Case Study #1 Bruce Monkman # Loriana Costanzo # Carlos Leon-Carlyle # Mike Bois #

Table Of Contents Description of case study Brief description of joint limitations based on structure and shape Brief description of muscles involved Assessment contraindications and precautions for range of motion Tests for PROM and AROM Limits in the range and how it may effect exercise prescription

Case Study A 35 year old male presents difficulty raising or lifting objects above his head or elevating his arm above his shoulder with or with out a load. He injured himself 3 weeks ago water skiing when he fell holding onto the rope too long. The shoulder has been treated for one week for a soft tissue musculoskeletal injury to the right shoulder where his range is limited in flexion and abduction plus there is a muscle spasm to the right aspect of the neck and upper back region. There is still discomfort on a pain scale of 6 out of 10 and range is still limited and the patient has been referred to you for range testing and prescription exercises for flexibility and strengthening and retraining to return to normal activities.

Joint Limitations of Elevation Through Abduction Elevation through abduction at the glenohumeral joint has a ROM of 180 degrees. Structural limiting factors include: the middle and inferior bands of the glenohumeral ligament, inferior joint capsule, shoulder adductors, greater tubercle of the humerus contacting the upper portion of the glenoid and glenoid labrum or the lateral surface of the acromion.

Joint Limitations of Elevation Through Flexion Elevation through flexion at the glenohumeral joint has a ROM of 180 degrees. Structural limiting factors include: the middle and inferior bands of the glenohumeral ligament, inferior joint capsule, shoulder adductors; greater tubercle of the humerus contacting the upper portion of the glenoid and glenoid labrum or the lateral surface of the acromion; scapular movement limited by tension in rhomboids, levator scapulae, and the trapezoid ligament.

Musculature Elevation through flexion –supraspinatus/infraspinatus, deltoid (anterior fibres), trapezius, serratus anterior, erector spinae Elevation through abduction –supraspinatus/infraspinatus, deltoid, subscapularis

Contraindications If any of the following are present, AROM/PROM should not be assessed: –Dislocation/Fracture –Recent surgery –Myositis Ossificans/Ectopic Ossification

Precautions Presence of infections or inflammation Patient taking pain medication or muscle relaxants Region marked by osteoporosis or where bone fragility is a factor Hypermobility or subluxation at the joint Regions with hematoma Patients with hemophilia Regions with boney ankylosis is suspected Regions with newly united fractures Prolonged immobilization of a joint.

General Scan Look for any of the following: –Deformations –Symmetry –Swelling –Skin discolouration –Palpate for scar tissue –Check for structural deformities –Pain Scale 1-10 –Mechanism of injury

Tests for AROM Functional Tests: –Patient places and object on the top shelf –Patient puts an article of clothing on the upper extremities –Patient opens a door on effected side AROM –Flexion – Patient elevates arm in the sagittal plane along the frontal axis –Abduction – Patient elevates arm in the frontal plane along the sagittal axis

If you can put on a jacket…

Substitution/Trick Movements Flexion –Look out for trunk extension and shoulder abduction Abduction –Look out for contralateral trunk side flexion, scapular elevation, and shoulder flexion

Tests for PROM Abduction at the Glenohumeral Joint Start Position: The patient is supine or sitting Stabilization: The therapist stabilizes the scapula and clavicle Therapist’s Distal Hand Placement: The therapist grasps the distal humerus End Position: The therapist applies slight traction to and move the humerus laterally and upward to the limit of motion of the glenohumeral joint abduction End Feel: Firm or hard

Elevation through Abduction at the Glenohumeral Joint

Tests for PROM Elevation Through Flexion Start Position: the patient is in crook-lying or a sitting position. The arm is at the side with the palm facing medially. Stabilization: The therapist places one hand on the axillary border of the scapula Therapist’s Distal Hand Placement: The therapist grasps the distal humerus End Position: While stabilizing the scapula, the therapist applies slight traction to and moves the humerus anteriorly and upward to the limit of motion to assess glenohumeral joint motion End Feel: Firm

Elevation through Flexion at the Glenohumeral Joint

Effects on Exercise Prescription The exercise program will have to be designed around the patients ROM. The movement range of the exercise must allow the patient to move pain free, or the exercises may not be effective. One must err on the side of caution when prescribing exercises on an individual with limited ROM to avoid the possibility of re-injuring the joint.