04/19/2013

S> AP, a 47 y/o (-) DM/Htn/Asthma handed pt c/o gr. 5/10 intermittent kirot at ngalay pain
(0=no pain; 10= worst pain on SPS) on shoulder(on what area: front, back, sides) in
simple movements (describe what kind of simple movements [simple movements with one
patient may vary from another patient]) but to gr. 7/10 upon movement to endrange as to
reaching overhead(what are the relieving factors/activites; describe and quantify if there is
still pain); (L) lumalagatok knee c pain (what kind of pain and on what area of (L) knee :
front, back, sides) @ gr. 3/10, pt claims pain is relieved c ice & sometimes subsides when
playing basketball(aggravating factors and activities and describe type and quantify if there
is pain). HPI: a mo. ago, pain was felt again on his shoulder(were there any activities that
he did prior to the injury) & gradually until 2 wks ago, when he felt the pain was not
tolerable anymore. He consulted a MD last April 12 & referred him to Dr. Reyes of MMC,
where he was Dx c adhesive capsulitis on shoulder last April 17; no meds were given. Xray was done but results were still to be read. PMHx: condition started last Jan 2012 during
pts volleyball training, he spiked c his shoulder & felt something like a pulled muscle;
placed ice pack right away. His coach advised him to take a 3-day rest, p resting, he
exercised c a yellowish theratube for a wk & felt okay. Lifestyle: (-) alcoholic beverages
drinker/smoker, works as an outside plant engineer, which requires driving, computer &
office works. Pt still plays basketball during his spare time. Home & social environment: Pt
lives c his wife & mom in a 2-storey house & claims he uses his (L) shoulder to reach their
overhead cabinets; computer @ work follows proper ergonomics. Goal: Magheal ung sugat
at makalaro nang maayos.
O> VS> BP= a: 120/80mm Hg
p:140/100mmHg
OI>endomorph
(-) redness of (B) UE
(-) trophic skin changes on (B) UE
(-) swelling & atrophy on (B) UE (anthropometric measurements)
Palpation> (+) gr1 tenderness on bicipital groove area
(+) crepitations upon shoulder ER&IR
(-) muscle spasm on shoulder
(-) muscle guarding on shoulder towards all planes
Anthropometric measurements> (to objectively confirm that there were really no swelling and
atrophy on B UE)
ROM> All joints of (B) UE are assessed (and are WNL) and found significance c shoulder:
(its better to include the findings on the (L) shoulder so we can compare it to the affected side)
AROM
PROM
Endfeel
Flex
0-150
0-160
Firm c pain @ endrange
Ext
0-30
0-35
Firm c pain @ endrange
Abd
0-90
0-108
Firm c pain @ endrange
ER
0-90
0-95
Firm c pain @ endrange
IR
0-80
0-85
Firm c pain @ endrange
MMT> All major muscles of (B) UE are graded 5/5 except:
shoulder flexor 4/5
shoulder abductor 4/5
shoulder extensor 4/5
Sig: Weakness maybe d/t pain.
Special tests> (+) Yergasons test on

(+) Speeds test on (both could be a false positive result since there is
already pain on the shoulder)
(-) Neer impingement test on
FA> Pt is indep in all aspects of ADLs, bed mob & transfers
Able to reach overhead but c pain
Able to don & doff shirt c mod difficulty

A> PT Dx: MD Dx of (primary or secondary)adhesive capsulitis (what stage) on shoulder

further defined by inability to do overhead activities normally 2 to pain & LOM on shoulder
Problem list:
1. Pain on what area & structure
2. LOM on what structure and laterality, motion
3. Functional limitation (difficulty in doing overhead activities on what structure and
laterality)
LTG> Rehabilitative: Pt will be able to reach overhead, move shoulder towards all
planess pain& play basketball c ease p 6 PT sessions
>Preventive: Pt will adhere to HEP& apply pt education p 1 PT session to avoid
further complications
STG>
1. Pt will report pain (on R shoulder) from 7/10 to 3/10 p 3 PT sessions to help him do his
work better
2. Pt will demonstrate AROM by ~10 on all movements of shoulder p 3 PT sessions to
aid in his work especially in doing overhead as to putting cables & wires.
P> Pt will be seen & treated as an OP for 6 PT sessions c ff mx:
shoulder
1. Continuous or Pulsed US x 1MHz x 1.5 w/cm x 5 on bicipital groove to pain
2. HMP x 20 on shoulder to pain
3. TENS x 20 on shoulder to pain
4. Joint mobilization grade 2 of shoulder towards ant, post, inf gliding x 30secs
oscillation x 2 reps to ROM (grade 2 Joint Mob doesnt increase ROM )
5. Arm pull of shoulder x 1 rep to relax muscles & joints
6. GPS towards shoulder abd, flex &ext x 15secs x 3 sets each to ROM
7. Overhead pulley towards shoulder flex &abd of shoulder x 10reps x 2 sets to ROM
8. Shoulder wheel towards shoulder ER & IR x 10reps x 2 sets to ROM
9. Finger ladder towards shoulder abd& flex c 6SH x 10 reps x 2 sets to ROM
(L) knee (include it in the problem list if there is Rx.)
1. HMP x 20 on shoulder & (L) knee to pain
2. Hamstring sets x 10 reps x 2 sets c 6SH o strengthen hamstrings (muscle setting
doesnt increase strength)
3. Short arc quads x 10 reps x 2 sets c 6SH to strengthen quadriceps
4. SLR c ext rot x 6SH x 10 reps x 2 sets to strengthen quadriceps
HEP>
1. Wand exercises
2. Self-stretching
3. Codman
Pt education>

1. Respect fatigue
2. Stretch properly prior to game & training