Comprehensive PT Practical Examination – 10 Case Study Notes

Case #1 – Rotator Cuff Tear (42-y/o M)

• Mechanism & Onset
• Lifted out-board motor ➔ acute pop + sharp pain 10 days ago.
• PCP dx “shoulder strain,” ordered PT; no relief, ↑ stiffness/weakness overhead.

• Key History
• Localized shoulder pain, no paresthesia, unremarkable PMH/PSH.

• Physical Examination
• No ecchymosis.
• Mild TTP: greater & lesser tuberosities, bicipital groove, medial scap border.
• Abnormal active elevation pattern (uses trunk side-bend; true AROM ≈ $40^{\circ}$ flex/abd).
• PROM IR/ER WNL but painful end-range.
• Special tests: – Yergason, Speed, Adson; + Drop-Arm, + Empty-Can.
• Neuro screen normal.

• Interpretation & Significance
• Positive drop-arm = full-thickness supraspinatus tear.
• Empty-can reproduces RTC weakness.
• Intact ER/IR suggests isolated supraspinatus vs massive tear.
• Differential excludes cervical radic (neg Adson) & biceps tendinopathy (neg Speed/Yergason).

• Patient-Care Skills Required
• Pain VAS, comfortable seated or supine draping.
• Blood Pressure (see “Vitals” below).
• Body-mechanic training: split-stance, scap-plane reach, avoid shrug/trunk compensation.

• Functional Anatomy
• Palpate:
• Greater Tubercle – attaches supraspinatus, infraspinatus, teres minor.
• Medial Scap Border – rhomboids, serratus anterior, levator scap.
• Teres Major – palpate lateral/post-inferior axilla.
• Active insufficiency example: biceps brachii during combined elbow flex + shoulder flex.
• Passive insufficiency example: triceps during full shoulder flex + elbow flex.

• Kinesiology Tasks
• PROM shoulder flexion (supine, stabilize thorax).
• Goniometry:
• Axis – lat. greater tubercle; Stationary – mid-axillary line; Moving – lat. epicondyle.
• Expected norm $0–180^{\circ}$; pt displays $0–40^{\circ}$ AROM, $0–160^{\circ}$ PROM (pain-limited).
• MMT Anterior Deltoid (sitting, 90° shoulder flex, neutral forearm).

• Therapeutic Modalities (examples)

1. Cryotherapy
   • Indications – acute pain, inflammation.
   • Contra – Raynaud, cold urticaria, impaired sensation.
2. NMES for supraspinatus re-ed
   • Indications – neuromuscular inhibition, muscle re-education.
   • Contra – pacemaker, over malignancy, pregnancy over trunk.

• Documentation – produce full SOAP including subjective pain 6/10, objective measures, assessment “RTC tear w/ impaired overhead reach,” plan: HEP + cryotherapy 10 min + NMES 15 min.

• Vital Norms & Consult Triggers
• BP norm ≈ $\text{SBP } <120 \text{mmHg},\; \text{DBP } <80$. • PT referral if resting SBP > $160\,\text{mmHg}$, DBP > $100\,\text{mmHg}$, symptomatic hypotension (<90/60).

Case #2 – Shoulder Impingement (22-y/o M)

• Presentation
• Insidious L shoulder pain ×2 wks, VAS 5–6/10, interrupting sleep, ↑ with backstroke, ADLs (hair-combing).
• Work restriction ≤10 lb.

• Physical Findings
• Tender anterior/medial shoulder; latissimus MMT pain.
• Reports crepitus (“cracking/popping”).

• Pathophysiology
• Subacromial mechanical impingement of supraspinatus/biceps tendon during abd/flex >60°.
• Overhead swimmers predisposed due to repetitive eccentric loading.

• Patient-Care Skills
• Pain VAS, drape supine.
• Vitals: BP, RR (norm $12–20\,\text{breaths/min}$), red-flag RR < 10 or > 30.

• Functional Anatomy
• Inferior angle scapula (T7 level) – attaches teres major.
• Sternal notch – origin of SCM, sternal portion.
• Palpate whole deltoid (3 heads).
• Shortened muscle example – latissimus dorsi when shoulder ext + IR + add.

• Kinesiology
• PROM abduction; normal $0–180^{\circ}$ – pt limited ≈ $0–140^{\circ}$ with pain arc $70–110^{\circ}$.
• Goniometric landmarks: A- acromion ant., Fixed – parallel to sternum, Move – midline humerus.
• MMT Lat Dorsi (prone arm ext/add).

• Modalities
• Ultrasound (3 MHz, 0.8 W/cm², pulsed) – indications: tendonitis, ↑ collagen extensibility; contra: malignancy, infection.
• Kinesiotaping – indications: postural cue, edema; contra: fragile skin, allergy.

Case #3 – Thoracic Outlet Syndrome (55-y/o F)

• Symptom Cluster
• Numbness/paresthesia R ulnar digits, worse with repetitive OH motion (>5 min).
• Coldness, mild intrinsic hand atrophy.
• Posture: FHP + rounded shoulders; hypertrophied pecs & scalenes.

• Diagnostics
• X-ray negative cervical rib; EMG/NCV negative (neurogenic vs vascular debate).
• Special tests: + Hyperabduction maneuver (Wright); others –.

• Mechanism
• Compression of neurovascular bundle in costoclavicular / pec minor space.
• Poor diaphragmatic breathing → accessory muscle hypertrophy.

• Functional Anatomy
• Infraglenoid tubercle – long head triceps origin.
• Coracoid process – short head biceps, coracobrachialis, pec minor.
• Palpate pec minor; shortened when scap protraction + anterior tilt.

• Kinesiology
• PROM ER: axis olecranon; expected $0–90^{\circ}$ (shoulder abd 90°). Pt PROM $0–47^{\circ}$.
• MMT Lower Trap (prone 135° abd thumbs up).

• Modalities
• Diaphragmatic breathing biofeedback – indication: accessory overuse; no contra.
• Stretching with moist heat; contra: acute vascular insufficiency.

• Vitals
• O₂ Sat norm >95\%; therapy hold < $90\%$.

Case #4 – Adhesive Capsulitis (Frozen Shoulder) (43-y/o F, uncontrolled DM-II)

• Natural History
• Stage 1 (painful) ➔ Stage 2 (freezing) ➔ Stage 3 (frozen) ➔ Stage 4 (thawing).
• Diabetes ↑ risk ×5; cytokine-mediated capsular fibrosis.

• Presentation
• Severe onset 7 mo ago; stiffness emerged 2–3 mo later.
• Sleep on R side aggravates.
• Two corticosteroid injections = transient relief.

• Exam Targets
• Palpate bicipital groove, superior angle scap, coracobrachialis.
• Coracobrachialis lengthened in shoulder abd + ER + ext.

• Kinesiology
• Shoulder IR norms $0–70^{\circ}$; capsular pattern limitation (ER > abd > IR).
• MMT Upper Trap (sitting shrug).

• Modalities
• Joint mobilization (Grade III/IV) with heat.
• Contra: acute synovitis (grade IV), uncontrolled HTN for heat.

• Vitals
• Pulse norm $60–100\,\text{bpm}$; PT consult if <$50$ or >$120$ resting.

Case #5 – Adolescent Idiopathic Scoliosis (16-y/o F, 59° thoracic DS)

• Radiographic Severity
• Severe AIS >$40^{\circ}$ Cobb; pt = $59^{\circ}$ T-curve → surgical candidate (fusion).
• Compensatory L-lumbar curve.
• Rib hump due to vertebral rotation.

• Psychosocial
• Body-image distress; ethical need for empathetic communication, consent re: fusion.

• Functional Anatomy
• Palpate T7 (align inferior scap angle), xiphoid, L QL.
• Lengthen L QL: stand, side-bend R.

• Kinesiology
• Thoracolumbar flexion norms $0–80^{\circ}$ (tape measure or inclinometer).
• MMT Obliques (supine curl-up with rotation).
• Inclinometer: difference between T12-S2 & C7-T12 readings.

• Patient-Care
• Teach squat-lift keeping spine neutral to avoid exaggerated rib hump.
• BP consult thresholds as above.

• Modalities
• Electrical stim for postural muscle endurance; contra pacemaker.
• Schroth 3-D respiratory exercises; no specific contra.

Case #6 – Lateral Epicondylitis (Tennis Elbow) (43-y/o M)

• Etiology
• ECRB/ECRL micro-tears from repetitive wrist ext + forearm pronation torque when manipulating tools.

• Comorbid Issue
• NSAID-induced GI bleed (ethical: med reconciliation, coordinate w/ MD).

• Exam
• Palpate lateral epicondyle, radial tuberosity, ECR Longus belly.
• Active insufficiency ECRL: wrist ext + elbow flex.
• Passive insufficiency ECRL: wrist flex + elbow ext + pronation.

• Kinesiology
• Elbow ext norm $0^{\circ}$; pt lacking $7^{\circ}$ flex contracture? (Case #8; for #6 assume full ROM; test anyway).
• MMT pronators (seated elbow 90°, resist pronation).

• Modalities
• Iontophoresis (\ce{Na^+–dex}) for inflammation; contra open wounds, allergy.
• Counter-force brace education (orthotic).

• Vitals
• O₂ Sat & BP per norm; monitor due to recent bleed (anemia risk ↑ HR).

Case #7 – Bicipital Tendinitis (48-y/o Painter)

• Risk Factors
• Overhead work (ceilings) ➔ long-head biceps abrasion under acromion.
• Prior RC impingement surgery.

• Clinical Tests
• + Speed (supinated resisted flex), + Impingement sign.
• Pain w/ resisted supination > pronated flex.

• Functional Anatomy
• Infraspinous fossa palpation (infraspinatus), clavicle (deltoid, pec maj).
• Biceps brachii active insufficiency: shoulder flex + elbow flex + supination.
• Passive insufficiency: shoulder ext + elbow ext + pronation.

• Kinesiology
• Elbow flex norm $0–150^{\circ}$; goni axis lat. epicondyle.
• MMT Brachioradialis (neutral forearm).

• Modalities
• Transverse friction massage; contra acute calcific phase.
• Photobiomodulation (class III laser) – indications tendon healing.

Case #8 – Medial Epicondylitis (Golfer’s Elbow) (27-y/o L-handed M)

• Findings
• Warmer anteromedial forearm, TTP, ROM loss ext 7°.
• Pain with resisted wrist flex/pronation + elbow ext.
• No neuro signs.

• Anatomy
• Palpate medial epicondyle (common flexor origin – FCR, FCU, PT, FDS).
• Radial head landmark (distal to lat epicondyle).
• FCR active insufficiency: elbow flex + wrist flex + RD.
• Passive insufficiency: elbow ext + wrist ext + UD.

• Kinesiology
• Forearm pronation norm $0–80^{\circ}$; record A/PROM.
• MMT Triceps (supine 90° shoulder flex, resist ext).

• Modalities
• Extracorporeal shock-wave therapy; contra pregnancy, coagulation disorder.
• Ice massage 5 min; contra cold hypersensitivity.

Case #9 – Chronic Neck Pain (43-y/o F, Office Worker)

• Occupational Factors
• 75 % desk; ↑ OT 2–3 h, mouse use 50 %.
• Sedentary lifestyle ➔ deconditioned postural musculature.

• Symptoms
• AM pain 2/10 ➔ PM 10/10, HA, R arm ache.
• “Tight/aching” upper traps, lev scap, occiput.

• Functional Anatomy
• Superior nuchal line (origin upper trapezius), 1st rib (attachment ant & middle scalenes, subclavius).
• Levator scap lengthened with cervical contralat flex + rotation & shoulder depression.

• Kinesiology
• Cervical flexion norm $0–45^{\circ}$ (goni axis ear lobe).
• MMT posterolateral neck extensors (prone head rotation 20°, resist ext).

• Modalities
• Ergonomic education + micro-break timer (biofeedback).
• Moist heat pack; contra impaired sensation.

• Vitals
• Carotid pulse norm $60–100\,\text{bpm}$; red flag irregular rhythm or >120 resting.

Case #10 – Degenerative Spondylolisthesis (60-y/o F)

• Pathology
• Anterior slippage (usually L4 on L5) due to facet & disc degeneration ➔ foraminal stenosis.

• Clinical Picture
• Central LBP, buttock, posterior thigh pain, ↑ with day/extension; no neuro deficits.
• Overweight, DM-II, hyperlipidemia.

• Functional Anatomy
• Palpate spinous process L4 (line of iliac crest).
• Rectus abdominis & lumbar iliocostalis; lengthen RA with backward lean over Swiss ball.

• Kinesiology
• Thoracolumbar lateral flex norms $0–35^{\circ}$.
• Goni/inclinometer: stabilize pelvis.
• MMT back extensors (prone trunk lift).

• Patient-Care
• Teach golfer’s lift or hip hinge for picking ball.
• BP flags same as above.

• Modalities
• Core stabilization program with surface EMG biofeedback.
• Interferential current for pain; contra pacemaker, cancer.

Universal Normative Vital Values (Quick Reference)

• Blood Pressure
• Normal <120/80\,\text{mmHg}.
• Elevated 120–129/<80.
• Stage 1 HTN $130–139/80–89$.
• PT hold ≥$180/110$ or symptomatic hypo <$90/60$.

• Pulse (Radial/Carotid) $60–100\,\text{bpm}$ (athlete ≥40 acceptable). PT hold >$120$ resting or <$50$ symptomatic.

• Respiratory Rate $12–20\,\text{breaths/min}$. PT hold <$10$ or >$30$.

• SpO₂ $\ge95\%$; <$90\%$ needs MD consult/oxygen titration.

Key Equations / Stats Mentioned

• Cobb angle measurement for scoliosis: $\theta = \arctan\left(\frac{\text{end-plate offsets}}{\text{vertebral body height}}\right)$ – radiographic software automates.
• BMI $= \dfrac{\text{mass (kg)}}{\text{height (m)}^{2}}$ – pt #10 = $\dfrac{?}{?}=28\;\text{kg/m}^2$ (overweight range 25–29.9).
• Blood glucose fasting goal for DM: $70–130\,\text{mg/dl}$; pt #4 = $237\,\text{mg/dl}$ (poor control).

Common Ethical / Practical Considerations Across Cases

• Coordination with referring MD for red-flag vitals, uncontrolled DM, GI bleed history, surgical indications (AIS fusion).
• Informed consent before modalities; clarify risks (e.g., heat burns, electrical stim).
• Psychosocial support: body-image (AIS), occupational stress (neck pain), work comp issues (lateral epicondylitis).
• Educate on HEP adherence; prior lapses (Case #4) linked to recurrence.

Linking Concepts

• Repetitive overhead motion is a unifying etiology in RTC tear, impingement, bicipital tendinitis, TOS.
• Capsular pattern loss (ER > ABD > IR) differentiates adhesive capsulitis from impingement.
• Medial vs lateral epicondylitis show mirror-image pathology of common flexor vs extensor origin; treat with similar eccentric loading principles.

These notes consolidate examination requirements, anatomical landmarks, kinesiology norms, modality principles, and vital-sign red flags for all ten presented cases, allowing direct study without the original transcript.