DISCUSSION: The proposed Treatment Based Classification (TBC) system for mechanical dysfunctions

This paper is going to be over rotator cuff injuries and what to do if this occurs to an athlete. The rotator cuff consists of four muscles which are the Subscapularis, infraspinatus, teres minor, and the supraspinatus and their associated tendons that insert into the Humerus. These groups of muscles are responsible for rotating the arm internally and externally as well as abducting the shoulder. The acronym for the four muscles of the rotator cuff is known as SITS. The best treatment for symptomatic, nontraumatic rotator cuff tears is unknown. The purpose of this trial was to compare the effectiveness of physiotherapy, acromioplasty, and rotator cuff repair for this injury. The way this trial worked was that 180 shoulders with the symptomatic,

Patient was encouraged to continue with heat, followed by his home exercise program and ice. He will continue with his transcutaneous electrical nerve unit (TENS). Patient was given an ice pack to use, to reduce pain. He was given a 60 mg Toradol injection on this visit.

Komblatt, the patient underwent extensive chiropractic treatment with 87 sessions from 10/07/11 through 07/11/12. It was opined that it does appear that the IW ha s undergone excessive passive-chiropractic treatment referable to both lumbar spine and right shoulder. It was further opined that the IW has reached MMI regarding the lumbosacral strain and contusion of the right shoulder within approximately 6-8 weeks post injury. Appropriate treatment would have consisted of aggressive right shoulder and low back rehabilitation to include aerobic conditioning, strengthening exercises involving the right upper extremity, lumbar spine and core, and resumption of normal recreational and work activities within 6-8

The patient was an active participant in both contact as well as non-contact athletic activities. The patient reported occurrence of different symptoms that included; pain, weakness, instability, paresthesia, crepitus, as well as instability of the shoulder during sleep. Sulculus sign was conducted to assess the rotator interval and load and shift test for determination of the patient’s posterior stability. The doctor diagnosed positive for multidirectional instability. The patient’s multidirectional instability was not caused by a traumatic event. The patient had not exercised the joint over a long period of time, hence he had a weak shoulder joint, particularly the rotator cuff. The doctor recommended that the patient should be treated for the pain and inflammation of the shoulder caused by the multidirectional instability and then placed on physical therapy aimed for one year aimed at helping in the strengthening of the muscles of the patient that support the scapula (shoulder blade) and the rotator cuff (shoulder joint) so as to help the patient in returning to normal physical activity and also prevent an injury at the same place

• Do exercises to strengthen and stretch your shoulder as told by your health care provider.

Regarding Acupuncture 2x4 to Right shoulder; CA MTUS does not consistently and overwhelmingly support the use of acupuncture in the management of shoulder injuries. However, ODG states that among those shoulder indications found to have positive outcomes from acupuncture were rotator cuff tendonitis, frozen shoulder, subacromial impingement syndrome, and rehab following arthroscopic acromioplasty. Additionally, ODG supports an initial trial of 3 to 6 visits. The patient is s/p right shoulder arthroscopy with acromioplasty and rotator cuff repair on 08/13/15. Considering the continued upper extremity pain and limited ROM following surgery; the medical necessity of acupuncture has been substantiated. However, the guidelines recommend an initial trial of 3 to 6 visits. The request is for 8 sessions. Recommend modified certification of Acupuncture 2X3.

*insert article *attachedBesides being able to see the inside of a shoulder, doctors use different physical tests to evaluate the shoulder in order to determine what type of injury and how severe an injury may be. One such test was recently developed by Dr. Carl J. Basamania at the Womack Army Medical center in Fort Bragg, N.C. The test was developed to evaluate shoulder instability in a patient. During the test the Dr. or examiner stands next to the patient who is to lay flat on his/her back. The hand of the examined should is held firmly by the examiner. The examiner then pushes against the clavicle to stabilize th scapula, while they also gently hold the pectoral muscle with their thumb in order to be able to assess relaxation. The examiner then rotates the arm form neutral to full external rotation. If the patient has AIGHL incompetence there is a lack of tightening as the arm reaches full external rotation. The test has appeared to be highly accurate and may be of value to Dr.'s and surgeons alike. After doctors have determined what type and what degree of injury a patient has sustained using various tests it is on to the next step, rehabilitation.

Many injuries result from the shoulder as it in an area that is used often. Since I am a physical therapist, a client came to me with the issues that they were having with their shoulder. This is a report of my interaction with the patient, as well as informing the patient as they showed an interest in my profession. Covering all the aspects of the education and certifications required to be a physical therapist, as well as an overview and a salary median, and then moving on to the injury by naming and explaining the anatomy and diagnosing the injury, and the treatment and recovery plan.

Thus helps in treatment planning and prognosis. Multiple factors are to be considered during treatment planning. It is important to identify the disorder and its clinical implications, to ensure the most appropriate treatment. Nevertheless, the choice of imaging test depends on personal experience, preference, local availability and the cost of imaging. The American College of Radiology has developed informative criteria that rate the relative usefulness of various imaging modalities for the evaluation of shoulder pain in different clinical scenarios. However, the diagnostic algorithm will ultimately be influenced by the therapeutic approach. The use of various imaging techniques to determine rotator cuff injuries is very controversial. Thus a technique used should not only be informative but cost effective as well. Arthrography is invasive with much health risk. US is a non-invasive, relatively inexpensive, no risk of exposure to radiation and therefore, can be used as initial line of investigation. MRI is sensitive and specific, to detect correct site and extent of tear and also non-rotator cuff related pathologies like

“Failure to respond to all available conservative treatment options including activity modification (e.g., restriction of athletic pursuits and avoidance of symptomatic motion), pharmacological intervention (e.g., nonsteroidal anti-inflammatory drugs [NSAIDS]), injections of local anesthetics into the joint) and physiotherapy”

However, the therapist here can referred the player to the physician and at the same time apply the initial treatment procedures as to ask him/her to reduce the level of activity 3-6 week, then return to normal activity (Boden et al., 2001), applying RICE, and educate him/her some gentle exercises that do not affect the injured area.by this way, the therapist will facilitate and improve the level of health care, avoid any complications may occur, enhance the treatment and shorten the time of returning to normal activity.

The purpose of this study was to discuss the disable throwing shoulder with a focus on the SICK scapula, scapular dyskinesis, the kinetic chain, and rehabilitation. SICK stands for Scapular malposition, Inferior medial border prominence, coracoid pain and palposition, and dykinesis of scapular movement. Appearing on examination as if one shoulder is lower than the other, SICK is asymmetric malposition of the scapula in the dominant throwing shoulder. They are grouped into 3 clinically recognizable patterns of scapular dyskinesis. Type I which is inferior medial scapular border prominence and type II, medial scapular border prominence. While those are 2 most commonly associated with labral pathology, type III is towards impingement and rotator

Barta reports his pain level was a 8 with any movement. Since the last appointment with Wesley Fischer PA the pain level has decreased to a /34 with movements. He was instructed on a home exercise program to avoid the shoulder becoming frozen. Mr. Barta’s examination showed an improvement with range of motion, and strength. Work restrictions were discussed. Per Mr. Barta he was told that he needs to be full duty to come back to work. I advised that the restrictions need to reflect what he can and cannot do with the right arm since that is the injured part. If the employer has the ability to bring him back to work then they must follow the restrictions. I asked that the restrictions reflect

no difficulties and showed no difficulty getting up from a chair. She did not use assistive devices or bracing materials. Full range of motion was recorded in the shoulder joints, elbows, wrists, hands, hips, knees, and ankles. Cervical spine rotation right and left was 80 degrees, with full flexion and extension. The straightaway walk was unremarkable as was the tandem step test, toe lift, heel walk, one-foot stand, and Romberg test. The claimant did not use any assistive devices. Dr. Keown diagnosed the claimant with chronic right shoulder pain, refractory bursitis, or a partial tear of the rotator cuff. She opined the claimant had the ability to sit six to eight hours, walk or stand six to eight hours, occasionally lift 35 to 40 pounds, frequently lift 10 to 15 pounds and would not require assistive devices (Ex. 7F).

As mentioned by Wilk and Leonard4 it has been found most shoulder lesions can be rehabilitated conservative without requiring operation.4 Furthermore, it can be speculated that rehabilitation after a required surgery is critical to return the patients to their functional goals. Additionally, a concrete designed rehabilitation program to increase the range of motion, strength, endurance while increasing the stability of the shoulder is a determinant factor as seen in athletes.4