H & P of CASE #1: A Case of the Shoulder
Alan G. is a 79 y.o male. He is a University Professor and teaches at least 1 day/week (this teaching includes carrying briefcases and writing on a white board).
Mr. G is a very active gentleman. He works out at least an hour a day, 6 days a week: he swam for the University as a student (in the days before googles!), continues to swim, bike, lift weights, use the elliptical, hike, takes Pilates twice/week, etc. As a lay person, he has taken Dr. Avers EDUCATA lecture on Strengthening Principles for the Aging Adult, and one of his goals in life is to finally get to meet Dale — he LOVED that lecture.
Mr. G. is medically sound with no medical co-morbidities. In the past decade he has had bilateral total knee replacements, unilateral total hip replacement, 2 levels (L3/4 and L4/5) lumbar laminectomies, 2 levels of cervical fusion C3/4 and C4/5.
He has a very high pain threshold, and anatomically generated pain that would be reported years earlier by other people, doesn’t even register for him. Throughout his PT history, he has been asked to ‘listen for his pain’. It appears that the lack of knowing of the pain has caused him more anatomical damage as opposed to if he had known it was hurting earlier.
Alan believes strongly in PT. If anything, this individual does too much — never too little.
Alan was referred by his internist with R shoulder pain. He reports that he can no longer carry his briefcase in his right hand nor can he lift his arm to write on the white board at school. (Additionally, his back is bothering him again.) Here is a brief summary of clinical findings:
- Shoulder pain of ‘10’ with active motion (and for this patient, that would be equal to about ‘100’ in another patient), pain at rest is ‘7’ and pain with passive motion is ‘8-9’.
- Total disruption of sleep – Alan is unable to sleep due to the pain and due to the fact that the pain mandates that he only sleep on his back (not his side)
- Marked atrophy in Supraspinatus
- Scapular winging (see image, below)
- Noted avulsion bilaterally of long head of biceps
- Strength and ROM
- Sensation is normal
|Flexion and abd||25 degrees||90 degrees||F+|
|ER||5-10 degrees||90 degrees||F|
So, now it is YOUR TURN. What would YOU do?