UCP/AL/11/190H.A.A Nilakshi

• Subjective examination• Name – Mr. Warnasuriya• Age - 46 years• Gender - male• Occupation – school teacher• Address - Gampaha• Civil status – married • Family - 2 children• Present complain - pain in left upper arm and forearm • Where is exact location of pain - deltoid muscle insertion area (more)• Type of pain - dull ache pain • Onset – gradual

• At what time pain is more – at night & cold weather • Behaviour of pain - constant pain over few months & activities of

arm increase pain, can’t lie on affected arm side• Measuring of pain using numerical pain scale - pt complained his

pain level number is 8• Hx of present complains – 4 months ago fallen and knock his shoulder

on wall • Past medical Hx - diabetics + hypertension –• Past surgical Hx –Nil• X-ray - not taken

• Objective examination• Observation • anterior view - left shoulder elevated • Lateral view - rounded shoulders protruded chin no colour changes in skin around left shoulder • Left arm swing is less in walking • Muscle wasting on deltoid area• Palpation temperature normal muscle spasm in left side upper trapezius area pain increase with palpation• All the movements are limited in left side shoulder compared

with right side

• But cervical and elbow movements are normal• Sensation - normal left side arm • Numbness – Nil • (degrees) AROM PROM• Flexion 85 130• Extension 30 48• Abduction 100 140• Internal rotation 55 58• External rotation 50 55• Horizontal abduction 35 40• Horizontal adduction 105 123 • These are left side shoulder joint movement

• Resisted isometric movements test in neck ,shoulder & elbow. Left shoulder movements are weak compare to right shoulder

• Special test Maitland’s locking test + anterior drawer test - posterior drawer test - speed test - empty can test + drop arm test - test for bicipital tendinitis - Apley scratch test +

• Functional assessment combing hair - difficult dressing - difficult scratch right side superior aspect of scapula – difficult eating -not difficult touching back of head - difficult• Physiotherapy diagnosis left side shoulder joint muscle wasting in deltoid area , spasm

in upper trapezius area & decreased ROM in same side shoulder joint

• Treatment plan short term goals • Patient education • Pain relief in left shoulder joint• Relief spasm in upper trapezius • Posture corrections long term goals • Gain FROM in limited movements• Strengthening muscles around shoulder joint• Gain the limited functional movement fully

• Pain relief - apply short wave diathermy for shoulder joint continuous mode 20 min 2 days per week This gives deep heat & that increase blood circulation loosening the

adhesions remove the waste products from there. That help to relieve pain. Hot water fermentation 15 min at home around shoulder 2 times per day.

• To reduce spasm - give deep transverse friction 10 min in spasm area in upper trapezius 2 days per week. Spasm is tight area of muscle. When it release feel relief of pain .

• To increase ROM - give accessory movement grade II , 60 oscillations 2 times per week (for AP,PA, Cephalo caudal , distraction)

• Ultrasound for supraspinatus tendon area to increase healing process & relief pain.

• Relaxation - shoulder girdle retraction & depression with hold then release should be practised regularly .

• Mobilization active exercises for shoulder area - every day 15 repetitions 2 times per day . Start from pendulum exercise & progress according to improve the limited movements of the shoulder. In pendulum exercise a weight in hand helps to apply traction to humerus & increase momentum.

• Putting in suspension for flexion, extension ,abduction ,adduction for left shoulder joint .This help to increase patient’s confidence & re-educate glenohumeral rhythm)

• Wall climbing exercise useful to gaining elevation of shoulder girdle.• Pulley exercises for ( flexion ,extension ,abduction ,adduction)• Strengthening exercises for especially deltoid & other muscle

groups(serretus anterior,rhomboids ,trapezius) around shoulder joint • Posture corrections -practise shoulder girdle & head retraction &

also depression of shoulder girdle

• Outcome measurement of the intervention after 4 sessions of treatment Pain is decrease in to 4 according to numerical pain scale Also increased ROM of shoulder joint BUT NOT FULLY. AROM PROMFlexion 97 164

Extension 45 58Abduction 135 160Internal rotation 62 65External rotation 60 70Horizontal abduction 40 45 Horizontal adduction 120 133

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