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PT ORTHO CASE STUDY (SAMPLE) Shoulder Dislocation.pptx
- 1. PT ORTHO CASESTUDY (SAMPLE) PREPARED BY SOMA BALAJI PT MSK & SPORTS
- 2. Question 1. 60 yearsold female had an anterior dislocation of right shoulder and immobilized in the position of adduction and medial rotation for 14 weeks. At present she complaints of pain on shoulder elevation in both frontal and sagittal plane. Explain in detail about the appropriate objective examination and plan of care for her.
- 3. Patient Details: •Patient Name:Mrs. X •Age/Gender: 60 years / Female •Occupation: XYZ •Chief Complaint: •Pain in the right shoulder during elevation in both the frontal and sagittal planes. •Stiffness and limited mobility after prolonged immobilization for 14 weeks post anterior dislocation.
- 4. Detailed History &Screening Mechanism of Injury: •History of anterior shoulder dislocation, commonly occurring due to external rotation and abduction trauma. •Immobilization for 14 weeks in adduction and medial rotation, leading to soft tissue contractures, muscle weakness, and joint stiffness. Medical/Surgical History: •No mention of previous shoulder injuries or surgeries. •Screen for osteoporosis, diabetes, and cardiovascular conditions due to age-related concerns. Red Flag Conditions (Warranting Referral)? •No obvious systemic red flags like fractures, infections, or malignancies. •Musculoskeletal red flags: Possible frozen shoulder (adhesive capsulitis) due to prolonged immobilization.
- 5. Yellow Flags (AffectingPrognosis) •Yes, prolonged immobilization can lead to pain sensitization, fear-avoidance behavior, and psychosocial impact (e.g., anxiety about movement). Blue/Black Flags (Occupational/Social Impact) •Yes, functional impairment affecting daily activities like dressing, lifting, and overhead tasks.
- 6. Neural & VascularInvolvement Screening Neural Tissue Involvement? •Yes, possible axillary nerve involvement due to anterior dislocation. •Symptoms: Weakness in deltoid & teres minor, numbness around lateral shoulder (C5 dermatome). Neurological Exam/Neural Tissue Mobility Test? •Yes, needed to assess nerve integrity and mobility. Dermatomes & Myotomes Examination? •Yes, particularly C5-C6. •C5 Myotome: Shoulder abduction & elbow flexion strength. •C6 Myotome: Wrist extension. Vascular Structure Involvement? •Unlikely, but check radial pulse for vascular integrity due to proximity to brachial plexus. Vascular Exam? •No, unless there are symptoms like coldness, discoloration, or diminished pulse.
- 7. Pain Assessment &Functional Impact •Site & Spread: Pain localized in anterior shoulder with spread to lateral deltoid. •Behavior of Symptoms: Pain increases with shoulder flexion & abduction. •Onset: Post-immobilization stiffness & muscular disuse. •Duration: Chronic (14 weeks post-injury). •Character: Deep aching pain with sharpness at end ranges. •Aggravating Factors: Lifting arm, overhead activities, external rotation. •Relieving Factors: Rest, heat therapy, gentle movement.
- 8. 24-Hour Pattern: •Morning stiffnessdue to immobility. •Increased pain with activity. Night pain if lying on affected side. Severity (S): 6/10 on NPRS (during elevation). Irritability (I): Moderate (pain lingers post-activity). Nature (N): Mechanical (joint stiffness, muscle weakness).
- 9. Hypothesis & DifferentialDiagnoses 1. Primary Hypothesis: •Post-traumatic adhesive capsulitis due to prolonged immobilization, leading to capsular tightness and muscular weakness. •Rotator cuff dysfunction, particularly subscapularis tightness limiting external rotation. 2. Alternative Hypotheses: •Axillary nerve involvement → Weak deltoid, sensory changes. •Glenohumeral joint stiffness → Inferior capsule tightness. •Subacromial impingement due to altered scapulohumeral rhythm.
- 10. Physical Examination 1. PosturalAnalysis •Forward head posture, rounded shoulders, compensatory scapular protraction. •Muscle asymmetry → Weak posterior deltoid, overactive pectoralis major/minor. 2.Myofascial Assessment •Trigger points in upper trapezius, subscapularis, and deltoid. •Muscle tightness in pectorals, latissimus dorsi, and internal rotators.
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- 12. 4. Joint Play(Articular) •Anterior capsule tightness → Reduced posterior glide of humeral head. •Inferior capsule restriction → Limited inferior glide. 5. Muscle Performance Assessment •Weak deltoid (C5-axillary nerve). •Weak rotator cuff (especially external rotators). •Overactive pectorals and subscapularis. 6. Functional Assessment (ICF Classification) •Body Part: Right shoulder. •Activity Limitation: Overhead tasks, dressing. •Participation Restriction: Limited household/work activities.
- 13. Special Tests 1. Neer’s& Hawkins-Kennedy Test (rule out impingement). 2. Load and Shift Test (assess anterior instability). 3. Sulcus Sign (inferior instability). 4. Drop Arm Test (rotator cuff function).
- 14. Problem Listing 1. Capsulartightness (anterior & inferior). 2. Weak rotator cuff (especially external rotators). 3. Altered scapulohumeral rhythm. 4. Pain and functional limitation in elevation.
- 15. Treatment Plan Goals • Reducepain & stiffness. • Improve ROM & muscle strength. • Restore functional movement patterns.
- 16. Intervention 1. Pain Relief:Moist heat, TENS for pain modulation. 2. Joint Mobilization: Grade III-IV anterior & inferior glides. 3. Stretching: Pectorals, subscapularis. 4. Strengthening: Rotator cuff (isometric → isotonic). 5. Neuromuscular Re-education: Scapular stability drills. 6. Functional Training: Assisted reaching, wall slides.
- 17. 3. Patient Education •Importanceof progressive ROM exercises. •Avoid compensatory movements (scapular hike). 4. Home Exercise Program (HEP) •Pendulum exercises. •Self-stretching for anterior capsule. •TheraBand ER strengthening. 5. Follow-up •Reassess ROM & pain weekly. •Progress to functional strength training in 4-6 weeks.