Chatham University Grand Rounds November 13, 2014 Rajiv Sawhney, PT, DPT, MS, OCS Allegheny Chesapeake PT Chatham University

63 year old male patient CC L shoulder pain Self-referral Patient is a MD

Patient’s Impressions If I go to a neurologist or neurosurgeon will have cervical surgery If I go to an orthopedic surgeon will have shoulder surgery Cardiac

CC Left shoulder Pain Sleep on L side Lateral overhead mvt Horizontal adduction, Exertion (walking up hill) Cervical pain with mvt

PMH Cervical discectomy and fusion, C3-C4 in 1999 Cervical fusion C4-C5 in 2001 L4-5 discectomies 1990 L2-3 disectomies 2004 Prior shoulder injury with tennis Multiple musculoskeletal problems over the last 30 yrs

Discussion Potential diagnoses Hypothesis?

Family Hx Heart disease HTN Skin cancer Hypercholesterolemia

Medications Isordil Lipitor Aspirin (82 mg) Beta blocker

Examination Cervical Pain with extension Pain with left side flexion + Spurling, less pain with distraction Diminished DTRs

Examination Shoulder Pain with tennis Symptoms last for some time post playing + Neer, Hawkins, full and empty can, pain reaching across body and overhead Pain laying on left side at night

What now? Treat shoulder? Treat C-spine? Refer to specialist? ??? Further testing?

Next step Vitals Modified BRUCE protocol on treadmill MODIFIED BRUCE: STAGE 1: 1.7 mph, 0% (METS 2.5) STAGE 2: 1.7 mph, 5 % (METS 3.5) STAGE 3: 1.7 mph, 10 % (METS 5) STAGE 4: 2.5 mph, 12 % (METS 4.2) STAGE 5: 3.4 mph, 14 % (METS 9.5) STAGE 6: 4.2 MPH, 16% (METS13)

Differential Diagnosis Direct Access Professionalism Vision 2020 Accepted by medical community as equals?

Questions? Thank you!