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

2. 63 year old male patient CC L shoulder pain
Self-referral
Patient is a MD

3. 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

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

5. 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

6. Discussion
Potential diagnoses
Hypothesis?

7. Family Hx
Heart disease
HTN
Skin cancer
Hypercholesterolemia

8. Medications
Isordil
Lipitor
Aspirin (82 mg)
Beta blocker

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

10. 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

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

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

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

14. Questions?
Thank you!