Cards for Ortho Lab practical

Card 2. ICF Classification: Subacromial Pain (SAP) with Mobility Deficits Physical Examination: Perform a Static Observation (4-views) of the shoulder/shoulder girdle with the patient in standing. Include: one (1) scapular position (e.g., position, winging (Kibler), etc.,), one (1) humeral position [e.g., internal rotation, supero-inferior translation, humeral extension, etc.), and one (1) general inspection (e.g., skin inspection, atrophy/muscle bulk, bony contours (e.g., clavicle, acromioclavicular joint separation, etc.)]. Note: Perform a bilateral comparison, right-sided involvement. NB: Use visual inspection, palpation, bony landmarks, and/or tape measure as needed (No inclinometer or Goniometer here). Explain findings to the patient in layman's terms. PT Intervention: Provide a "reset" technique to the right Glenohumeral Joint to increase shoulder flexion for a patient in the early remodeling stage of tissue healing with low tissue reactivity. Dosage (e.g., grade, reps, sets, oscillations, hold time, range, position, pain reproductions, etc.) *Describe the PT intervention

-Since patient is in the early remodeling phase must provide GH Jt mob to increase shoulder flexion in the OPP (55°ABD, 30°H.ADD) would be a posterior glide. -Grade III or IV depending on apprehension -4 sets of 30 sec oscillations -Then ask if reproduction of pain. -Then have patient go through motion and see if decreased pain and increased ROM

Card 22. ICF Classification: Subacromial Pain (SAP) with Mobility Deficit Physical Examination - Joint Play Assessment: The patient has right anterolateral shoulder pain at end range arm elevation. Perform Joint Play Assessment (JPA) to the Acromioclavicular Joint (i.e., antero- inferior glide & postero-superior glide). Note: Perform bilateral comparison. NB: 1) This is a stiffness dominant patient and 2) Explain findings to the patient in layman's terms. PT Intervention: Provide a joint mobilization "reset" technique to the right Glenohumeral Joint to increase shoulder flexion for a patient in the late remodeling (maturation) stage of tissue healing with no tissue reactivity. Dosage (e.g., grade, reps, sets, oscillations, hold time, range, position, pain reproductions, etc.). Describe the PT interventions.

Grade III or IV for 4 sets of 30 sec oscillations -Direction of glide depends on where restriction is...if between 0-60 then do post glide, 60-120 of shoulder flex then do inferior glide w/their elbow bent against your chest. if beyond that and shldr is between 120-180° of flexion then do anterior glide on humeral head.

Card 5. ICF Classification: Subacromial Pain (SAP) with Movement Coordination Deficits Physical Examination: Perform a Dynamic Observation to assess for scapular dyskinesia during arm elevation and arm lowering. Note: Perform a bilateral comparison, right-sided involvement. NB: Include scapular position assessment with the arm at 90° of arm elevation (i.e., flexion, scaption, or abduction). Was this movement painful? If so, was the pain familiar? Where in the range did it occur? How intense was the pain? Explain any scapular dyskinesia findings to the patient in layman's terms. PT Intervention: Provide a "retraining" technique to the right shoulder girdle to promote posterior scapular rocking/tilting or upward rotation and facilitation of the lower trapezius muscle. Dosage: (e.g., sets, reps, resistance, exercise choice, cueing, feedback, etc.). Monitor patient. What special tests would be used? Describe the PT interventions.

*Assess scapulohumeral rhythm, quality of movement as well as quantity, dyskinesis (inadequate scap UR, ER, post tilt, winging, premature DR during arm lowering). **B/L w/wts. 3# if <150lbs, 5# if >150lbs. Have patient B/L perform shldr abd. There should be 30° of scapula UR. PT intervention: -Prone Y's with DB

Card 4. ICF Classification: Subacromial Pain (SAP) with Movement Coordination Deficit Physical Examination: Perform a Dynamic Observation & AROM to assess the end-range position of the scapula during arm elevation using an inclinometer: A) Upward Rotation or B) Posterior Tilt. Was this movement painful? If so, was the pain familiar? Where in the range did it occur? How intense was the pain? Note: Perform a bilateral comparison, right-sided involvement. Explain findings to the patient in layman's terms. PT Intervention: Provide a "retraining" technique to the right shoulder girdle to promote posterior scapular rocking/tilting or upward rotation and facilitation of the serratus anterior or lower trapezius muscle. Dosage: (e.g., sets, reps, resistance, exercise choice, position, cueing, feedback, etc.) NB: Monitor patient. (Week 3) Describe the PT interventions.

*have patient do ABD -Dynamic UR: 30° at shldr abd to 90, 60° when shldr in full arm abd -Dynamic Post Tilt: 23.5° overall, but will get a 10° reading in full elevation (because goes from 13.5° ant tilt to 0 to 10° post tilt) -PT Intervention: SA or LT to increase UR. Prone Y's for LT engagement. banded wall climbs for SA UR engagement.

Card 21. ICF Classification: Subacromial Pain (SAP) with Mobility Deficit Physical Examination - Joint Play Assessment: The patient has right anterolateral shoulder pain during arm elevation. Perform Joint Play Assessment (JPA) to the Glenohumeral Joint (i.e., anterior, posterior, and inferior glide). Note: Perform bilateral comparison. NB: 1) Pain & Stiffness and 2) Explain findings to the patient in layman's terms. PT Intervention: Provide a joint mobilization "reset" technique to the right Glenohumeral Joint to increase shoulder flexion for a patient in the early remodeling (maturation) stage of tissue healing with low tissue reactivity. Dosage (e.g., grade, reps, sets, oscillations, hold time, range, position, pain reproductions, etc.) Describe the PT interventions.

-Grade III in OPP for shoulder flex increase so posterior glide must be applied to patient to increase flex. 4 sets of 30 sec of oscillations must be applied.

Card 18. ICF Classification: Subacromial Pain (SAP) with Muscle Performance Deficit Physical Examination - Strength Testing: The patient has right anterolateral shoulder pain. Perform a Shoulder Break Test during arm elevation to differentiate between weakness of the Glenohumeral Force Couple versus the Scapulothoracic Force Couple (i.e., shoulder flexion in 125° or shoulder abduction 110°). Which one "broke"? Note: Perform a bilateral comparison. NB: Explain findings to the patient in layman's terms. PT Intervention: Instruct the patient in performing a "reloading" technique to increase strength of the right serratus anterior or lower trapezius in either the prone or backward rocking arm lifting position. Note: Provide the patient with adequate resistance (i.e., dumbbell or TheraBand) and dosage (hold time, reps, sets, etc.) to promote strength gains. NB: Monitor the appropriateness of the difficulty of the exercise and pain level. Monitor patient. What special tests would be used? Describe the PT interventions.

-Have patient abduct to 110° and try and break that. *If ST joint breaks due to LT or SA *If GH breaks due to supraspinatus/mid delt -PT intervention: Prone Y's w/DB or supine protraction w/DB

Card 14. ICF Classification: Subacromial Pain (SAP) with Mobility Deficit Physical Examination - Muscle Length & Capsule Assessment: The patient has right anterolateral shoulder pain. During Static Observation you note: Excessive scapular anterior tilt (18°) and the head of the humerus is >1/3 anterior to the anterior acromium. Please perform passive Low & High Internal Rotation Tests to differentiate between Posterior Cuff (Teres Minor & Infraspinatus) versus Posteroinferior Capsule extensibility. Note: Perform a bilateral comparison. NB: Explain findings to the patient in layman's terms. PT Intervention: Provide a manual Mobilization with Movement (MWMs) "reset" technique to the right posteroinferior glenohumeral structures. Example: "Glide & Wind" technique either oscillations or 1- minute hold (with or without a mobilization belt). Dosage (e.g., grade, force, reps, sets, oscillations, hold time, range, position, pain reproductions, etc.) What special tests would be used? Describe the PT interventions.

-Low IR test: tests infraspinatus and teres min. Pat supine, pats arm to be on the edge of the table, push arm into extension 50-60°. If tight then caused by muscles. -High IR test: 60° of shldr flex then IR forearm. if tight then posterior capsule Pt intervention: -IRs are tight so want to stretch into IR to increase ER because infra and t.min are ERs and need to stretch them to increase IR. Glide and wind: Pt lies supine with shldr ABD between 60-120° and ER position BUT HAND IS facing outward (IR). The PT passively glides the humerus posterior into resistance then the PT passively ERs humerus to end range. Can take pt from neut to ER (R2) or IR to ER (R2). apply post pressure to head of humerus. -4 sets of 30 oscillations or 1 min hold x 2

Card 20. ICF Classification: Subacromial Pain (SAP) with Muscle Performance Deficit Physical Examination - Strength Testing: The patient has right anterolateral shoulder pain. During a Shoulder Break Test (shoulder flexion in 125°) the Glenohumeral Force Couple was strong but the Scapulothoracic Force Couple "broke" (downward rotation of the scapula as determined via palpation of the inferior angle). Perform a Specific Manual Muscle Test of the Lower Trapezius muscle. Note: Perform a bilateral comparison. NB: Explain findings to the patient in layman's terms. PT Intervention: Instruct the patient in performing a "reloading" technique to increase strength of the right lower trapezius in either the prone or backward rocking arm lifting position. Note: Provide the patient with adequate resistance (i.e., dumbbell or TheraBand) and dosage (hold time, reps, sets, etc.) to promote strength gains. NB: Monitor the appropriateness of the difficulty of the exercise and pain level. Describe the PT interventions.

-MMT for LT: patient head to opposite side being tested, prone stabilize opp trunk and then push down in scaption direction to break LT. -PT intervention: Prone Y's with DB, 2 x12 twice daily. shoulder feel somewhat hard

Card 8. ICF Classification: Subacromial Pain (SAP) with Mobility Deficit Physical Examination - AROM (right side involved): Please measure total active shoulder abduction. The patient has 60° of scapular upward rotation bilaterally. Determine the degrees of glenohumeral active shoulder abduction bilaterally [using a goniometer and math (subtraction)]. Note: Perform a bilateral comparison, right-sided involvement. NB: Was this movement painful? If so, was the pain familiar? Where in the range did it occur? How intense was the pain? Explain findings to the patient in layman's terms. RECALL: Scapulohumeral Rhythm approximately 2:1 PT Intervention: Provide a joint mobilization "reset" technique to the right Glenohumeral Joint to increase shoulder abduction for a patient in the late remodeling (maturation) stage of tissue healing with no tissue reactivity. Dosage (e.g., grade, reps, sets, oscillations, hold time, range, position, pain reproductions, etc.) What special tests would be used? Describe the PT interventions.

-Measure shoulder abduction (full abd is 180° Landmarks: stationary arm:// to midline of body, moving arm: // to humerus, Axis: anterior surface of acromion) -If the patient has 60° of scapular UR , take total ABD of GH jt and subtract 60° = GH joint motion during ABD. -Perform first on L then on R. PT intervention: -Inferior glide at 90 ABD or can be closer to restriction -4x 30 sec oscillations

Card 19. ICF Classification: Subacromial Pain (SAP) with Muscle Performance Deficit Physical Examination - Strength Testing: The patient has right anterolateral shoulder pain. During the Scapular Stabilization Test in the Plank Position, you note Scapular Winging - Kibler Type 2 after a 10-second hold. Perform a Manual Muscle Test to determine the strength of the Serratus Anterior Muscle. Note: Perform a bilateral comparison. NB: Explain findings to the patient in layman's terms. PT Intervention: Instruct the patient in performing a "reloading" technique to increase strength of the right serratus anterior in either the Plank or Push Up position (e.g., Push Up Plus exercise). Note: Provide the patient with appropriate dosage (hold time, reps, sets, etc.) to promote strength gains. NB: Monitor the appropriateness of the difficulty of the exercise, correct performance, and pain level. Describe the PT interventions.

-SA test: have patient protract scap and try and break that. -Have patient do wall push up-with scap protraction. 2x 12x5" twice daily. Can advance to push-up plus on ground.

Card 29. ICF Classification: Shoulder Pain with Stability & Movement Coordination Impairments Physical Examination - Special Testing: Glenohumeral Stability Testing (posterior instability) The patient has right anterolateral shoulder pain and apprehension which is exacerbated with rugby participation. Perform a Special Test to rule-in a possible posterior glenohumeral instability. Also verbally provide your grader with another special test that you could have used to rule-in this condition. Note: Perform bilateral comparison. NB: 1) Did the test produce classic signs and symptoms? 2) Reproduction of familiar symptoms? and 3) Explain findings to the patient in layman's terms. PT Intervention: Provide a "reloading" technique to the right shoulder girdle to promote glenohumeral joint strength & stability. Dosage: (e.g., sets, reps, resistance, exercise choice, progression, position, etc.). Monitor patient effort. Which special test would you perform? What others could you perform to rule in posterior instability? Describe PT intervention

-Special Test to rule in posterior instability: Posterior apprehension test -Other tests to rule in posterior instability: Jerk test -PT intervention: 1. To strengthen ERs patient can perform ER with a Tband at side or can isometrically with a Tband do 90/90 ER standing by walking back and forward. Then progress to concentric motion. Then progress to ER with corestix. Then progress to use of cross symmetry bands pull to high row with ER rotation. Can do this 2x12, but start w/ 1x12.

Card 25. ICF Classification: Subacromial Pain (SAP) with Movement Coordination Deficit Physical Examination - Special Testing: Supraspinatus Tendinopathy. The patient has right anterolateral shoulder pain during arm elevation. Perform a Special Test to rule-in a possible supraspinatus tendinopathy. Also verbally provide your grader with another special test that you could have used to rule-in this condition. Note: Perform bilateral comparison. NB: 1) Did the test produce classic signs and symptoms? 2) Reproduction of familiar symptoms? 3) Cyriax Resisted Testing Findings: Painful? Painfree? Weak? Strong? and 4) Explain findings to the patient in layman's terms. PT Intervention: Provide a "retraining" technique to the right shoulder girdle to promote posterior scapular rocking/tilting or upward rotation and facilitation of the serratus anterior muscle. Dosage: (e.g., sets, reps, resistance, exercise choice, position, cueing, feedback, etc.). Monitor patient. What special tests would be used? Describe the PT interventions.

-Special test for supraspinatus tendinopathy: Lateral Jobe -Other tests for supraspinatus tendinopathy: Empty can, full can, drop arm test -PT interventions: SA facilitation for UR. SA wall walks w/band starting at level or elbow and climbing wall until full arm flex. Supine DB protraction for serratus

Card 27. ICF Classification: Subacromial Pain (SAP) with Muscle Performance Deficit Physical Examination - Special Testing: Subscapularis Tendinopathy (tear) The patient has right posterior shoulder pain during arm elevation. Perform a Special Test to rule-in a possible subscapularis tendinopathy (tear). Also verbally provide your grader with another special test that you could have used to rule-in this condition. Note: Perform bilateral comparison. NB: 1) Did the test produce classic signs and symptoms? 2) Reproduction of familiar symptoms? 3) Cyriax Resisted Testing Findings: Painful? Painfree? Weak? Strong? and 4) Explain findings to the patient in layman's terms. PT Intervention: Provide a "reloading" technique to the right shoulder girdle to promote strength (progressive overload) of the lower trapezius muscle. Dosage: (e.g., sets, reps, resistance, exercise choice, progression, position, etc.). Monitor patient. What special tests would be used? Describe the PT interventions.

-Special test to rule in Subscapularis tendinopathy: Bear-hug -Other test to rule in Subscapularis tendinopathy: Belly-compression, HBB -PT interventions: LT strengtheners. Prone Y's then add DB, -Patient should have lumbar/thoracic spine extension and lift both arms up in the form as a Y in the scaption plane and hold for 5 seconds. Make sure scapula URs. Slowly lower. W-> Y's at wall with lift off in scaption plane and can add tband for progression. Make sure they don't arch their back. 1X12 to see if tolerable then progress to 2X12 twice a day.

Card 28. ICF Classification: Shoulder Pain with Stability & Movement Coordination Impairments Physical Examination - Special Testing: Glenohumeral Stability Testing (anterior instability) The patient has right anterolateral shoulder pain and Kinesiophobia of shoulder abduction with external rotation during sports. Perform a Special Test to rule-in a possible anterior glenohumeral instability. Also verbally provide your grader with another special test that you could have used to rule- in this condition. Note: Perform bilateral comparison. NB: 1) Did the test produce classic signs and symptoms? 2) Reproduction of familiar symptoms? and 3) Explain findings to the patient in layman's terms. PT Intervention: Provide a brief "re-education" session to help teach the patient protective and activity avoidance strategies. What test would you use to rule-in anterior instability? What others could you use to rule-in? Describe PT intervention

-Special test to rule in anterior instability: Load and shift -Other tests to rule in anterior instability: Crank or sulcus sign -PT intervention: Avoid ABD/ER overhead or any motions where the patient feels it will dislocate

Card 24. ICF Classification: Subacromial Pain (SAP) with Mobility Deficit Physical Examination - Special Testing: "Impingement" The patient has right anterolateral shoulder pain in the "painful arc" portion of arm elevation. Perform a Special Test to rule-in a possible subacromial impingement. Also verbally provide your grader with another special test that you could have used to rule-in this condition. Note: Perform bilateral comparison. NB: 1) Did the test produce classic signs and symptoms? 2) Reproduction of familiar symptoms? and 3) Explain findings to the patient in layman's terms. PT Intervention: Provide a joint mobilization "reset" technique to the right Glenohumeral Joint to increase shoulder abduction for a patient in the early remodeling (maturation) stage of tissue healing with low tissue reactivity. Dosage (e.g., grade, reps, sets, oscillations, hold time, range, position, pain reproductions, etc.) What special tests would be used? Describe the PT interventions.

-Special test to rule in subacromial impingement: Yocum -Other special tests to rule in subacromial impingement: Hawkin's Kennedy -PT intervention: To increase ABD in early remodeling, grade III in OPP, do inferior glide. 4 sets of 30 sec.

Card 30. ICF Classification: Subacromial Pain (SAP) with Muscle Performance Deficit Physical Examination - Special Testing: Superior Labrum, Anterior Posterior (SLAP) Lesion/Tear The patient has deep right anterolateral shoulder pain which is exacerbated by pull ups and activities at Hanger 18 Climbing Gym. Perform a Special Test to rule-in a possible SLAP Lesion. Also verbally provide your grader with another special test that you could have used to rule-in this condition. Note: Perform bilateral comparison. NB: 1) Did the test produce classic signs and symptoms? 2) Reproduction of familiar symptoms? and 3) Explain findings to the patient in layman's terms. PT Intervention: Provide a manual mobilization with movement "reset" technique to the right posteroinferior glenohumeral capsule to reduce Glenohumeral Internal Rotation Deficit (GIRD). Example: "Glide & Wind" technique either oscillations or 1-minute hold (with or without a mobilization belt). Dosage (e.g., grade, force, reps, sets, oscillations, hold time, range, position, pain reproductions, etc.) Which test would you do to rule in a SLAP lesion? What other tests could rule-in SLAP lesion? Describe your PT intervention

-Special test to rule-in SLAP lesion: Biceps II load test -Other tests to rule in SLAP lesion: O'briens, *Speed test (felt deep) -PT intervention: Glide and Wind to reduce GIRD (IR deficit) so external rotators are tight, so stretch into IR, make sure to apply post pressure onto hum head -Can do 4 sets of 30 sec oscillations into IR

Card 26. ICF Classification: Subacromial Pain (SAP) with Movement Coordination Deficit Physical Examination - Special Testing: Bicipital Tendinopathy (tenosynovitis) The patient has superficial right anterolateral shoulder pain during arm elevation. Perform a Special Test to rule-in a possible bicipital tendinopathy (tenosynovitis). Also verbally provide your grader with another special test that you could have used to rule-in this condition. Note: Perform bilateral comparison. NB: 1) Did the test produce classic signs and symptoms? 2) Reproduction of familiar symptoms? 3) Cyriax Resisted Testing Findings: Painful? Painfree? Weak? Strong? and 4) Explain findings to the patient in layman's terms. PT Intervention: Provide a "retraining" technique to the right shoulder girdle to promote posterior scapular rocking/tilting or upward rotation and facilitation of the lower trapezius muscle. Dosage: (e.g., sets, reps, resistance, exercise choice, cueing, feedback, etc.). Monitor patient. What special tests would be used? Describe the PT interventions.

-Special tests to rule in bicipital tendinopathy: Speed's test -Other special tests to rule in bicipital tendinopathy: upper cut -PT intervention: Have patient perform shoulder abduction with UR cueing and could have patient work on prone Y's to facilitate LT to assist with UR.

Card 3. ICF Classification: Subacromial Pain (SAP) with Mobility Deficits Physical Examination: Perform a Static Observation to assess the static position of the scapula using an inclinometer: A) Upward Rotation or B) Anterior Tilt. Note: Perform a bilateral comparison, right-sided involvement. Explain findings to the patient in layman's terms. Right-sided involvement. PT Intervention: Provide a "reset" technique to the right Glenohumeral Joint to maintain shoulder flexion for a patient in the proliferation stage of tissue healing with moderate tissue reactivity. Dosage (e.g., grade, reps, sets, oscillations, hold time, range, position, pain reproductions, etc.) Helpful Hint: Maintain mobility = Grade II translatoric glides *Describe normal values for UR and ant. tilt in static *Describe PT intervention

-Static: UR (5° on spine of scapula) -Static: Anterior Tilt (13.5° on smooth triangular space to inferior angle) -PT Intervention: Grade II GH Jt mob to maintain shoulder flex in OPP -Posterior glide for 4 sets of 30 sec (oscillations) of large amp must be performed at beginning to mid range

Card 11. ICF Classification: Subacromial Pain (SAP) with Movement Coordination Deficit Physical Examination - AROM with Ameliorating/Corrective Maneuver: The patient has right anterolateral shoulder pain while performing end-range arm elevation tasks. Perform one (1) ameliorating or corrective maneuver to either the right scapular (i.e., upward rotation, posterior tilt) or humerus (i.e., external rotation, translatoric glide) and determine its effects on the patient's symptoms. Explain findings to the patient in layman's terms. PT Intervention: Provide a"retraining" techniqueto the right shoulder girdle to promote posterior scapular rocking/tilting or upward rotation and facilitation of the serratus anterior muscle. Dosage: (e.g., sets, reps, resistance, exercise choice, position, cueing, feedback, etc.). Monitor patient. What special tests would be used? Describe the PT interventions.

-have patient go into shldr abd and provide assistance with UR of scapula with cueing PT intervention: -SA exercises for UR: scap wall push ups, supine protraction w/DB

Card 17. ICF Classification: Subacromial Pain (SAP) with Mobility Deficit Physical Examination - Muscle Length Assessment: The patient has right anterolateral shoulder pain. During the Static Observation you note excessive scapular anterior tilt, downward rotation, and internal rotation on the right. You note right coracoid tenderness on the right. Perform a Muscle Length Assessment to determine if a tight or shortened anterior scapulothoracic muscle may be the cause. Note: Perform a bilateral comparison. NB: Explain findings to the patient in layman's terms. PT Intervention: Provide a "reset" stretch technique (e.g., static, hold-relax, or contract-relax) to the right pectoralis minor/major muscle. Please provide an adequate stretch dosage (e.g., hold time, sets, intensity) as well as providing the patient with a "reinforcement" home program to maintain muscle extensibility gains. Monitor for pain reproduction. Describe the PT interventions.

1. Excess Ant. Tilt (>13.5°) static 2. Excess DR (0°?) static 3. Excess IR (> 41°) static 4. Notice R coracoid process tenderness on the R...excess DR, ant tilt caused by pec minor, levator, rhomboid tightness 5. Pec Minor test: Have patient lie supine and measure distance between posterior aspect of acromion to the table. Should be about 2 finger width (2.54cm), if tight/short >2.54cm -PT intervention: 1. Pec minor stretch: Pat lies supine w/shldr at 90ABD/90ER. PT applies posterior force into coracoid process and externally rotate arm. 2. Dosage: static stretch for 30 sec...2 min total for mob deficit 3. CR: (7,15,20) perform 2-3 sets 4. HEP for pec minor stretch: with a mob band, look around door or sturdy bed post at hip height and place close to neck of scapula...have pat step forward to stretch pec minor. 3x30" holds -can also do pec mini wall stretch

Card 13. ICF Classification: Subacromial Pain (SAP) with Mobility Deficit Physical Examination - Muscle Length Assessment: The patient has right anterolateral shoulder pain. During active range of motion & dynamic assessment you note that the patient lacks adequate humeral external rotation on the right. Perform Muscle Length Assessment to two (2) of the following muscles (i.e., Latissimus Dorsi, Pectoralis Major - Costal Fibers, & Teres Major) to determine which might be responsible for the inadequate humeral external rotation. Note: Perform a bilateral comparison. NB: Explain findings to the patient in layman's terms. PT Intervention: Provide a muscle stretching "reset" technique to the muscle tested above for a patient in the early remodeling (maturation) stage of tissue healing with low tissue reactivity. Dosage (e.g., grade, sets, hold time, pain reproductions, etc.) Note: Static or Proprioceptive Neuromuscular Facilitation (PNF) stretching (i.e., contract/relax, hold/relax). What special tests would be used? Describe the PT interventions.

1. Have patient perform scaption to loom for olecranon to see if ER is inadequate. Can also check with having them perform PROM and AROM of ER supine. 2. Perform muscle length assessment on 2 of the following (IRs) to see if they limit hum ER. -Lats: Have patient lie supine with knees bent. Place one hand on the SP of L3 and take arm into full flex. Stop when SP elevates off PTs finger (reached R2). 180° of shldr flex =normal, <180° means lats are tight/short. -Pec Major-Costal Fibers (shldr at 120° flex) The PT should perform H.ADD from 150° flex/abd to the second tissue barrier. Arm should be able to horizontal w/table with an additional 15-20° of OP. -Teres Major: take patient perform shldr flex and see when the lat. border pops out to see if teres major is tight before full ROM is achieved. Should have 120° of GH flex. T. major is tight if <120° is achieved.... or 90/90 ER with palm on lat border of scapula, take patient into ER. ***tight t. major can cause greater UR of scap due to scap and hum not adequately separating during arm elevation. *Perform B/L. Start with L side first. PT intervention: Since all IRs...stretch into ER. Perform HR or CR with pat at end range of ER push into IR for 7 sec, stretch for 15 sec, then rest for 20 sec.

Card 9. ICF Classification: Subacromial Pain (SAP) with Mobility Deficit Physical Examination - AROM ("Scarecrow Test"): The patient is a 25-year-old right-handed collegiate baseball pitcher. With the patient in sitting and their shoulder abducted to 90° measure active shoulder internal rotation. Note: Perform a bilateral comparison, right-sided involvement. NB: Was this movement painful? If so, was the pain familiar? Where in the range did it occur? How intense was the pain? NB: Was the active movement asymmetrical? If so, does the patient have Glenohumeral Internal Rotation Deficit (GIRD) (Recall: 15° asymmetry)? Explain findings to the patient in layman's terms. PT Intervention: Provide a manual Mobilization with Movement (MWMs) "reset" technique to the right posteroinferior glenohumeral capsule to reduce Glenohumeral Internal Rotation Deficit (GIRD). Example: "Glide & Wind" technique either oscillations or 1-minute hold (with or without a mobilization belt). Dosage (e.g., grade, force, reps, sets, oscillations, hold time, range, position, pain reproductions, etc.) What special tests would be used? Describe the PT interventions.

1. Scarecrow test. Patient sits and performs IR with shldr ABDd to 90° 2. First record active IR rotation of L then the R. Landmarks (stationary: vertical, moving arm: ulnar styloid process, fulcrum: olecranon). Check for symmetry. 3. When patient performs IR on R side, ask if the movement is painful? Is the pain familiar? 4. Where in the range was it painful? On a scale from 0-10, how intense was the pain? 5. See if asymmetry is caused by GIRD. (patient should have 180° of motion IR+ER combined, regardless of asymmetry) IR B/L >15° between involved and uninvolved side = GIRD PT intervention: -Glide and wind: Pt lies supine with shldr ABD between 60-120° and IR position BUT HAND IS ROTATED INTERNALLY (palm facing out). Posterior glide on humeral head -The PT passively glides the humerus posterior into resistance then the PT passively ERs humerus to end range. Can take pt from neut to ER (R2) or IR to ER (R2). -Perform grade III or grade IV close to end range of ER oscillations -Dosage: 4x 30 sec oscillations

Card 6. ICF Classification: Subacromial Pain (SAP) with Mobility Deficit Physical Examination: Perform a Dynamic Observation to assess the Hand Behind Back (HBB) functional ability. Note: Perform a bilateral comparison, right-sided involvement. NB: Was this movement painful? If so, was the pain familiar? Where in the range did it occur? How intense was the pain? Was there scapular winging (i.e., Kibler I-III)? Was there a mobility deficit? Explain findings to the patient in layman's terms. PT Intervention: Provide a joint mobilization "reset" technique to the right Glenohumeral Joint to increase shoulder extension for a patient in the early remodeling (maturation) stage of tissue healing with low tissue reactivity. Dosage (e.g., grade, reps, sets, oscillations, hold time, range, position, pain reproductions, etc.) What special tests would be used? Describe the PT interventions.

1. Patient can stand or sit. Have patient place L hand behind back (includes GH IR/Ext/ADD) and (includes ST IR/DR/Ant tilt). Have patient perform on R arm. 2. Was the movement painful on the R? If so during which motion? Is the pain familiar? On a scale from 0-10, how intense is the pain? 3. Check for scapular winging. Kibler (I-III) 4. Can include OP with ADD, IR, or Ext to see if any of those reproduce pain. (Only apply Op if the active motion does not produce (+) or re-produce (++) symptoms. Do the OP provoke or ameliorate symptoms? 5. Was there a mobility deficit? Hypomobile. 6. Joint mobilization to increase GH ext during early remodeling (so must be done in OPP) PT intervention: -ANTERIOR GLIDE in OPP. Patient prone on edge of table with towel under GH jt. Apply a grade I distraction and grade III or IV translatoric glide. Hand 1: grasp the posterior aspect of the proximal humerus, hand 2: grasp the post aspect of distal humerus. 4 sets of 30 sec

Card 10. ICF Classification: Subacromial Pain (SAP) with Mobility Deficit Physical Examination - AROM with Over-pressure (OP): During the subjective examination the patient reports moderate (5/10) right shoulder pain during prolonged or repetitive arm elevation activities at work. However, during the AROM portion of the physical examination (PE) the patient reports no pain provocation (0/10). Please apply up to 3-ramped OPs at end-range for one of the following active movements (i.e., flexion, scaption, or abduction). Note: Perform a bilateral comparison, right-sided involvement. Does this maneuver reproduce your patient's pain? Explain findings to the patient in layman's terms. PT Intervention: Provide a joint mobilization "reset" technique to the right Glenohumeral Joint to increase shoulder flexion for a patient in the late remodeling stage of tissue healing with no tissue reactivity. Dosage (e.g., grade, reps, sets, oscillations, hold time, range, position, pain reproductions, etc.) What special tests would be used? Describe the PT interventions.

1Provide patient with OP during flex, scap or abd. Take to end range and apply 3 OPs in each direction to see if there is a reproduction of pain. Does this movement produce pain? Is it familiar? ***only apply OP if the active motion does not produce (+) or re-produce (++) PT intervention: -inf glide with shldr flex to near end range w/elbow bent. -Grade III or IV -4x30 sec oscillations

Card 23. ICF Classification: Subacromial Pain (SAP) with Mobility Deficit Physical Examination - Joint Play Assessment: The patient has right anterolateral shoulder pain at end range arm elevation. Perform Joint Play Assessment (JPA) to the Scapulothoracic Joint (i.e., scapular superior/inferior glide & upward/downward rotation). Note: Perform bilateral comparison. NB: 1) This is a stiffness dominant patient and 2) Explain findings to the patient in layman's terms. PT Intervention: Provide a joint mobilization "reset" technique to the right Glenohumeral Joint to increase shoulder abduction for a patient in the late remodeling (maturation) stage of tissue healing with no tissue reactivity. Dosage (e.g., grade, reps, sets, oscillations, hold time, range, position, pain reproductions, etc.). Describe the PT interventions.

PT intervention: Grade III inferior glide near restriction to increase ABD. 4 sets of 30 sec (oscillations)

Card 1: ICF Classification: Subacromial Pain (SAP) with Overuse/Overload Subjective Examination: The patient is a 33-year-old tree trimmer that has right shoulder pain while working overhead. Hobbies: Plays tennis with their doubles partner every Tuesday and Thursday evenings. Service: To give back to their community, the patient washes the stain-glass windows at this church on the weekends.Special Questions/Aggravating Factors: Determine occupational- &/or hobby-related activities that aggravates your patient's right shoulder symptoms. What is your patient's baseline (resting) pain level? Irritability: Are your patient's symptoms easy or difficult to aggravate? How intense are the symptoms? How long do the provoked symptoms last after the activity has ceased? PT intervention: Provide your patient with a "re-education" intervention (e.g., counseling, etc.) that match the Subjective Examination findings. *Describe the PT intervention

PT intervention: Re-educate patient on use of active rest by reducing load and frequency with his hobbies. Ask if during work he can be put in a position in which he is not reaching overhead, but instead trimming at shoulder level. For the stain glass window same thing. Ask if he can use a taller ladder to not put himself in positions that cause aggravation, which are overhead. Make sure when you are lowering your work tools to bring them closer to your body by bending your elbows, such as the chainsaw so its less stress on the shoulder. Keep elbows close to body to reduce repetitive stress and load on your shoulder. *if night pain then and sleep on back, prop involved arm on shoulder, if SL sleeper, sleep on the uninvolved shoulder and stack 1-2 pillows under involved arm to prop up, for stomach sleepers, not really recommended.

Card 7. ICF Classification: Subacromial Pain (SAP) with Mobility Deficit Physical Examination - AROM with Over-pressure (OP): The patient has shoulder pain while performing right Hand Behind Back (HBB) functional activities. Using AROM with OP determine which of the three (3) combined movements are responsible for your patient's symptoms (i.e., adduction, internal rotation, and extension). If painful, which isolated movement(s) most fully reproduced the patient's familiar pain? How intense was the pain? Note: Perform a bilateral comparison, right-sided involvement. Explain findings to the patient in layman's terms. PT Intervention: Provide a joint mobilization "reset" technique to the right Glenohumeral Joint to increase shoulder extension for a patient in the early remodeling stage of tissue healing with low tissue reactivity. Dosage (e.g., grade, reps, sets, oscillations, hold time, range, position, pain reproductions, etc.) What special tests would be used? Describe the PT interventions.

Physical Exam 1. AROM w/OP for HBB w/OP applied to ext, ADD, IR. 2. With each OP ask patient if they are having a reproduction of pain. Is it familiar? Ask after each OP. 3. On a scale from 0-10, what is your pain level? 4. Perform B/L. L first PT intervention: -GH Jt mob to inc shldr ext in prone (Ant. Glide) place patient prone in OPP with shldr ABD 55° and H.ADD 30° if possible. -Dosage: 4 sets od -30sec of oscillations of Grade III(large at mid-end range) or IV (small at end range) -Position: Place pat in OPP 7. Pain reproduction: *shldr extension measurement (0-60°), (prone, stationary arm: // to trunk, moving arm: // to humerus (lat. Epicondyle), axis: tip of acromion) *can have patient do motion again and ask if the pain reproduction is the same as it was before.

Card 16. ICF Classification: Subacromial Pain (SAP) with Mobility Deficit Physical Examination - Passive Range of Motion/Muscle Length Assessment: The patient has right anterolateral shoulder pain and limited passive shoulder External Rotation. Perform two (2) PROM assessments to differentiate between tightness of the Subscapular Muscle and Adhesive Capsulitis (global capsule). Note: Perform a bilateral comparison. NB: Explain findings to the patient in layman's terms. Was this a Joint Mobility Dysfunction or a Tissue Extensibility Dysfunction? PT Intervention: Provide a muscle stretching "reset" technique to the muscle tested above for a patient in the late remodeling (maturation) stage of tissue healing with no tissue reactivity. Dosage (e.g., grade, sets, hold time, pain reproductions, etc.) Note: Static or Proprioceptive Neuromuscular Facilitation (PNF) stretching (i.e., contract/relax, hold/relax). What are the Subscapularis and adhesive capsulitis tests? Describe the PT interventions.

Physical Exam: -Subscap test: take patient into 90° of ER by side, see if tightness -Adhesive capsulitis test: Take patient into 90ABD/90ER to see if there is tightness/pain. Will have less PROM of ER in this position PT intervention: 1. Subscapularis muscle stretch: can do HR or CR going into ER (7, 15, 20) near end range bc IR are tight. 2. Ask about pain

Card 15. ICF Classification: Subacromial Pain (SAP) with Mobility Deficit Physical Examination - Passive Range of Motion: The patient has right anterolateral shoulder pain and a positive "Scare Crow" Test on the right. Perform one (1) PROM assessment to rule in or rule out Glenohumeral Internal Rotation Deficit (GIRD). Note: Perform bilateral comparison. NB: Explain findings to the patient in layman's terms. PT Intervention: Provide a manual Mobilization with Movement (MWMs) "reset" technique to the right posteroinferior glenohumeral structures. Example: "Glide & Wind" technique either oscillations or 1- minute hold (with or without a mobilization belt). Dosage (e.g., grade, force, reps, sets, oscillations, hold time, range, position, pain reproductions, etc.) What special tests would be used? Describe the PT interventions.

Physical Exam: 1. (+) scarecrow means loss of IR 2. Assessment to rule out GIRD: measure IR and ER and measure B/L. If more than 15° difference between L and R IR in shoulders, and loss of total rotation (less than 180°) then GIRD. They may also have a (+) sulcus sign and tight pec minor PT interventions: -Mob for 2 min -If lacks IR, tight external rotators so take arm to 90°ABD (forearm IRed so facing out) and then into end range of IR, posterior glide on humeral head and perform oscillations into end range. 4 sets of 30 sec or static hold for 1 min.

Card 12. ICF Classification: Subacromial Pain (SAP) with Mobility Deficit Physical Examination - Apley's Scratch Test - 3-Tests: The patient has right anterolateral shoulder pain while performing end-range functional tasks. Instruct the patient to perform all three (3) directions of the Apley's Scratch Test to determine functional ability (e.g., eating/shaving, grooming hair/scratching upper back, and hand behind back activities). Also determine each of the 3-movements effect on the patient's right shoulder symptoms. Explain findings to the patient in layman's terms. PT Intervention: Provide a joint mobilization "reset" technique to the right Glenohumeral Joint to increase shoulder flexion so that they can groom their hair for a patient in the late remodeling (maturation) stage of tissue healing with no tissue reactivity. Dosage (e.g., grade, reps, sets, oscillations, hold time, range, position, pain reproductions, etc.) (Week 3) Helpful Hint: Shoulder positioned near resistance in approximately 90° of shoulder flexion. What special tests would be used? Describe the PT interventions.

Physical exam: 1. Have patient perform Apley's scratch test (3 directions) Ask if any of the motions reproduce pain. -1. Have patient reach across their chest and the hand of affected arm to the opposite shoulder. *Observe if patient is unable to do so (inability to do this include restrictions in GH H.ADD/IR, Scap protraction (ADD and IR) -2. Have patient perform an overhead reach and try and touch superior angle of opposite scapula, *observe if they are unable to do so. (inability to do this would include restrictions in GH flex/ER/ABD, and scapular UR/Post Tilt/Elev/Retract (ADD/ER)) PT intervention: Either posterior or inferior glide is needed, depending on how high their can get their shldr. Glide near restriction. -Grade III glide, 4 x 30 sec (oscillations)