Download I - APTSA

Physical Therapy for Shoulder Joint
I.
BASIC DATA:
Chart number: _______
Name:_______
Age:_____ Gender: ○M ○F
DATE:_____/_____/_____
Body weight: ____Kg; Body Height: ____cm; Date of PT starting: _____/_____/____
Impression:
Involved shoulder: □ right □ left
Dominant shoulder: □ right □ left
Work status: □ Not working
□ Working
Brief history: (Onset, causes, duration, pain status, affecting factors, and previous history should be
included.) night pain: □ yes □ no; Visual analog scale:
Does pain increase in the
previous one month □ yes □ no
Frequency: □ pain all the time
□ per day
□ per week
II.
PHYSICAL EXAMINATION:
1. Observation:
Shoulder Posterior view
□Both sides are horizontal
□Elevated/depressed
Shoulder Lateral view
□Plumb bisects acromion
□Tilt
□Forward (round shoulder)
Scapula Posterior view
□Medial borders are
□Adducted / Abducted
parallel, about 2” from the spine
□Downward / Upward rot
□Elevated / Depressed
Scapula Lateral view
□Scapula held flat against
□Winged
the thorax, 30° anterior to
□Tipped Anteriorly
frontal plane
Humerus posterior view
□Olecranon processes face posteriorly
□Internally/Externally rotated
Humerus lateral view
□Distal humerus vertically
□Distal humerus anterior/
in line with the proximal humerus
posterior to the proximal
2. Palpation:
Muscle origin and insertion as well as bursa;
tenderness to palpation in the region of the greater tuberosity, acromion, or rotator
cuff tendons
3. Selective tissue tension test
Active:
Pain1;Willingness1
Flexion
Abduction
Internal rotation
External rotation
1
+: positive; -:negative
. Range: initial, mid, end
3
Hard, firm, soft, empty
4
Strong, weak
2
Passive:
Resisted:
Pain1,2; Endfeel3 Pain1; Strength4
4. Range of motion
Left arm
Movement
Right arm
Flexion
Extension
Abduction
Internal rotation arm by side
External rotation arm by side
Internal rotation 90 degrees abd
External rotation 90 degrees abd
Anterior shoulder tightness5
Posterior shoulder tightness5
5. Joint play:
Anterior-posterior6
Superior-inferior6
Glenohumeral joint:
Scapulothoracic joint:
Acromioclavicular Joint:
6. Movement analysis
scapulo-humeral rhythm
Rhythm7
Arm ascending
Arm descending
5
6
7
8
Additional information
Hyper or hypo mobility
Normal or abnormal
+:positive ot -:negative
Pain8
7. Muscle dysfunction test9
Strength9
Tightness9
Pectoralis minor
Levator scapulae
Rhomboids
Trapezius Upper
Trapezius Middle
Trapezius Lower
Serratus anterior
Pectoralis major
Latissimus dorsi
Coracobrachialis
Biceps
Triceps
Pectoralis major
(upper, lower)
Teres major
Supraspinatus and
middle deltoid
Infraspinatus
Teres minor
Subscapularis
Deltoid anterior
Deltoid posterior
9. Functional activity
Performance-based tests10
HAND-IN-NECK; HAND-TO-SCAPULA; HAND-TO-OPPOSITE SCAPULA
MODIFIED KIBLER’S LATERAL SCAPULAR SLIDE TEST
Self-reported test: DASH11 and FLEX-SF12
Functional self efficacy13
Option:
9
Selected muscles as appropriate; +:positive (strong or tight); -:negative (weak or no tight); ne: not
examination; na: not available
10
See additional information for scoring
11
DASH: Disabilities of the Arm, Shoulder and Hand; http://www.dash.iwh.on.ca/
12
FLEX-SF: Flexilevel score of shoulder function; Cook, K.F., Roddy, T.S., Gartsman, G.M., Olson, S.L.
Development and psychometric evaluation of the Flexilevel Scale of Shoulder Function. Med.
Care. 200341, 823-835.
13
Functional self efficacy: Maly MR, Costigan PA, Olney SJ. Determinants of self efficacy for
physical tasks in people with knee osteoarthritis. Arthritis Rheum. 2006 15;55:94-101.
Shoulder Pain and Disability Index
Simple Shoulder Test
American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form
Quality of life
10. Special test
□ Impingment test □ Neer impingement test, □ Hawkins impingement test
□ painful arc of movement (60°–120°) □ Add tests as necessary
III.
ASSESSMENT: (Problems and reasons should be added.)
IV.
PT PROGRAMS:
V.
HOME PROGRAMS: