Topic 2 - Assessment

SITUATION
Mr M. is a 26 year old male, who was referred to the physiotherapy department post anterior dislocation of the left shoulder and avulsion of the greater tubercle. His main complaint is pain over his anterior-lateral shoulder with movement, along with restriction of full flexion, abduction and external rotation. Mr M. is a car mechanic and has not been able to work post incident for four weeks. He states the majority of his work is underneath the cars, which means that he needs his hands above his head. This poses a problem considering he is restricted into this range and therefore not able to work. Mr M. has no red or yellow flags, with his problems seeming to be mechanical in nature and appropriate for physiotherapy intervention. Mr M. was transferred to me from a previous undergraduate physio student so therefore a thorough subjective and objective assessment is not required. Mr M. has so far been compliant with post-op surgical orders, which means you can assume he will be compliant with a post-op range of movement and strengthening program.

TASK
To complete a follow-up assessment on Mr M's asterisks signs to be able to make an accurate and relevant analysis and plan to be able to decrease Mr M's pain and improve his range.

ACTION
After introducing myself to Mr M. I asked him what I could help him with today, and establish whether he was better, same or worse since the previous physio session. Next I enquired about what his pain level were if he was in pain, and what his main concerns/ problems were. I then found out if any of the previous treatment was successful or not and whether anything new has occured since the last visit. Next was to re-asses the asterisk signs from the objective assessment of the last visit. First I observed his posture. Flexion, abduction and external rotation ranges of movements were then assessed along with his ability to put his hand behind his head and hand behind his back, giving me his P and R values. Next I palpated the painful area and the musculature around the shoulder girdle. After palpation I did a passive accessory movement assessment to see whether there was any restrictions in his joint. From there I then observed how he was performing his exercises to see whether he was getting any pain from then, and if the pain was caused by incorrect technique and whether he was ready for progression of the exercises.

RESULT
Mr M. sat with a forward chin poke, protracted scapula, increased thoracic kyphosis and decreased lumbar lordosis. On palpation Mr M has increased tone in his upper traps, levator scap, he also had positive trigger points in his anterior and posterior deltoid, long head of biceps and lat dorsi. Mr M's concordant pain was reproduced when I palpated over the deltoid insertion. Mr M's ROM are as follows:
F 100 P1
ABD 90 P1
ER WNL
Passive accessory movements showed that AP and caudad glides were hypomobile. Mr M. was also performing all exercises correctly and could be progressed to strengthening exercises.

EVALUATION
Although I performed the basic assessments, the way I conducted my assessment could have been better. I continuously got my patient into different positions to conduct my assessment. This left my assessment inefficient and time consuming, which resulted in less time for treatment. It would have no doubt been annoying for my patient also. Although this was the case, I was able to collect results from my assessments to be able to make an analysis and plan of my patients problems and possible treatments. I also would like to go through my PAMs assessment with my supervisor as I was unsure of exactly what I was feeling and what the results meant. I also need to brush up on my anatomy and I was unable to clinically reason what the concordant pain on palpation over the deltoid insertion was caused from. After consultation with my supervisor, he stated that it was likely to be cause from an inflamed bursae under the deltoid muscle.

STRATEGIES
I think making a list of all the assessments for the shoulder then dividing them into the positions you conduct them in would be helpful so I could do all of my standing assessments first, then sitting, supine and prone etc. This would then allow me to do a more efficient assessment and be more convenient for the patient, especially if they were pain dominate. Another idea would be to have a list of assessments and then during my subjective assessment crossing assessments off that are I believe would be irrelevant so I have a list of assessments I would need to conduct, and if I run out of time/ becoming short of time, I have a list i could put that in my 'review' part of my SOIER to perform on the next visit. Hopefully efficiency will come with the more practice I get.