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Jenna Faiella
MSE Assignment
Problem I:
N.J. was born in 1993 and is currently in her first semester of graduate school. Her chief
complaint consists of intermittent right shoulder pain. She attributes this onset of pain after having a
partial labral tear in her right shoulder. This injury occurred two years ago after falling onto an
outstretched hand while playing soccer. After receiving an X-Ray and MRI, it was confirmed that she
had a partial posterior tear of her labrum and was advised to receive physical therapy for her injury.
While receiving rehabilitation, she started to experience pain in the anterior region of her shoulder, as
well as the scapular region, while she was doing various strengthening exercises. Due to insurance
reasons, she decided to forego physical therapy after experiencing this new pain and did not go back
for further treatment of her partial labral tear.
II. Subjective:
o Current condition/chief complaint(s): The patient reports that her R shoulder pain began
2 years ago. This pain occurred while receiving physical therapy for a partial posterior
labral tear, as the exercises she was performing started to cause a new pain in the
anterior region of her shoulder and R shoulder blade. She stated that exercises
performed at or above her shoulder level seemed to aggravate the pain the most and
caused her to stop participating in therapy, as well as because of insurance reasons. This
was the first time she had experienced anterior and scapular shoulder pain and had no
similar problems related to her shoulder, besides the labral tear. Currently, she
experiences pain at night and in the morning when she wakes up after sleeping in certain
positions. Pain also occurs when she reaches above shoulder level or holds positions for a
sustained amount of time. She rated the pain as an 8/10 on the Numeric Rating Scale
(NRS) at worst and her current pain while sitting at a 1/10. The patient describes the pain
as mostly “dull and achy,” but sometimes is a quick sharp pain that occurs in an instant
and will go away when her shoulder is at rest. She states that resting and holding her arm
in the position such as if she were to have a sling on (at her side, supporting her forearm
across her chest) relieves the pain. Since she is currently in graduate school, she is sitting
as her computer for long hours in a static position and notices that the she will gradually
experience pain in the anterior part and scapular region of her R shoulder after sitting for
a long time typing on the computer. She copes with the problem by finding ways to
relieve the pain and not putting her shoulder in positions that will further aggravate it,
especially overhead movements.
o Current Functional status/Activity level: As a result of the patient’s pain, she is no longer
able to perform upper extremity exercises that she used to do such as lifting weights
because of the pain that it has caused her. She has a part-time job as a waitress and can
no longer hold the tray with her right upper arm because her shoulder becomes weak
and tired so she has adapted to holding the tray with her left hand instead. Other than
that, no adaptive/assistive devices are needed during physical activities and she is
independent with mobility, gait, and other activities.
o Social history: There are no cultural/religious beliefs affecting patient care. Patient lives
with her aunt and says she has a strong support system if she ever needed help.
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MSE Assignment
o Employment status: As stated above, patient works part-time as a waitress and has
switched to holding the tray when carrying food out to the unaffected side instead. She is
also a full-time student and experiences pain while working at her computer for long
hours, holding her book bag on the right shoulder, as well as reaching down to pick up
the book bag.
o Living environment: There are no environmental obstacles that the patient must
overcome or accomplish due to her condition/injury.
o General health status: N.J. considers her health status as “good,” but would like it to be
better. She attributed not being able to exercise as much as she wants to due to having a
busy schedule with school and work. During the past year, she moved from living at home
with her parents to living with her aunt because it was closer to attend school.
o Social/health habits: Occasionally will have 1-2 drinks on the weekend, does not smoke,
exercises 2x/week doing abdominal and lower body strength training such as planks, squats,
lunges, and various other lower body strengthening machines at her local gym.
o Family health history: Heart disease, pancreatic cancer, asthma
o Patient’s Medical/Surgical history: X-ray and MRI for posterior labral tear: May 2013
Spinal Fusion from C7-L5 for Scoliosis: 1996
o Medications: None
o Other clinical tests: Nerve Conduction Testing for Brachial Plexus: Negative (June 2014)
o Patient goals (for PT):
Short Term Goal (STG)
1. Decrease pain in R shoulder
2. Increase strength in shoulder and back muscles
Long Term Goal (LTG)
3. Eliminate pain completely in order to be able to perform upper body strengthening exercises
at the gym
III. PHYSICAL EXAMINATION:
Objective
 Review of Systems
System:
Results:
Cardiovascular/Pulmonary
HR: 62 bpm
RR: 14 breaths/minute
BP: 110/78 mmHg
Edema: Not present
Impaired/Not Impaired
Not Impaired
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MSE Assignment
Integumentary
Musculoskeletal
Communication Ability
Affect
Cognition
Learning Barriers, Learning
Style, Educational Needs
Postural Assessment:
Static Sitting
Static Standing
Observations:
Palpation
Scapular Assistance Test
Modified Scapular Test
Not applicable
Gait
Locomotion
Balance
Motor Function
Not impaired
Not Impaired
Not Impaired
Oriented to person, place,
time: oriented x 3
-Patient wears contacts daily
-Learns best with pictures,
visual information, hands on
demonstration
-Would like to more
information on healing
process/exercises she can
perform safely and without
pain
Not impaired
Not impaired
Observations:
 Slouched in chair
 Forward Head
 Posterior Pelvic tilt
 Left shoulder lower than Right (Due to corrective
surgery for scoliosis, patient stated that after
surgery, shoulder height was still not able to be
completely aligned in a horizontal fashion and right
shoulder was still a little higher than left)
 Scapular Winging bilateral – (upward rotation and
anterior tilt of scapula- R scapula winging more than
left)
 Normal spinal curvatures (Due to fused vertebrae
after corrective surgery for scoliosis)
Results
Increased tenderness when palpation to R anterior
acromion region
Positive- N.J. experienced decreased pain with assistance
Positive – Patient’s pain was reduced when given
assistance with scapular upward rotation/tilt
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MSE Assignment
Scapular Retraction Test
Positive – N.J. demonstrated increased strength when
resistance was added to static position and less pain was
noted
Upper Quarter Screen:
Dermatomes
Myotomes
Deep Tendon Reflexes
Impaired/Not Impaired
Not impaired
Not impaired
Biceps Brachii (C5): 2+
Brachioradialis (C6): 3+
Triceps Brachii (C7): 2+
[Not Impaired]
Range of Motion
AROM vs.
PROM
AROM (all)







Shoulder Movements
Flexion
Extension
Horizontal Adduction
Horizontal Abduction
Abduction (Scapular Plane)
Internal Rotation
External Rotation
Left
L shoulder AROM
normal
Right
R shoulder AROM
normal
EXCEPT:
R Internal Rotation:
50° due to pain
Manual Muscle Testing: Isometric Break-Test
Manual Muscle Testing
Motion/Muscle Tested
Left
Right
(Isometric Break Test
for all)
Flexion
5/5
3+/5 Pain
Extension
5/5
5/5
Abduction
4/5
3+/5 Pain
IR
5/5
5/5
ER
5/5
3+/5 Pain
Serratus Anterior
5/5
5/5
Upper Trap
4+/5
4/5
Middle Trap
4/5
3/5 pain
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MSE Assignment
Lower Trap
4/5
3/5 pain
Rhomboids
4/5
3/5 pain
Flexibility testing2
Muscle tested:
Pectoralis Minor Muscle
Length
Patient Position
-Patient supine, arms at side,
shoulders laterally rotated
-Forearms supinated
-Measurement taken from
posterior border of acromion
process to table
Special Test:
Hawkins-Kennedy
Testing for:
Subacromial Impingement
Drop Arm Test
ER Lag Sign
Yergason’s Test
Rotator Cuff Tear (Supraspinatus)
Rotator Cuff Tear (Infraspinatus)
Bicipital Tendinopathy
Results:
L: 2 inches  6.35 cm
R: 3 inches  7.62 cm
[When compared to the gold
standard of 2.6 cm (about 1
inch) for pec. Minor length,
patient has significant
pectoralis minor tightness
bilaterally]
Results: Positive/Negative
Positive on R shoulder
Similar pain was reciprocated
when test performed on R UE
Negative
Negative
Negative
Assessment:
1. Possible hypothesized diagnoses that my patient presents with include:
 Subacromial (anterior) impingement syndrome (SIS)
 Rotator cuff tear (RTC Tear)
 Bicipital tendinopathy
Initially, the location and nature of the patient’s pain lead me to think of subacromial
impingement syndrome (SIS) because of pain with overhead movements and the location in
which she pointed to (directly underneath the acromion, in the subacromial space). N.J. also
stated that certain movements such as reaching across her body would cause a quick, instant
pain along the anterior aspect of her shoulder and her arm would feel better when she held it
down against her side, supporting it, as if she were wearing a sling. She also noted that she
would have inconsistent morning pain and would try to sleep on the unaffected side (left), but
her R shoulder would have more pain in the morning, so she tries to sleep on her back instead.
This lead me to think of SIS even more because when she slept on her left side, the right
shoulder is in an adducted, internally rotated position across the body, which is the position
impingement commonly occurs. This happens because the supraspinatus tendon is being pulled
over the humeral head and starts to compromise blood flow because of the zone of avascularity,
Jenna Faiella
MSE Assignment
which is why this tendon is particularly susceptible to impingement.1 This is also why I did not
think it was bursitis because laying on the affected side would cause pain due to compression;
however, it was the L side that caused her pain instead. Palpation to the R anterior acromion
also elicited tenderness, another classic sign of the subacromial space being impinged. Postural
assessment showed excessive winging and medial border protrusion on the R scapula. The
scapular assistance, modified scapular test, and scapular retraction tests confirmed that
assistance with these motions decreased the patient’s pain. These altered scapular kinematics
are a common finding with impingement problems and is termed “scapular dyskinesis”. 3 Manual
muscle tests showed that the rotator cuff muscles were also weak. Strong RTC muscles depress
the humeral head when the arm is elevated. However, the depressing and centralizing effect
is lost when these muscles are unable to do their job and the humeral head rides
upwards, closer to the acromion at risk of causing impingement. When the Hawkin’s
Kennedy special test was performed first on the nonaffected shoulder, and then the affected
shoulder, the patient was positive because it reciprocated the same sharp pain that she had
been feeling in her R shoulder. I started with the Hawkins-Kennedy test because it is highly
sensitive, so if it proved to be negative, I was going to be able to rule this out. However, since it
was positive, I kept impingement in the running for one of my primary diagnoses.
Pain in her scapular region, more towards the medial border lead me to think rotator cuff
muscles, specifically the external rotators, as well as the scapular stabilizer muscles. Postural
assessment showed excessive scapular winging of the right scapula, which made me think that
the scapular stabilizer muscles may be weak and further manual muscle testing confirmed there
was weakness. Reciprocation of the “dull, achy pain” was elicited during these movements,
specifically during R: shoulder flexion, abduction, external rotation, middle trapezius, lower
trapezius, and the rhomboid muscle group. Due to the dynamic stabilizers being weak, I was
able to hypothesize that the humeral head was not being depressed adequately and instead,
was being excessively displaced and possibly contributing to impingement to the subacromial
space as well.3 To rule out rotator cuff pathology, I performed the drop arm test, which
specifically targets the supraspinatus, and it was negative (patient was able to keep her arms
raised in the designated position). To further rule out RTC pathology, I performed the ER Lag sign
and Belly Press Tests to test other muscles of the RTC specifically. All of these tests were
negative. This lead me to think that instead of a RTC tear, the patient was displaying scapular
dyskinesis (which was also confirmed with the scapular assistance tests noted above).
My third hypothesized diagnosis was bicipital tendinopathy because the long head of the
biceps brachii is also in the subacromial space and could be getting impinged with overhead
movements as well. Therefore, I performed Yergason’s test and it was negative. Yergason’s is
highly specific so if it were positive, I would have been able to rule it in. This is also why I
performed a highly specific test last and the highly sensitive tests first.
In the subjective portion, the patient noted that she did not do any kind of upper
extremity strengthening exercises because of the pain that it caused her during physical therapy
when she initially went for her labral tear. Therefore, I expected strength deficits in her upper
extremity because she had not strengthened her UE for the past 2 years. I thought that her
scapular stabilizers would be especially weak because she is a student and is sitting at her
Jenna Faiella
MSE Assignment
computer all day in a slouched, rounded posture, and presented with significant scapular
winging.
When performing range of motion, she was especially limited in R shoulder Internal
Rotation, while having a normal range on the unaffected side. In concordance with the circle
concept, I hypothesized that she may have posterior capsule tightness, which may lead to more
anterior and inferior translation of the humeral head, further impinging the structures in the
subacromial space. This was confirmed through joint play of the shoulder, as the posterior
capsule was tighter on the affected side when compared to the non-affected, as well as when
compared to the anterior capsule. Also, because of the scapular winging, I hypothesized that
serratus anterior (SA) would be weak. However, the patient had exceptional strength when the
SA was tested so this was definitely an inconsistency with my hypothesis that the serratus would
be weak. Her upper and lower trapezius muscles did show weakness though, which aide in
upward rotation of the scapula with the SA, so even though the serratus was strong, it was
probably compensating for the weak upper and lower trapezius muscles. Therefore, due to the
positive Hawkins-Kennedy test and confirmation of weak scapular and dynamic stabilizers of the
shoulder, I ruled in my diagnosis of Subacromial (Anterior) Impingement Syndrome.
2..The impairments identified from my examination relate to the functional deficits of the
patient because she demonstrated weak scapular and dynamic stabilizers of the shoulder,
which was further leading to her impingement. I believe that the patient continues to perform
motions that are eliciting her pain and inflammation in the subacromial space, which is causing
her impingement to intermittently flare up and cause her pain. This pain is causing her to have
functional deficits on a daily basis because she is not able to perform upper extremity
strengthening exercises due to the pain. However, these muscles are going to continue to be
weak if she cannot strengthen them, which is why she needs adequate patient education on
the motions that are causing her pain and allow time and rest in order for the capsule to
decrease in inflammation.
3..A suggested referral could be to get an MRI to confirm findings of subacromial impingement.
However, the patient stated that because of insurance reasons, she had wanted to, but was not
able to get an MRI. Other than that, no other referrals are recommended at this time to other
health care professionals, as the patient does not exhibit any red flags to therapy.
Prognosis
 N.J. has excellent rehab potential. She is in good health, of younger age, and has a
positive attitude and wants to get better and decrease her pain as much as possible.
 It is is predicted that STG 1 of decreasing pain can be completed in 2 weeks. This will
require patient education of certain positions that will allow her impinged shoulder
to heal and not become aggravated further. It is predicted that STG 2 of increasing
her shoulder strength can be completed in 4 weeks, after the pain and inflammation
decreases, and she is able to begin isometric and resistive exercises. It is predicted
that LTG 1 of eliminating pain completely and being able to perform upper extremity
strengthen exercises on a consistent basis can be completed in 6 weeks of physical
therapy and following a home exercise program (HEP).
Jenna Faiella
MSE Assignment



Factors that could influence the patient’s prognosis could be her work and school
situation. She is sitting for long hours and then goes to work while she is on her feet
for many hours at a time, this is impacting her amount of time that she is able to
attend therapy, as she is a very busy college student. Also, patient states that she
has had pain since her last time in physical therapy, so patient may be skeptical
about the exercises prescribed to her if they further increase her pain.
There are no unusual expected outcomes or anticipated goals present.
No future services needed at this time.
IV. Plan of Care (POC):
A. Expected Outcomes:
1. Patient will be able to study for 1 hour with 0/10 pain in R shoulder in 6 weeks.
2. Patient will able to hold serving tray during work with R arm with 0/10 pain in 6
weeks.
3. Patient will be able to perform upper body strengthening exercises during exercise
classes with 0/10 pain in 6 weeks.
B. Anticipated Goals:
Short Term:
1. Patient will have 0/10 pain at rest and 2-3/10 pain during everyday activities in 2
weeks.
2. Patient will increase R external rotation strength to 4/5 in 2 weeks.
Long Term:
3. (LTG): The patient will achieve bilateral upper extremity strength (5/5) in all shoulder
motions in 5 weeks.
C. Intervention Plan:
The intervention plan for N.J. will focus on deficits including: range of motion, flexibility,
and strength. Patient will be seen 2x/week for 6 weeks (12 total visits), while following a
home exercise program (HEP). Based on the results of the examination findings, the
following interventions include:
1. Sleeper Stretch3
 Deficit Addressed: R Internal Rotation ROM
 Initial Treatment: Patient side lying with affected shoulder underneath. Uses
unaffected arm to push other arm down until stretch is felt. (See Figure 1
below)
- Hold for 30 seconds x 3 sets bilaterally. 2x day/5x week
 ROM re-evaluation will be performed at weeks 3 and 6
 Rationale: Tightness of the posterior capsule and stiffness of the muscle
tendon unit of the posterior rotator cuff have both been described as factors
that limit internal GH rotation. Tightness of the posterior capsule has also
been linked to increased superior migration of the humeral head during
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MSE Assignment
shoulder elevation (causing further impingement to the subacromial space).3
The sleeper stretch is beneficial to perform to increase internal rotation ROM
because it uses body weight to stabilize the scapula, which optimizes the
value of the stretching procedure, and patient can perform actively.
Figure 1: Sleeper Stretch





2. Cools Scapular Exercise3
Deficit Addressed: Pec Minor Length (Flexibility)
Initial Treatment: PT performs passive retraction and posterior tilting of the scapula with
the shoulder in a neutral elevation position and slight external rotation.
Hold for 30 seconds. Repeat 3x bilaterally. (Perform during PT session 2x/week)
Re-evaluation of pectoralis minor flexibility/muscle length at weeks 3 and 6.
Rationale: Patient demonstrated scapular dyskinesis during the scapular assistance test,
modified scapular test, and scapular retraction tests. When referring to a clinical
reasoning algorithm (see Figure 2 below), flexibility deficits are addressed by stretching
and mobilization techniques. Since patient had significant pectoralis minor length
deficits, adequate stretching exercises will benefit this patient. It was found that
performing retraction in a 30° forward flexion position results in the largest changes in
pectoralis minor length.3 Other stretches included performing passive horizontal
abduction with the shoulder in 90° of abduction and external rotation. However, the
authors felt that this would put the patient’s shoulder in a position that could possibly
cause pain in the case of subacromial or internal impingement, so they suggested
performing passive retraction and posterior tilting of the scapular with the shoulder in a
neutral elevation position and slight external rotation. (See figure 3 below).
Jenna Faiella
MSE Assignment
Figure 2: Scapular Rehabilitation Algorithm3
Figure 3: Cool’s Scapular Exercise3
3. Lawn Mower Exercise3
 Deficit Addressed: Scapular stabilizer strength (Especially Lower trapezius)
 Initial Treatment: Patient starts in a quarter-squat position with feet parallel, shoulder-width
apart, body slightly forward and flexed, and grasping 1 lb. dumbbell in front of the contralateral
knee. Patient pulls dumbbell by extending knee and hip, rotating the trunk, and flexing the elbow
until scapula is maximally retracted. Forearm should be supinated at end of exercise. (Refer to
Figure 4 below.)
 Perform 3 sets x 10 repetitions (1x day/5x week) with 1x dumbbell (Can be adjusted based on
patient tolerance)
 Further re-examination: Manual Muscle Testing (Isometric break testing) will be performed @
weeks 3 & 6
 Rationale: Scapular contraction can be exercised in basic positions, movements, and exercises. The
“lawn mower” exercise activates key scapular-stabilizing muscles without putting high demands
on the shoulder joint. This is important because the patient previously had pain while undergoing
physical therapy while performing shoulder exercises so starting with exercises that can target her
weak scapular stabilizing muscles, while putting the least amount of stress on the shoulder joint,
will be beneficial in the early stages of the rehab process.
[Figure 4: Lawn mower exercise. Patient performs the free-motion exercise using a dumbbell
in a diagonal pattern from the contralateral leg through the trunk to the ipsilateral arm.]
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MSE Assignment
4.

•
•
Side lying External Rotation3
Deficit Addressed: Rotator Cuff Strength, external rotators (Specifically
Infraspinatus & teres minor)
Initial Treatment: Patient side lying on a firm, flat surface. With towel under top arm,
elbow bent to 90°, 1 lb. dumbbell in hand, (can have pillow under head for comfort).
Keeping elbow against side, slowly rotate arm at the shoulder, raising the weight to a
vertical position (keeping forearm in line with elbow). Slowly lower weight to starting
position. Refer to Figure 5 below.
Perform 3 sets of 15 repetitions bilaterally. 1x/day/5x week with 1 lb. dumbbell
•
Rationale: Primary goal is to elicit high levels of rotator cuff and scapular muscular
activation using movement patterns and positions that do not increase significant
subacromial contact or undue stress to the static stabilizers of the GH joint. It was noted that
in general, three sets of 15-20 repetitions are recommended to create a fatigue response and
target the development of local muscular endurance.3 As always, these numbers are
subjective and will be individualized based on patient’s response to treatment. The addition
of a small towel roll placed in the axilla not only assists in the isolation of the exercise and
controlling unwanted movements, but this slight position of abduction has shown to elevate
muscular activity by 10% in the infraspinatus muscle. Other advantages include that the towel
places the shoulder in approximately 20-30° of abduction, preventing decreased blood flow in
the supraspinatus tendon and increasing subacromial space.3
Figure 5: Side lying ER
•
Progression: Prone horizontal abduction exercise3
Position: Patient prone with arm over edge of table, fully extended at 90°, palm facing
down. Holding a 1 lb. dumbbell, arm is lifted into horizontal extension. (See Figure 6
below)
Perform 3 sets of 15 repetitions bilaterally. 1x/day/5x week with 1 lb. dumbbell
Further re-examination: Strength testing will be performed at weeks 3 and 6.
Rationale: This exercise is used at 90° of abduction to minimize the effects from the
subacromial contact. Research has shown this position to create high levels of
supraspinatus muscular activation, making it an alternative to the widely used “empty
can” exercise, which can often cause impingement due to the combined inhered
Jenna Faiella
MSE Assignment
movements of internal rotation and elevation.1 This can be progressed by increasing the
weight of the dumbbell such as to 2 or 3 lbs.
Figure 6: Prone horizontal abduction
exercise
Further Progression: These isotonic exercises can be coupled with a standing external
rotation exercise with elastic tubing, as well as external rotation oscillation exercises.3
Outcome measure for patient: Simple Shoulder Test (Patient completed prior to examination).
Jenna Faiella, SPT 4/29/2016
Jenna Faiella
MSE Assignment
References:
1. Reese NB, Bandy WD, Yates C. Joint Range of Motion and Muscle Length Testing. St. Louis, MO:
Saunders/Elsevier; 2010.
2. Pantano, K. The Shoulder Complex Powerpoint: Rotator Cuff Disease Impingement Syndrome. DPT
774 Complex Conditions IV. Cleveland State University, 2016.
3. Ellenbecker TS, Cools A. Rehabilitation of shoulder impingement syndrome and rotator cuff
injuries: an evidence-based review. British Journal of Sports Medicine 2010;44(5):319–327.
doi:10.1136/bjsm.2009.058875.