Clinical reasoningArea of symptoms suggest that the following structure may be implicated.For the pain over the scapular region perhaps due to weakness of the scapular muscles, rotator cuff injury or muscles spasm.For upper arm pain: rotator cuff pathology, muscle strain or muscles spasm. All symptoms aggravated mostly upon movement may indicate joint stiffness, muscle tightness or muscles strain over the affected or pain area.Relationship of symptomsP1 occur then slowly as the ROM increase, pain over the P2 and P3 will follow through. Pain will elicited by passive ROM or any passive manipulation that put pressures the limits of patient’s condensed ROM and also generalized weakness or atrophy may be seen (variability in all cases) ( Reider B,1999)Based on Reider B, 1999 , supraspinatus resistance will be painful and usually weak and may associated with supraspinatus atrophy in severe cases. Loss of active movement especially abduction which may produce a positive Drop Arm test. After injection into the sub-acromial space, pain may improves but the weakness of the rotator cuff still leftovers the same.Aggravating factors• While combing his hair and touch the back of his head and when pick up his wallet from the back pocket• When using computer for prolong time at the workplace• Lying on right shoulder: pain at right shoulder.• Elbow movements: pain during extension• External rotation/internal rotation of the shoulder : pain• Supination/pronation: no pain Identifies source of symptoms as follows:• The movement of combing the hair and pick up his wallet will aggravate the pain as patient need to externally rotate his shoulder and repetitive movement may cause discomfort and pain• Rotator cuff muscle involvement (muscular pain).-pain may because of reduction of the joint space due to the prolong pressure acting to the gleno-humeral joint –based on Nicola J p,2011 while lying on the shoulder there will be a compression force acting onto the GH joint- Elbow pain during extension may be produced due to the tightness over the biceps that currently become one of the prime mover of the shoulder flexor ( this perhaps due to the muscular imbalances)- external and internal rotation of the shoulder joint perhaps produce due to the capsular tightness and also because of the weakness of the rotator cuff muscles-negates the supination and pronation of the forearm .SeverityPatient claimed pain become severe as he perform his daily activities at workplace such as typing for prolong time High, as the patient can continue his activity but with pain .Regarding to Janda,1985, pain over the shoulder will caused the upper trapezius to react to pain and then become hypertonic.This perhaps one of the factor why even when patient performing movement the pain will become severe.IrritabilityPut down or support the forearm and shoulder will reduce the pain but only to 4-5/10 Irritable, as the symptom ease slowly and will increase as they are reproduce for a prolonged period of time.24-hour behavior• Constant pain on the day dependent on activity.• Difficulty to sleep with constant P1 and P2 • Although the pain is usually related to muscle activity, it may be constant (Alvarez and Rockwell, 2002).• Special questionPatient’s recreational activities is to read books, therefore it may produce a prolong static position of the shoulder and arm to hold the book – Prolong static position over the shoulder joint may cause the pain over the shoulder joint.- Based on Kellgren,1938, pain produced by the muscles may referred to other part, therefore in this cases patient may experience referred pain over the shoulder joint perhaps because of muscles that supporting the joint is affected.History of present condition (HPC)Gradual pain at P1 since past 1 year, and symptoms become worse around 5 months ago. Does not release the cause of pain. Patient felt P1 first and then gradually followed by the pain over the P2 then P3. The onset of his pain is gradually increases as his shoulder become more limited over time.Patient only put ointments and try to limit his movement to relieve pain.Previously patient having this pain but he ignores and continue with his activity daily living. Past medical history• History of muscular pain at the shoulder already present for past 3 years.• Patient having Hypertension and on medication• No diabetic mellitus and not diagnosed with rheumatoid arthritis • This is not first episode of pain, not good prognosis.• Patient claimed that over the past 5 months, the pain no really reduced and the pain still there.Special historyPatient working nature is to hold the position of the shoulder because he need to use computer-patient still working and currently at the moment he try to reduce his time frame without stop during his working hours Area of pain that is produce by this patient is common related to nature of his job. Patient drive only around 5 minute distance and most of the time patient will spent his time at the workplace because patient is a workaholic person. Education about ergonomic intervention such as writing position must be given to reduce and prevent recurrent symptoms. Plan of physical examinationThe onset of the symptoms is linked and the symptoms mostly aggravated as the patient perform movement over the shoulder joint especially abduction and flexion through elevation. However patient does not complain sharp or shooting pain that indicate nerve root involvement (Magee 1997, Newham & Mills 1999). This patient complain of constant dull ache and pulling pain that indicate muscle involvement (Magee 1997, Newham & Mills 1999).Based on Nicola JP,2011 physical examination must be carried out after reconsidering the effect of reproducing the symptom. Therapist must decide either it will be necessary t overpressure the joint and to highly consider if there any precautions or contraindications of the physical examinations to be explored further such as neurological involvement or any cardiac problem. Physical examinationObservation in sittingReduce cervical lordosis, retracted shoulder girdle and protruded chin.- No significant swelling or redness over the shoulder girdle- Kyphosis posture of the patient during sitting- Height of the shoulder is more on the right side compare to the left side Clinical reasoning-Prolong static and poor postural control may altered the function or the activation of muscles over the shoulder joint. -Based on Glousman et al. 1988, compensation or protective mechanism produced over a painful joint caused by the increase in the activation of the alpha motor neuron pool supplying the muscles.-this poor posture may lead to the alteration of the muscles activated when performing movement over the shoulder joint. And aspects of altered motor control must be looked into: muscles inhibition,timing of onset, increased muscles activation and altered activation of agonist and antagonist ( Nicola J P,2011)-kyphosis posture will causing the protraction of the scapular and causing the anterior part of the shoulder to become tight. This may lead to pectorals muscles tightness.-height of the shoulder is slightly higher compare to the left side cause by the hypertonicity of the trapezius muscles. Activation of the trapezius in compensate with the pain over the shoulder joint due to reaction to the pain produced ( Janda ,1985)Cervical spine active movementsFlexion – no symptom producedExtension – no symptom producedLLF and LLrot. – no symptoms producedRLF and RLrot. – no symptoms produced Test of movement over the cervical region does not produced symptoms over the shoulder and arm.Pain is not produced during the movement of the cervical region.No significant prove that may shows the relationship between the cervical causing the pain over the shoulder joint.Shoulder active movementsFlexion over the left side= no pain and no limitationOver the right side = pain and limitation ( actively 0-70 deg) ( passively 0-95 deg)Extension – pain but no limitationAbduction –severely pain and severely limited ( abduction actively 0-40 deg) (passively 0-50deg)Adduction (pain but no limitation)External rot. – limited and produce P1 and P2 Internal rot. – limited and produce P1 and P2 Symptoms over the shoulder joint increase as patient actively perform movement and passively by therapist.-Cervical spine accessory movementsIn combined positions – no symptom produce Negates cervical spineShoulder accessory movementsPain and limitation (end feel over the shoulder accessory movement is hard end feel)- ratio of the scapular with the movement over the glenohumeral joints reduced into 1:1 -hard end feel often occurs in capsular and degenerative pathology ( Kesson & Atkins,2004)-this may indicate the joint limitation perhaps due to the tightness over the capsule.-abnormal muscular pattern and imbalances over the weakened and tightened muscles causing the motion of scapular being altered.Passive lengthening of muscleright upper trapezius – pain producedright levator scapular – no pain producedright supraspinatus – symptoms producedright pectoralis muscles become tightened and pain when passively and horizontally abduct -activation or production of pain over the upper trapezius perhaps due to the compensatory movement for the shoulder pain-supraspinatus become pain because of the weakness or perhaps there are some inflammation over the supraspinatus muscles due to the increase work load during abduction of the glenohumeral joint-abduction of the glenohumeral joint causing stretch to the pectoralis msucles group.During this movement the pectoralis muscles needs to contracts eccentrically but due to the tightness of the msucles, reduction and production of pain produced over the anterior part of the shoulderPalpation of muscle-palpation of the trapezius muscles producing pain and jump sign-painful over the pectoralis muscles-painful over the infraspinatus and the teres muscles – Spasm of the trapezius muscles cause by the compensatory movement of the shoulder during abduction and loss or weakness of the supraspinatus muscles during the abduction of the glenohumeral joints- -weakness and inhibition of the supraspinatus musces due to pain causing inhibition to the activation of these msucles ( Arvidsson et. Al. 1989, Urbach & Awiszus, 2002)- Tenderness over the pectoralis muscles due to the tightened muscles fiber causing increase of pressure when palpation being carried out- -infraspinatus acts as a shoulder external rotator, and because of prolong immobility of the infraspinatus,causing the muscles to strain- infraspinatus constantly and prolong use to stabilize the glenohumeral joint during internal rotation of the shoulder joint( patient internal rotate his shoulder during typing at his workplace)- Teres muscles painful when palpated due to the tension, teres become tightened due to the prolong isometric stabilizers when patient reaching forward during usage of computer.Scapular assisted-addition to the ROMGenerally increase around 5-10 deg -when scapular being assisted during abduction of the glenohumeral joint and also flexion, there is only a little addition to the ROM-perhaps patient already produce weakness over the scapular stabilizers and also tightening of the capsularSpecial test• Spurling test• Distraction test• Empty can test• Speed test • Negative radiculopathy involvement. Negates cervical spine.• Negative radiculopathy involvement. Negates cervical spine.• Positive rotator cuff involvement.• Positive rotator cuff involvement. ImpressionDuring taking data on subjective, the symptoms that shown by this patient can be said as cervical radiculopathy. However, result from physical examination negates a cervical as a source of symptom. From the special test that has been done, rotator cuff pathology may involve, however there is also a limitation to the result because patient also having joint stiffness -therefore the limitation of movement occur around the glenohumeral joint perhaps due to the combination of weakness and inflammation over the supraspinatus tendinitis, tightened pectoralis muscles and teres muscles and associated with the glenohumeral joint stiffness.Treatment day 11) Treatment given:• Heat therapy• Joint mobilization• Stretching exercise for the teres and the pectoralis muscle• Scapular strengthening exercise -Heat therapy given to reduce muscle tension and to prepare before joint mobilization performed. Heat therapy used in conservative treatment for shoulder rehabilitation and often used before therapy ( SBrent Brotzman ,Kevin E.W, 2007)Heat therapy will reduce pain and may help therapist in performing treatment without too much of discomfort to the patient.-Joint mobilization perform to the patient with caudal glide with 10 oscillation and repeated 3 sets.-according to Threlkeld,1992 , we will produce micro trauma to the joint and it is needed to elongate the collagenous tissues permanently. For this patient, joint mobilization perform to reduce the pain which only to reduce the tension inside the plastic zone and try to minimize to stretch to the collagenous structure.Joint mobilization will help to improve slightly the joint space and allowing the movement perform smoother.Stretching exercise for the teres muscles and the pectoralis muscles is given.Patient will actively stretch the teres by performing a wall finger.Stretched teres muscles will reduce the pulling tension that cause scapular to retracted to the lateral. Pectoralis muscles stretched is to reduce the pulling force during abduction, which this msucles may restrict the movement of the humerus onto the glenoid fossa of the scapula due to its tightness over the insertion.Pectoralis muscles also stretched in order to prevent pulling force acting over the clavicle which may cause reduction of glide of the clavicle.Scapular strengthening exercise must be carried out, in order to ensure the scapular msucles stabilize during the motion taken over the glenohumeral joint.Strong scapular stabilizers will stabilize the scapular which will allow the humeral head to rotate over the glenoid fossa of the scapula.Day 2Patient report on pain reducing at P1 and P2. But only minimal reduction claimed by patient.P3 pain reduce as the exercise to stretched the pectoralis muscles carried out. Shoulder active movementsNot much improvement can be seen, still limited but pain reduced Good prognosisPalpationTenderness at:palpation of the trapezius muscles producing pain and jump sign-painful over the pectoralis muscles-painful over the infraspinatus and the teres muscles Good prognosis-pain sill produced but much better compare to the previous visit.Treatment1) Continue same pain management but focus to upper trapezius and strengthening the scapular muscles2) Posture correction on increase cervical lordosis.3) Ergonomic intervention on writing.4) HEP Shows minimal progression yet still getting better.Patient claimed that the movement still no improvement but the pain slightly reduced.Patient still not taken any pain killer to reduce his pain.ReassessmentNo jump sign for upper trapezius .No significant improvement over the ROM of the shoulderPain still produced but reduce slightly.