OMPTS Weekend 3 Shoulder Case

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This topic contains 10 replies, has 7 voices, and was last updated by  Steven Lagasse 2 days, 17 hours ago.

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  • #8040

    Steven Lagasse
    Participant

    Please speak to the following questions

    Working hypothesis and differential diagnosis:
    a.) What is your working hypothesis regarding this patient?
    b.) What are your next 2-3 differentials? (Ranking order)

    Special testing:
    a.) What are your thoughts regarding the special testing chosen for this patient?
    b.) Do you feel the treating therapist should have performed any additional tests? If so, what? If not, why?

    Clinical Pattern:
    a.) Does this patient’s presentation fit a clinical pattern?
    b.) Briefly, what are your thoughts regarding his headache?

    Evolution of Patient’s Symptoms:
    a.) What are your thoughts regarding the patient’s symptoms starting insidiously, progressing over time, and finally being augmented by a MOI.
    b.) Are there any red flags?

    Treatment
    What Manual therapy and HEP would you give the patient on the first day?

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  • #8044

    Steven Lagasse
    Participant

    The patient is a 22-year-old male

    My apologies for leaving this information out of the PDF!

  • #8048

    pbarrettcoleman
    Participant

    Working hypothesis and differential diagnosis:
    a.) What is your working hypothesis regarding this patient?
    – Cervical Discogenic pain with torn shoulder labrum.

    b.) What are your next 2-3 differentials? (Ranking order)
    – Upper Cervical Facet, Mid-Cervical Facet, Thoracic
    – RTC Tendinopathy, Impingement, RTC Tear

    Special testing:
    a.) What are your thoughts regarding the special testing chosen for this patient?
    – I think the cervical radiculopathy cluster was warranted.
    – While the impingement type tests were a mixed bag (arc, ER, Scap assist), I think it helped clear out some of my differentials and gave me a big indicator of treatment options with scap assist being +.
    -Given MOI description, I think it was a good choice to have done the apprehension test.

    b.) Do you feel the treating therapist should have performed any additional tests? If so, what? If not, why?

    – I know there are a thousand other labral tests, but finding that he does have (+) apprehension, I wonder if it would have been worthwhile to try and reproduce it with other ones? I’m not sure this would have really changed your treatment plan, just food for thought.

    Clinical Pattern:
    a.) Does this patient’s presentation fit a clinical pattern?
    – I feel comfortable saying the scapular pain fits a discogenic referral and the provocative factors back that up. The shoulder is a mixed bag and I’m not sure I feel as confident saying he’s just one category: it looks a little labral, a little scap dyskinesia, a little muscular.

    b.) Briefly, what are your thoughts regarding his headache?
    – Kind of a curveball with everything else going on, but you reproduced it which makes me feel it is more mechanical. I bet if you did some CPA/UPAs, you could find which of the upper cervical are involved.

    Evolution of Patient’s Symptoms:
    a.) What are your thoughts regarding the patient’s symptoms starting insidiously, progressing over time, and finally being augmented by a MOI.

    I think that’s how most of us live our lives: we have some aches and pains that aren’t too bad so we ignore them; they eventually get harder to ignore; then we have an event that puts us over the top and we go see someone.

    b.) Are there any red flags?
    – None that I can see.

  • #8050

    awilson12
    Participant

    Working hypothesis and differential diagnosis:
    a.) What is your working hypothesis regarding this patient?
    – labral tear with cervicothoracic myofascial involvement (upper trap and paraspinals)
    b.) What are your next 2-3 differentials? (Ranking order)
    – Mid-cervical disc pathology
    – RTC tendinopathy/tear

    Special testing:
    a.) What are your thoughts regarding the special testing chosen for this patient?
    – It was a bit all over the place but can see where you are trying to bring in various tests to help rule in and rule out differentials
    b.) Do you feel the treating therapist should have performed any additional tests? If so, what? If not, why?
    – With potential labral pathology looming and a traction mechanism of injury (I think… might just be visualizing the injury incorrectly) another labral test to consider adding is biceps load II

    Clinical Pattern:
    a.) Does this patient’s presentation fit a clinical pattern?
    – I don’t feel like there is a very clear clinical pattern for just one area of involvement; seems more like there is a mixed bag of shoulder and cervical/myofascial
    b.) Briefly, what are your thoughts regarding his headache?
    – I would want to know more information (i.e. location and aggravating factors) and if that presentation is in line with objective findings

    Evolution of Patient’s Symptoms:
    a.) What are your thoughts regarding the patient’s symptoms starting insidiously, progressing over time, and finally being augmented by a MOI.
    – He potentially could have had an underlying shoulder and/or neck pathology that predisposed him to a specific MOI
    b.) Are there any red flags?
    – doesn’t seem like it

    Treatment:
    What Manual therapy and HEP would you give the patient on the first day?
    – manual: scapular mobilization because of pain alleviation with scapular assist test, STM
    – HEP: row with (B) ER and prone scapular retraction (“I’s”) to facilitate lower trap activation

  • #8054

    helenrshep
    Participant

    Working hypothesis and differential diagnosis:
    a.) What is your working hypothesis regarding this patient? GH instability/labrum pathology
    b.) What are your next 2-3 differentials? (Ranking order) thoracic outlet, cervical radiculopathy, RTC tendinopathy

    Special testing:
    a.) What are your thoughts regarding the special testing chosen for this patient? I think it was good, I might have included load and shift and crank to further assess instability symptoms.
    b.) Do you feel the treating therapist should have performed any additional tests? If so, what? If not, why? See above, also maybe Jobe to look at RTC involvement.

    Clinical Pattern:
    a.) Does this patient’s presentation fit a clinical pattern? Not a true pattern – seems “nerve-y” possibility from shoulder or neck.
    b.) Briefly, what are your thoughts regarding his headache? I think it’s worth asking him if it seems related to his shoulder pain at all. He might not have indicated it on the body chart because the patient doesn’t believe it’s related, up to us to determine if that’s actually the case.

    Evolution of Patient’s Symptoms:
    a.) What are your thoughts regarding the patient’s symptoms starting insidiously, progressing over time, and finally being augmented by a MOI. – I feel like this is more common than we actually think. Symptoms tend to be “bucket effect” where it’s a lot of things that contribute to the manifestation of symptoms and then a “final straw.”
    b.) Are there any red flags? I don’t think so.

    Treatment
    What Manual therapy and HEP would you give the patient on the first day? manual facilitation of scapular upward rotation with MWM technique in scaption; did you look at scapular motions in sidelying? seems like a scap mob could be worthwhile depending on what that revealed; prone ITY for HEP

  • #8063

    lacarroll
    Participant

    Working hypothesis and differential diagnosis:
    a.) What is your working hypothesis regarding this patient?
    – Labral pathology with resultant GH instability
    b.) What are your next 2-3 differentials? (Ranking order)
    – Secondary impingement
    – Mid-lower cervical facet
    – RTC tendinopathy/partial thickness tear

    Special testing:
    a.) What are your thoughts regarding the special testing chosen for this patient?
    – I feel like the special tests were a little scattered, but I think the ones chosen definitely helped rule out different systems.
    b.) Do you feel the treating therapist should have performed any additional tests? If so, what? If not, why?
    – I think that a few more labral tests could have been utilized just to have more information on the integrity of the structure and maybe see if there is any biceps involvement there as well.

    Clinical Pattern:
    a.) Does this patient’s presentation fit a clinical pattern?
    – I definitely feel like this isn’t a very clean-cut case. There seems to some shoulder stuff going on with some neck stuff, especially with one complaint being more chronic and one being more acute.
    b.) Briefly, what are your thoughts regarding his headache?
    – I think it’s worth asking him more about onset and frequency, especially with reproduction of it during the cervical screen.

    Evolution of Patient’s Symptoms:
    a.) What are your thoughts regarding the patient’s symptoms starting insidiously, progressing over time, and finally being augmented by a MOI.
    – I think it’s a pretty normal progression, especially for a younger guy with a manual labor type job. He probably thought it would get better eventually until something else happened and it got noticeably worse.
    b.) Are there any red flags?
    – Not that I can think of

    Treatment
    What Manual therapy and HEP would you give the patient on the first day?
    – Manual: STM to periscapular area, scapular mobs with movement
    – Prone Ys, Ts, rows; seated no monies with band

    • This reply was modified 4 days, 18 hours ago by  lacarroll.
  • #8065

    Working hypothesis and differential diagnosis:
    a.) What is your working hypothesis regarding this patient?
    Cervical disc pathology and Labrum tear
    b.) What are your next 2-3 differentials? (Ranking order)
    Cervical facet artrhopathy
    Subacromial impingement syndrome
    Thoracic facet arthropathy
    Special testing:
    a.) What are your thoughts regarding the special testing chosen for this patient?
    Good cervical screening and shoulder testing. Impingement was on my differential so I like that line of testing.
    b.) Do you feel the treating therapist should have performed any additional tests? If so, what? If not, why?
    Cervical – Complete the cluster with distraction
    Shoulder – Other labrum tests: Crank, grind, biceps load
    Clinical Pattern:
    a.) Does this patient’s presentation fit a clinical pattern?
    No clear pattern here. The neck seems to be driving most present symptoms, but not in one direction that you can truly differentiate disc from facet.
    b.) Briefly, what are your thoughts regarding his headache?
    Interesting that mid cervical quadrants reproduced the headache. Would have liked to see a CFRT to check upper c/s involvement
    Evolution of Patient’s Symptoms:
    a.) What are your thoughts regarding the patient’s symptoms starting insidiously, progressing over time, and finally being augmented by a MOI.
    The insidious onset with UE movements exacerbating makes me think this case has a strong cervical component.
    b.) Are there any red flags?
    None
    Treatment
    What Manual therapy and HEP would you give the patient on the first day?
    MT: L foraminal opening via R SB PPIVM/PAIVM
    TherEx: either SA or lower trap activation to simulate scap assist test (test one, if it works give it, if it doesn’t, try the other.

  • #8066

    Steven Lagasse
    Participant

    A lot of great answers rolling in. Thanks, everyone!

    Full disclosure, this is far from a perfect evaluation- there were questions left unasked, tests not performed, and body regions that were, unfortunately, neglected. Although you’ll all hear more about the case Saturday, might anyone have specific questions? I will do my best to provide answers!

    • #8068

      awilson12
      Participant

      Don’t think there is such thing as a perfect evaluation just about ever!

      Feel free to defer any question if it is already a part of your discussion for Saturday, but just a few things I was curious about-

      Did all of the areas have the same aggravating and easing factors and could you/did you establish the relationship between all of them? Was there anything in particular that for sure aggravated all of the symptoms?

      You mentioned irritability was min-mod, could you elaborate on this?

      You touched on PAM being non-painful and AP “feeling good”; were there any limitations there?

      There were areas that were TTP but did any of them specifically reproduce this patients pain?

  • #8069

    breynolds
    Participant

    Working hypothesis and differential diagnosis:
    a.) What is your working hypothesis regarding this patient?
    1)cervical discogenic dysfunction with acute rotator cuff tear

    b.) What are your next 2-3 differentials? (Ranking order)
    1) labral tear, instability
    2) C6/C7 facet arthropathy

    Special testing:
    a.) What are your thoughts regarding the special testing chosen for this patient?
    -I feel as though you did special tests for both cervical and shoulder which is good but did not perform enough of each cluster or enough to better help rule out or rule in a specific possible diagnosis. For example you performed two labral test and then two impingement tests, and two radiculopathy tests.

    b.) Do you feel the treating therapist should have performed any additional tests? If so, what? If not, why?
    Cervical – distraction and compression
    Shoulder – Load and shift, sulcus, active compression, ER ROM and strength,
    AC and SC – screen to rule out
    Palpation-which periscapular musculature (any referral/tingling associated w/ palpation)

    Clinical Pattern:
    a.) Does this patient’s presentation fit a clinical pattern?
    At this point, I don’t see a clinical pattern but definitely can see the puzzle pieces fall in to place especially with some more testing.

    b.) Briefly, what are your thoughts regarding his headache?
    Hard to tell with information given. If the headache has been before the MOI it may be cervical related. If after the MOI, it may be related to muscular compensation d/t the shoulder injury. With flexion as well as L side bend it makes me think it may be myofascial-related.

    Evolution of Patient’s Symptoms:
    a.) What are your thoughts regarding the patient’s symptoms starting insidiously, progressing over time, and finally being augmented by a MOI.
    I believe they are two different injuries that are in close proximity and therefore the symptoms may be overlapping.

    b.) Are there any red flags?
    Not that I can see.

    Treatment
    !) periscapular strengthening/neuro reed – prone Y’s/T’s to assist in decreasing anterior tipping
    2) STM to periscapular musculature
    3) Posture education

    • This reply was modified 2 days, 17 hours ago by  breynolds.
  • #8070

    Steven Lagasse
    Participant

    Anna:

    Did all of the areas have the same aggravating and easing factors and could you/did you establish the relationship between all of them? Was there anything in particular that for sure aggravated all of the symptoms?

    Great question – this will be addressed tomorrow. However, to give you an answer, no. I failed to map these. Reflecting on this, I should have been more comprehensive in asking which tests provoked which symptoms. I do not believe one test reproduced all symptoms.

    You mentioned irritability was min-mod, could you elaborate on this?

    This patient had a very low baseline level of pain, however, the evaluation quickly elevated those pain levels (5-7 / 10 on NPRS). After about a minute his pain would return to baseline. I felt this warranted min to mod irritability.

    You touched on PAM being non-painful and AP “feeling good”; were there any limitations there?

    AP to the right GHJ felt stiff compared to the contralateral side.

    Some areas wereThere were areas that were TTP but did any of them specifically reproduce this patients pain?

    Right periscapular musculature and upper trap

    Thanks for the questions!

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