1. PATIENT PRESSENTATION 2 nd – 6 th February 2011 Fritz Joubert

2. MAIN COMPLAINT 33 Year old rugby player Complaining of pain with overhead activity Pain with external rotation Pain when sleeping on shoulders

3. HISTORY MEDICAL Hyper Tensive on treatment Well controlled SURGICAL Previous medial collateral ligament repair- Left knee 2002 ORIF bilateral on radius

4. MECHANISM OF INJURY Tackled player in 1 st Division rugby match. Felt pain on impact and when falling on the ground. Pain was not severe at time of incident, therefore carried on playing. Pain got progressively worse. Presented to me app 3 weeks post injury.

5. EXAMINATION Observation was normal from – Front – Back – Side Active movements – Arm elevation – External Rotation painful – External rotation at 90 degrees of abduction – most painfull – Internal rotation – NAD – Horizontal Flexion – minimal pain

6. PASSIVE MOVEMENTS Arm elevation – Painfull External Rotation – Not very painfull, except at end point External rotation 90 ⁰ degree abduction – most painfull Internal Rotation – NAD Horizontal Flexion - NAD

7. RESISTED MOVEMENTS External Rotation – Painfull Gerbers Test – Negative but painfull Deltoid Test – Painfull Biceps Speeds Test – Negative Yurgusons Test - Negative

8. PALPATION AC Joint -Negative Shoulder Joint-Negative Rotator Cuff Tendon-Negative Bicipital Groove -Minimal Pain Rotator Cuff Muscle-Painfull Periscapularis Muscles and Coracoid Muscles normal

9. SPECIAL TESTS AC Joint Compression – NAD Scapular Test – Not Done Impingement – Hawkins/Kennedy Test - Not Done -Neer Test -Painfull

10. SPECIAL TESTS Sulcus Test – Normal Slap Test – Not Done Cervival Spine - NAD Instability Test Load & Shift Test - Not Done Apprehension, augmentation, relocation – Not Done

11. INVESTIGATION X-Ray – NAD Ultra Sound - Result – Features consistent with an early developing calcific tendinopathy with a subacromial Subdeltoid Bursitis

12. TREATMENT Sub-acromial Depo-Medrol with lignocaine 40 mg injection Thought pathology due to instability of shoulder muscles and direct trauma

13. EXERCISE External Rotation Internal Rotation Horizontal Flexion Combined exercises

14. PROGRESSION OF INJURY On 1 month follow up, shoulder was still painfull with over head activity. On 2 month follow up, in shoulder was significantly better.