Shoulder Pain.
By Omer Turkmen, Swinburne Physiotherapy Student.
CLINICAL REASONING FORM
This template was gratefully adapted from La Trobe University’s Postgraduate Physiotherapy Degree.
SECTION ONE - PLANNING: To be completed after the subjective examination
First Name/Initials: KH
Main problem: Tension in suboccipital neck muscles especially near C5 and shoulder blade
A. COMMUNICATION
1. What is the patient’s main problem?
Tension in suboccipital neck muscles especially near C5 and shoulder blade
Also noticing p&n on keyboard all day
Dizziness associated with neck tension
2. What are the patient’s main functional limitations?
Dizziness
Feels like she loses balance
Pins and needles on keyboard all day
Difficulty moving neck in prolonged sitting during/after office job
3. What are the patient’s expectations of the consultation?
Address and minimise symptoms
Seek physiotherapists advice on possible treatment, exercises, general advice
Identify management strategies for future
Exercises to do at home/work to help relieve symptoms
B. CLINICAL PATTERN
1. Do the subjective findings appear to be consistent with a particular disorder/condition?
Clinical Pattern
Features from the subjective consistent with the pattern
Tension in suboccipital neck muscles and shoulder blade
Neck pain/discomfort
Sits many hours in office job, could naturally be in slouched position for hours
VBI
Dizziness, loses balance
Discogenic neck pain
Neck pain/discomfort
Facet joint irritation+nerve compression
Neck pain/discomfort
P&N when on keyboard
Cervical radiculopathy
Neck pain/discomfort
P&N down to arms when sitting on keyboard all day
Peripheral nerve entrapment
P&N down to arms when sitting on keyboard all day
Cervical Osteoarthritis
Reported degeneration in C5
Neck pain/discomfort
Cervical myelopathy
Dizziness
Degeneration reported in C5
Vertigo
Dizziness
2. What is your hypothesis of the most likely source(s) and pathobiological mechanism(s) of the symptom(s)? Give reasons for your answer.
Suboccipital neck tension due to minimal movement and slouched position during office job.
Condition appears to be muscular in nature as tension is dull and localised to neck and shoulder blade
P&n could be due to nerve compression which could minimise supply to nerve in constant position on keyboard
Shoulder blade issues likely due to remaining in seated position for long hours
Dizziness and loss of balance could be due to referred pain from Cx spine, or possibly have a vestibular issue such as vertigo
3. Do you feel there are any contraindications or that caution is required in assessment or treatment? Please specify:
Must rule out myelopathy with VBI
No associated trauma → fracture unlikely
No signs of systemic illness
Mentioned C5 degeneration has been confirmed beforehand so should keep in mind that
C. PHYSICAL EXAMINATION
1. What are your aims for the initial consultation?
To understand client’s presenting issues/ concerns
Complete subjective Ax (i.e. mechanism of injury, symptoms and their location, 24h pain pattern, pain scores on movement + rest, aggravating and easing factors, medications, medical history and red flag screening
Complete full objective (i.e. body structure/ function and activity-based tests palpation, Cx ROM, VBI screening, DNF strength ax
Patient driven goal setting
Education surrounding why injury occurred, and management strategies.
Provide a HEP they can complete until next physio session
Rapport building (encompasses the other elements of the initial)
2. Outline a realistic physical examination. Indicate how likely symptom sources and pathobiological mechanisms will influence the examination.
Cx ROM to determine what are the limiting factors and which movements aggravate and or relieve symptoms.
Palpation of C1-C7, upper Tx spine, scapula to feel areas of pain, tightness or muscle guarding
ULNT tests for p&n
Spurling’s test to rule in/out cervical radiculopathy
Neurological tests (dermatomes, myotomes, reflexes) due to symptoms radiating past shoulder to assess sensation, strength and reflexes giving an indication of the nerves involved
Examination findings and interpretation
1. What are your hypotheses/findings in the following categories? Justify your answers.
Symptom sources and mechanisms
Hypothesis of source/tissue mechanism
Supporting features from subjective and physical examination
Negative features from subjective and physical examination
Tension in suboccipital neck muscles and shoulder blade
Prolonged sitting in job, could lead to constantly slouched position
C5 degeneration could possibly mean neck isn't able to sustain positions efficiently for long time, suboccipital neck muscles take greater load
Palpation indicates suboccipital neck muscles and levator scap are tender
Pain more localised to suboccipital neck muscles won’t explain p&n
Vertigo
Patient reported to have vertigo upon further questions in subjective ax
Won't cause the neck and shoulder blade pain (must be a separate condition)
VBI
Reported dizziness and loss of balance
5D’s, 3N’s, 1A negative
Discogenic neck pain
Cx stiffness
Suboccipital neck muscle tension
Cx AROM esp. flexion not provocative (commonly flexion is provocative but can be other movements as well)
Facet joint irritation+nerve compression
p&n present in arms
Cx spine stiffness
Cx AROM esp. extension not provocative (commonly extension is provocative but can be other movements as well)
Cervical radiculopathy
p&n present in arms
Neck pain
Didn’t assess Spurling’s and ULNT
p&n normally arises when sitting on keyboard so must be more so peripheral nerve compression
Peripheral nerve entrapment
p&n present in arms esp. On keyboard all day
Didn’t assess ULNT
Cervical Osteoarthritis
C5 degeneration confirmed
Cx spine feels tight which could be attributed to suboccipital neck muscles overworking to compensate for stability component that
Unlikely to cause neurological symptoms
Cervical myelopathy
Dizziness
p&n in arms
VBI screening -ve
2. Psychosocial impairments, attitudes and beliefs
Stress + fatigue attributed to work and lockdowns
Seems to be open to exercising and finding active strategies to manage her situation
No signs of fear avoidance or apprehension
Seems to have an idea of what to expect from physio and what needs to be done
3. Physical impairments
Cx spine and shoulder blade tension
p&n down to arms
Dizziness
4. Functional limitations
Uncomfortable during work throughout the day
More difficulty with prolonged sitting
Pain with looking around whilst driving
5. Contributing factors
Prolonged sitting, slouched position in office job
C5 degeneration
Stress from work
2. What further examination procedures will you perform to assist in testing your hypotheses?
ULNT tests for p&n
Spurling’s test to rule in/out cervical radiculopathy
Neurological tests (dermatomes, myotomes, reflexes) due to symptoms radiating past shoulder to assess sensation, strength and reflexes giving an indication of the nerves involved
3. Are there investigations or imaging modalities that might be indicated for this patient? Justify your answer.
Most neck pain tends to be due to suboccipital muscle neck tension and forward slouching
Imaging could also display degenerative changes in asymptomatic people
Imaging not a concern unless patient was getting progressively worse or unless there was a suspected red flags
B: Management / Discharge planning
1. Describe and justify your initial treatment and summarise its immediate effect.
Education on scans - degeneration is common, what matters is what is causing what you're feeling
STW on trapezius and suboccipital neck muscles // felt looser and more relaxed
2. a) What are your short term goals with this patient? Include timeframes.
Reduce pain in neck and shoulder blade in 1/52
Return to work and review 1/52
Asked about goals but didn't address anything apart from reducing pain/discomfort in neck and shoulder blade
b) What techniques will you use to achieve these goals?
STW to increase blood flow and desensitise area, could also consider dry needling as an alternative
Stretching to relieve tension
Patient education surrounding HEP and management strategies
Exercises and HEP
Ask when patient will be able to perform exercises during the day
c) What outcome measures will you use to measure the short term treatment effect?
Recovery %
NPRS at rest and on movement
ROM
3. a) What are your long term goals with this patient? Include timeframes.
Improve muscle strength and conditioning in 6/52
b) What techniques will you use to achieve these goals?
Strengthening DNF and surrounding musculature
Patient education surrounding HEP and management strategies
Progression of HEP where appropriate
Ask when patient will be able to perform exercises during the day
c) What outcome measures will you use to measure the long term treatment effect?
Recovery %
NPRS at rest and on movement
Exercise technique, repetitions, weight
4. Do you feel that input from other Health Care Professionals will be necessary to achieve an optimal outcome? If so, describe.
Possibly psychologist if she is feeling stressed/overwhelmed with work
C: Prognosis / Discharge planning
1. List the factors that indicate a favourable prognosis.
Seems to be muscular, localised tension so should respond well to STW
2. List the factors that indicate an unfavourable prognosis
Age
Stress
C5 degeneration may bring about tension as suboccipital neck muscles take on greater load to stabilise neck
3. What do you believe will constitute a successful treatment outcome for this patient?
Find active strategies to manage neck and shoulder blade tension
Regularly move and be active every hour or two during work
Find strategies to manage an overall healthy lifestyle with stress, nutrition, exercise etc.