1. Rudolph De Wet

2.  Mr. Moratehi J. Sebophe  Age 33  March 2010 (1 st )  MCshoulder pain during activity.  Dx -small supspin tendinopathy  Mx-PT + strengthening 4/52  Outcome-FNW

3.  Presented again in October 2010  Same complaints  Pain free for 2weeks only  Better prepared

4.  Occupation-Driller  Handed-Left  Med Hx-Nil  Injury Hx-R clavicle # ‘98 -Back sprain 2000

5.  Mechanism: Chronic overuse injury  Time of injury or Sx: Acute on chronic  Severity /10 + 2-5  Time more painfull Constant dull pain. >activity. >day  Radiate Hand from shoulder  Agrevate OR Relieve >90°ant flexion/ abduction. >weight baring

6.  Sensory Sx (numb/ pins&needles / weakness)  Ocasional dull pain lat aspect upper arm. Pins and needles hand +arms  Pysio or Rehab received  NSAIDS chronic  Description of specific job  Neck pain or stiffness?  Stiff trapezius

7.  Observe (AP +Lat): Wasting / position etc.  Muscular, R shoulder slight droop  Active movements:  Elevation +scap dyskinesis  Ext rot. (90 abd)+ weaker + pain

8.  Passive movements:  Ext rot. (90 abd)Pain at limit of passive ext rot  Int rot (90 abd) Pain at limit of int rot  Resisted movements:  Ext. rot.4+/5 Right 5/5 left  Subscapularis (Gerber’s Test) 4+/5 Right 5/5 left  Deltoid4+/5 Right 5/5 left  Supra Spinatus +tendinopathy +scap dyskinesis Speed’s test-Yergason’s test-

9.  Palpation:  Scapula+ Bump felt right old fracture   Periscapular R slight <developed  Cervicobrachial Tender + stiffness of neck  Trigger points Nil

10.  Paxinos test*SAT  Drawer *Sulcus sign  Apprehension & Augmentation  Ant slide*O’Brian  Crank*Tenell

11.  Neers  Hawkins  Neural structures contribution to pain (Upper limb tension test)  Adson’s test (mild)  Roos

12. Describes and demonstrates abnormal posture *Leans forward *Supports drill at +/-100⁰

13.  Thoracic outlet syndrome  Supraspintus tendinpathy  Scapular dyskinesis

14.  Shoulder X-ray  -Healed right clavicle fracture with exostosis  -+ Beaking of acromion  C-spine X-ray  - ↓ disc spaces C5-7 mild  EMG  - ↓ conduction brachial plexus  -Carpal tunnel syndrome  Ultrasound  -Supraspinatus tendinopathy

15.  Thoracic outlet syndrome  Carpal tunnel syndrome  Supraspintus tendinpathy  Scapular dyskinesis

16.  Orthopeadic consultation  Surgiacal carpal tunnel release was performed firstly  Rehabilitation program.

17.  Trigger points found and treated (scalene muscles)  Pectoral, scalene stretching  Soft tissue mobs + mobs 1 st rib  Scapular dyskinesis - strengthening focus on serratus ant.  Scapula stabilizing + rotator cuff strengthening

18.  Exercises started up scalled according to pain  Attempt made to elevate right shoulder  Attention to posture and ergonomics occupation specific

19.  *After 4weeks  ROM  thoracic outlet syndrome still +  Orthopeadic consultation  Resection of exosthosis + 1 st rib was performed

20.  Range of motion exercises started day 1 post op.  Program restarted. Always pain free arcs.  After 6weeks returned to work with full range of motion and pain free.

21.  Thorough history + all relevant questions  Thorough, focused and complete clinical examination, including all surrounding structures.  Don’t cut examination short when one positive finding (or diagnosis) is made, as there may be precipitating or secondary effects linked to findings

22.  Watch pt during training to insure correct execution, check for compensatory mechanisms and observe symptoms and signs that may appear only during activity  Interpreting results history taken + clinical examination, a good grasp of anatomy and biomechanics is needed to make the diagnosis and tailor the rehabilitation