Presenting Complaints:
A 45-year-old male presents to the clinic with complaints of persistent pain, swelling, and limited movement in his right shoulder. He reports that the pain initially started a few weeks ago and has progressively worsened. The patient mentions that the pain is particularly noticeable during activities that involve overhead movements, such as reaching or lifting objects.
History of Presenting Complaints:
The patient states that the symptoms of pain and limited mobility in his right shoulder began spontaneously and without any identifiable cause. He denies any recent trauma or injury to the shoulder. The pain has been gradually increasing in intensity, interfering with his daily activities and causing sleep disturbances.
Chief Complaints:
The patient’s chief complaints include persistent pain, swelling, and limited range of motion in the right shoulder, primarily during overhead movements.
Past Medical and Surgical History:
The patient has a past medical history of hypertension, which is well-controlled with medication. There are no previous surgical procedures or relevant medical conditions reported.
Family History:
The patient denies any significant family history of musculoskeletal disorders or tendinitis.
Socioeconomic Status:
The patient is employed in an administrative role and reports a stable socioeconomic status.
Present and Pre-morbid Functional Status:
Before the onset of symptoms, the patient had no significant limitations in his functional abilities. He was able to perform daily activities without difficulty and had an active lifestyle.
General Health Status:
Apart from the shoulder symptoms, the patient reports being generally healthy. He denies any other systemic complaints or illnesses.
Vitals:
The patient’s vital signs, including blood pressure, pulse rate, respiratory rate, and temperature, are within normal limits.
Aggravating Factors:
The patient reports that activities requiring overhead movements aggravate the pain and swelling in his right shoulder. He specifically mentions lifting heavy objects, reaching for items on high shelves, and performing repetitive movements involving the shoulder.
Easing Factors:
Rest and avoiding activities that involve overhead movements provide temporary relief to the patient’s symptoms. Applying ice packs to the affected area also offers some comfort.
Examination:
Physical examination reveals tenderness and swelling around the right shoulder joint. Active and passive range of motion tests provoke pain, particularly during abduction and flexion. The affected shoulder exhibits reduced strength during resisted movements. There are no signs of erythema, warmth, or joint deformity.
Sleep and 24-hour Pattern:
The patient reports difficulty sleeping due to shoulder pain, especially when lying on the affected side. He often wakes up during the night due to discomfort.
Duration of Current Symptoms:
The patient reports that the symptoms in his right shoulder have been present for approximately four weeks.
Mechanism of Injury/Current Symptoms:
The patient denies any specific injury or trauma preceding the onset of symptoms. The symptoms developed gradually without any specific triggering event. He reports pain, swelling, and limited range of motion as the primary symptoms.
Progression Since the Current Episode:
The patient notes a gradual worsening of symptoms since the onset. Initially, he experienced mild discomfort, but the pain has become more severe, affecting his daily activities and overall quality of life.
Significant Prior History:
There is no significant prior history of tendinitis or similar musculoskeletal conditions reported by the patient.
Previous Treatment:
The patient has not sought any prior treatment or interventions for his shoulder symptoms. He attempted self-management with rest and over-the-counter pain relievers, but the symptoms persisted.
Diagnostic Test/Imaging:
No diagnostic tests or imaging studies have been conducted at this stage. However, if the condition does not improve with conservative management, further investigations such as X-rays or MRI may be considered to rule out other underlying pathologies.
Differential Diagnosis:
Rotator cuff tendinitis
Biceps tendinitis
Subacromial bursitis
Frozen shoulder (adhesive capsulitis)
Shoulder impingement syndrome
Postural Observation:
Postural observation reveals no significant abnormalities or asymmetry in the patient’s shoulder or overall posture.
Precautions and Contraindications:
The patient should avoid activities that exacerbate the symptoms, such as overhead movements and heavy lifting. He should also refrain from activities that cause pain and discomfort.
Functional Movement Analysis (Sign):
During functional movement analysis, the patient displays limited range of motion and decreased strength during abduction and flexion of the right shoulder. These movements provoke pain and discomfort.
Quick Screening Tests/Clearing of Additional Joint Structures:
The quick screening tests, including shoulder provocation tests and assessment of nearby joints and structures, are within normal limits.
Range of Motion (ROM):
Active and passive range of motion tests indicate decreased range of motion, particularly during abduction and flexion of the right shoulder.
Special Tests:
Special tests, such as the Neer impingement test, Hawkins-Kennedy test, and Speed’s test, may be performed to further evaluate specific structures and confirm the diagnosis.
Assessment:
Based on the patient’s history, clinical examination, and presenting complaints, the assessment indicates that the patient is likely experiencing tendinitis of the right shoulder, possibly involving the rotator cuff or biceps tendon.
Problem List/Complaints:
Right shoulder pain, swelling, and limited range of motion
Sleep disturbance due to shoulder pain
Difficulty performing overhead movements and lifting objects
Treatment:
The initial treatment approach for the patient’s tendinitis may include:
Rest and activity modification: Advising the patient to avoid aggravating activities and incorporate periods of rest to alleviate symptoms.
Pain management: Prescribing non-steroidal anti-inflammatory drugs (NSAIDs) or analgesics to alleviate pain and inflammation.
Physical therapy: Referring the patient to a physical therapist to develop a tailored exercise program to improve strength, flexibility, and range of motion.
Ice and heat therapy: Instructing the patient to apply ice packs or cold compresses to reduce inflammation and swelling, followed by heat therapy to promote blood flow and relaxation.
Shoulder immobilization: If necessary, immobilizing the shoulder joint with a sling or brace to reduce stress and allow healing.
Prognosis:
With appropriate treatment and adherence to recommended interventions, the prognosis for tendinitis is generally favorable. The majority of patients experience a gradual improvement in symptoms and restoration of normal shoulder function over time.
Goals:
Reduce pain and inflammation in the right shoulder.
Improve range of motion and strength in the affected shoulder.
Restore functional abilities and enable the patient to perform daily activities without limitations.
Interventions:
Medication management: Prescribing NSAIDs or analgesics to manage pain and inflammation.
Physical therapy: Referring the patient to a physical therapist for a comprehensive rehabilitation program, including stretching, strengthening, and range of motion exercises.
Modalities: Utilizing modalities such as ice and heat therapy, ultrasound, or electrical stimulation to alleviate pain, reduce inflammation, and promote tissue healing.
Patient education: Providing the patient with information about tendinitis, its causes, self-management strategies, and the importance of adherence to treatment plans.
Activity modification: Advising the patient on lifestyle and occupational modifications to avoid exacerbating movements and activities.
Home exercise program: Prescribing a home exercise program tailored to the patient’s needs, emphasizing regular participation and adherence.
Patient/Family Education:
The patient and his family should be educated about tendinitis, its causes, and the importance of adhering to the treatment plan. They should be provided with information on self-management strategies, proper body mechanics, and ergonomic principles to prevent future occurrences.
Discharge Plan:
The patient will be discharged with appropriate prescriptions for pain management and a referral to a physical therapist. He will be advised to follow up with his primary care physician or orthopedic specialist for further evaluation and monitoring of his progress. The patient will also receive instructions on home exercises, activity modifications, and self-care strategies.