 degree Left 0-70 degree
Manual Muscle Testing:
Muscle Grade
Serratus anterior Grade 2
Trapezius (upper) Grade 4
Trapezius (middle and lower) Grade 2
Rhomboids Grade 2
Ant. Deltoid, Corachobrachialis Grade 2
Middle Deltoid, Supraspinatus Grade 2
Post Deltoid, Teres major, Latissimus dorsi Grade 2
Pectoralis major Grade 2
Infraspinatus and teres minor Grade 2
Subscapularis Grade 2
Biceps brachii, Brachioradialis, Brachialis Grade 3
Triceps brachi Grade 2
Supinators Grade 4
Pronator teres and Pronator quadratus Grade 4
Muscle Length Testing
Muscle (Left) Tightness
Upper trapezius present
Levator Scapulae present
Scalene (anterior) Present
Scalene (middle) Present
Scalene (posterior) Present
Sternocleidomastoid Present
Pectoralis major and minor Present
Sensory:

Superficial- Intact Deep-Intact

• Pain • Proprioception
• Touch • Kinesthesia
• Pressure • Stereognosis
• Temperature • Graphesthesia
• 2 point discrimination
• Tactile localization
Reflex Testing:

Grade
Biceps (Left) Normal
Triceps (Left) Normal
Brachioradialis (Left) Normal
Outcome measures
1. Numeric Pain Rating Scale (NPRS)
2. Shoulder Pain and Disability Index (SPADI)
Numeric Pain Rating Scale
Current pain: 9
Worst pain (24 hours) : 10
Least pain (24 hours) : 8
Score (mean value) : 9
Shoulder Pain and Disability Index (SPADI)

Total score: 101 (77.7%)

Differential Diagnosis

• Secondary adhesive capsulitis

• Acromioclavicular joint dysfunction
Investigation

Plain Radiograph: AP view

Findings

• Irregularities on the cortex of bone (humeral head)

• Hill-Sachs lesion
• Decrease in distance between the AC joint
• Decreased coracoclavicular distance
• Internally rotated humerus
 Diagnosis

Secondary adhesive capsulitis

Adhesive capsulitis of the shoulder: Review of pathophysiology and current clinical treatments, J of shoulder and elbow, 2010;5(4): 266-273
Problem list
• Pain around the shoulder region
• Limitation in movements around the shoulder
• Decreased muscle strength
• Incorrect posture
Goals

Short term: Long term:

• To decrease pain • To restore strength
• To improve ROM
• To reduce tightness around the
involved structures
• Postural correction
Physiotherapy Management

Week 1:
• Hydrocollator pack- 15 min (around shoulder joint)
• Interferential therapy- 15 min, 60 hz
• Subscapularis, pectorals and upper trapezius muscle release
• AC joint mobilization (ant glide)- 60 glides, 2 sets (Grade 3)
• Scapular mobilization- 10sets, 10 reps
• GH joint maitland mobilization (inferior glide)- 30 glides, 2 sets (Grade 1)
• Shoulder mobility exercises (within available ROM)

Effectiveness of scapular mobilization versus myofascial release of subscapularis on pain, ROM and function in subjects with chronic frozen shoulder: A comparative
study, Int J of health sciencesand research, 2019
Week 2:
• Hydrocollator pack- 15 min
• Interferential therapy- 15 min, 60 hz
• Subscapularis muscle release
• Muscle Energy Technique (Pectorals, upper trapezius)- 8sec hold, 30 sec
relax, 3-4 times
• Scapular mobilization
• AC joint mobilization (anterior glide)- 30 glides, 3 set (grade 4)
• GH joint mobilization (inferior and posterior)- 30 glides, 3 set (grade 2)
Week 3:
• Hydrocollator pack- 15 min
• Subscapularis muscle release
• Muscle Energy Technique (Pectorals, upper trapezius)- 8sec hold, 30 sec
relax, 3-4 times
• Scapular mobilization
• AC joint mobilization (anterior glide)- 60 glides (grade 4) (alternative days)
• GH joint mobilization (inferior glide, posterior glide)- 30 glides, 3 set (grade
2 and 3)
Follow up:
Range of Motion:

Shoulder Elbow Wrist

Flexion 0-85 degree Flexion 0-140 degree Flexion 0-70 degree
Extension 80-0 degree Extension 130-0 degree Extension 0-80 degree
Abduction 0-90 degree Pronation 0-75 degree Radial deviation 0-20 degree
(forearm)
Medial rotation 0-30 degree Supination 0-80 degree Ulnar deviation 0-35 degree
Lateral rotation 0-35degree

Cervical
Flexion 0-45 degree
Extension 0-64 degree
Lateral flexion Right 0-35 degree Left 0-40 degree
Lateral rotation Right 0-70 degree Left 0-74 degree
Manual Muscle Testing:
Muscle Grade
Serratus anterior Grade 3
Trapezius (upper) Grade 4
Trapezius (middle and lower) Grade2
Rhomboids Grade 2
Ant. Deltoid, Corachobrachialis Grade 3
Middle Deltoid, Supraspinatus Grade 3
Post Deltoid, Teres major, Latissimus dorsi Grade 3
Pectoralis major Grade 2
Infraspinatus and teres minor Grade 3
Subscapularis Grade 3
Biceps brachii, Brachioradialis, Brachialis Grade 4
Triceps brachi Grade 3
Supinators Grade 4
Pronator teres and Pronator quadratus Grade 4
NPRS
Current pain: 4
Worst pain (24 hours) : 6
Least pain (24 hours) : 2
Score (mean value) : 4
 Week 4:
• Hydrocollator pack- 15 min
• Subscapularis muscle release
• Muscle Energy Technique (Pectorals, upper trapezius, scalene, SCM)-
8 sec hold, 30 sec relax, 3-4 times
• Scapular mobilization
• GH joint mobilization (inferior glide, posterior glide)- 30 glides, 3 set
(grade 3)
• Spencer’s technique
• Scapula setting exercise (lower trapezius and serratus anterior)

Effect of spencer muscle energy technique on pain and functional disability in cases of adhesive capsulitis of shoulder joint, Int archives of integrated medicine, 2016
Spencer’s technique
Week 5:
• Hydrocollator pack- 15 min
• Subscapularis muscle release
• Muscle Energy Technique (Pectorals, upper trapezius, SCM)- 8sec hold, 30 sec
relax, 3-4 times (alternative days)
• Scapular mobilization
• GH joint mobilization with movement (inferior glide)- 30 glides, 3 set (grade 4)
• Spencer’s technique
• Scapula setting exercise (lower trapezius and serratus anterior)
• Shoulder weight bearing exercises (push up against wall, push ups in 4-point
kneeling)- 10 reps
Mobilization with movement (Inferior glides)
Week 6:
• Hydrocollator pack- 15 min
• Subscapularis muscle release
• Muscle Energy Technique (Pectorals, upper trapezius, SCM)- 8sec hold, 30 sec
relax, 3-4 times (alternative days)
• Scapular mobilization
• AC joint mobilization (anterior glide)- 60 glides (grade 4)
• GH joint mobilization with movement (inferior glide)- 30 glides, 3 set (grade 4)
• Spencer’s technique
• Scapula setting exercise (lower trapezius and serratus anterior)
• Shoulder weight bearing exercises (push up against wall, push ups in 4-point
kneeling)- 10 reps
Follow up:
Range of Motion:

Shoulder Elbow Wrist

Flexion 0-130 degree Flexion 0-145 degree Flexion 0-70 degree
Extension 130-0 degree Extension 130-0 degree Extension 0-80 degree
Abduction 0-140 degree Pronation 0-75 degree Radial deviation 0-20 degree
(forearm)
Medial rotation 0-45 degree Supination 0-80 degree Ulnar deviation 0-35 degree
Lateral rotation 0-60degree

Cervical
Flexion 0-50 degree
Extension 0-70 degree
Lateral flexion Right 0-40 degree Left 0-42 degree
Lateral rotation Right 0-75 degree Left 0-75 degree
Manual Muscle Testing:
Muscle Grade
Serratus anterior Grade 3
Trapezius (upper) Grade 4
Trapezius (middle and lower) Grade 3
Rhomboids Grade 3
Ant. Deltoid, Corachobrachialis Grade 4
Middle Deltoid, Supraspinatus Grade 4
Post Deltoid, Teres major, Latissimus dorsi Grade 3
Pectoralis major Grade 3
Infraspinatus and teres minor Grade 4
Subscapularis Grade 4
Biceps brachii, Brachioradialis, Brachialis Grade 4
Triceps brachi Grade 4
Supinators Grade 5
Pronator teres and Pronator quadratus Grade 5
NPRS
Current pain: 1
Worst pain (24 hours) : 2
Least pain (24 hours) : 0
Score (mean value) : 1
Shoulder Pain and Disability Index (Post Intervention)
Total score: 24 (18.5%)
THANK YOU