E D Group Project

E&D Project Case 3:
1. Working Diagnoses and Rationale:

 Subacromial Impingement (age, hx of overhead athlete, dominant shoulder, deep
pain, reaching in the back pocket/overhead increases his symptoms)
 Labral Tear (Possibly a SLAP tear): (peel back mechanism, deep pain, active with
arm and increased pain with compression, such as applying pressure through his
arms when he’s on his hands and knees)
 Rotator cuff tear/tendinopathy: (athlete, overhead, referral pattern, deep pain, age)
 TOS: (overhead/ repetitive→ pain, pain changes with posture head extension
leads to symptoms)
2. Objective Information/Tests & Measures
 Posture/Inspection: See if their habitual posture could contribute to tissue stresses/pain
 Swelling: the location of the swelling can indicate inflammation of certain
muscles or TOS if the arm was “puffy”
 Tissue color: look for pallor indicates TOS
 Atrophy of supraspinatus and infraspinatus, scapula position, look for forward
head posture
 Upper Quarter Screen: Perform this to rule out any neurological involvement. TOS may
also involve neurological abnormalities in this screen due to brachial plexus compression
 Palpation: Note any changes in the tissue or provoke the patient’s pain with palpation
 Bony Prominences: coracoid process, greater and lesser tubercles of humerus,
 Soft Tissue: Supraspinatus, infraspinatus tendons and muscle belly. Long head of
the biceps tendon.
 Tissue temperature: TOS or inflammation of the tissue could increase the
temperature.
 Scapulothoracic rhythm, including scapular dyskinesis. This could tell us if their UE
functions normally
 ROM: To see if there are any limitations to movement or if certain movements provoke
symptoms or pain.
 Shoulder abduction, adduction, flexion, IR, ER, horizontal adduction
 Painful arc of motion
 Joint play Assessment of GHJ and Scapulothoracic Joints: Check to see if they have
hyper/hypo-mobility or pain. Note if pt is muscle guarding during assessing joint play, or
we might feel crepitus, clicking, catching, grinding (indicates labral tear).
 MMT: Perform this to see if there is muscle weakness or provokes pain/symptoms.
 RTC muscles (rule out Rotator cuff tear). Bicep for labral/impingement. Deltoid,
traps, serratus anterior tests force coupling of the shoulder important for
impingement.
 Special Tests: Each of these categorized diagnoses will help us rule in or rule out the
suspected pathology to provoke the suspected pathological tissue.
 Impingement Special Tests: Neer’s compression test, Hawkins/ Kennedy
impingement test, coracoid impingement, cross-arm test.
 Labral Tear (SLAP): Obrien’s test, Biceps Load test, Crank test
 Rotator cuff tear: Empty can/full-can test/Drop arm test (Supraspinatus), Lag
signs (infraspinatus; supraspinatus).
 TOS: Adson’s test, Allen’s test, Wright’s test, Costoclavicular syndrome test.
Exam and Diagnosis II: Case 4
Working Diagnoses and Rationale:
 Lumbar Radiculopathy (suspected at L4-S1 and could be a HNP): neurological symptoms in
LE that occasionally travels down her entire leg to lat. lower leg. Pain can be relieved with
rest lying supine or right trunk SB. Pt has pain in the lower back.
 Piriformis Syndrome/Sciatic Nerve Compression: sensory supply of the sciatic nerve could
be felt in the anterior/posterior leg, and sole/dorsum of foot. She’s a runner and her running
gait pattern could either contract or stretch the piriformis compressing the sciatic nerve.
 Plantar fasciitis: rule in or rule out since the doctor has prescribed this diagnosis and pt has
pain on plantar and dorsum lateral portion of foot. Her activity level and running routine may
be stressing the plantar fascia and not allowing adequate rest/healing.
Objective information/Test & Measures
 Posture/Inspection: their frequent/preferred postures could put stress on their lumbar spine or
feet. Pt’s posture could also tell you if they are shifting away from pain in the case of a
herniation leading to a radiculopathy. Check: iliac crests, lumbar lordosis, pelvic tilt, leg
length, pes planus/cavus, supination/pronation (too many toes sign). Look at shoes/calluses to
see where they are putting stress on their feet.
 Lower Quarter screen: Perform this to rule out any neurological involvement and determine
if sensory loss is in a dermatomal pattern (L4, L5, S1) or peripheral nerve distribution (sciatic
nerve).
 Gait: This can tell us about stresses she is putting on her body throughout normal activity.
Observe step length, check running form since she is continuing with this activity, Toe in/toe
out, limping, Dynamic knee valgus, pronation (plantar fasciitis)
 Palpation: tenderness/pain of piriformis or provoke neurological symptoms, tenderness/pain
at medial calcaneus or plantar fascia (plantar fasciitis), TTP at greater trochanter for
piriformis insertion.
 Joint Play Assessment: Lumbar vertebra springing may provoke pain.
 ROM: Note any limitations to movement or if certain movements provoke symptoms or pain.
Trunk forward bending, backward bending, rotation, sidebending. H and I testing for their
lumbar spine. Hip flexion, extension, ER, IR.
 Muscle Length Testing: Hamstring length can contribute to LBP (SLR and 90/90 test),
gastroc/soleus can be tight with plantar fasciitis
 MMT: We would perform to see if there is weakness or provokes pain/symptoms. This could
also help support myotomal weakness (nerve root pathology) or show muscle weakness due
to a peripheral nerve. MMT Piriformis, hamstrings, gastroc/soleus, tibialis anterior/posterior
 Special tests: Each of these categorized diagnoses will help us rule in or rule out the
suspected pathology to provoke the suspected pathological tissue.
o Lumbar radiculopathy: Compression test, Distraction test, slump test, Straight leg
raise, Heel Walking/Toe walking: Toe walking is a S1 nerve root problem if they are
unable to perform, heel walking can be L4/L5 nerve root issue if they cannot perform.
(Heel walking would be painful for plantar fasciitis)
o Piriformis syndrome: Piriformis syndrome test.
o Plantar Fasciitis: Windlass Test: PT performs passive Great Toe Extension. Plantar
fascia becomes tight when big toe extends. Pain could be provoked with plantar
fasciitis

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E&D Project Case 3:

1. Working Diagnoses and Rationale:

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