LAPORAN KASUS Frozen Shoulder
Disusun oleh:
Iva Pinasti
C111 11 366
Andi Erdiankuneng Erdiankuneng
C111 11 370
Supervisor dr. Husnul Mubarak, Sp. KFR
DEPARTEMEN KEDOKTERAN FISIK & REHABILITASI MEDIK KEPANITERAAN KEPANITERAAN KLINIK UNIVERSITAS HASANUDDIN 2016
Pain at left shoulder Data Based Identity (24 Februari 2016)
Name
: Ny. Siti Hasnani
Sex
: Woman
Age
: 57 year
Occupation
: housewife
Religion
: moeslim
Ethnic
: Bugis
Chief Complaint : Pain at left shoulder History of present illness
Pain at left shoulder since 2 months ago, sharp pain and radiating until upper left shoulder. Pain when she try to moving her left shoulder. patient feel difficult to move her left shoulder. VAS 5/10.
History of trauma (-) patient have a habit of sleeping with left position. Patient always carrying her grandchild using her left hand. She already got therapy for 6 times at Tadjuddin Chalid Hospital.
Patient working as a housewife and always doing a daily activity like wash the dishes. Patient also tell us if she always carrying her grandchild for a long time.
History of past illness
DM
: (-)
HT
: (-)
History of gout arthritis (+)
Physical examination
General status
Compos Mentis, Independent ambulation, Gait : Normal, Postur : Normal, Right ha nded
BP : 100/80 mmHg, HR :82 x/mnt, RR : 20 x/mnt, S: 36,5 C
Head & Neck
: Normal
Thorax : Cor
: Normal
Pulmo
: Normal
Abdomen
: Liver/Spleen : Impalpable
Extremitas
: upper extremity
:
Inspection
: Normal
Palpation
: pain in left shoulder
Lower extremity
: Normal
Musculoskeletal Examination ROM
MMT
Flexion
Full (0-450)
5
Extension
Full 0-450)
5
Lateral Flexion
Full/Full (0-450)
5/5
Rotation
Full/Full (0-600)
5/5
Flexion
Full (0-800)
5
Extension
Full (0-300)
5
Lateral Flexion
Full/Full (0-350)
5/5
Rotation
Full/Full (0-450)
5/5
Flexion
Full(0-1800)/limited (0-1000)
5/5
Extension
Full (0-600)/limited (0-500)
5/5
Cervical
Trunk
Shoulder
Abduction
Full (0-1800)/limited (0-1200)
5/5
Adduction
Full (0-450)/full (0-450)
5/5
Ext. Rotation
Full (0-700)/limited (0-500)
5/5
Int. Rotation
Full (0-900)/full (0-900)
5/5
Flexion
Full/Full (0-1350)
5/5
Extention
Full/Full (135-00)
5/5
Forearm Supination
Full/Full (0-900)
5/5
Forearm Pronation
Full/Full (0-900)
5/5
Flexion
Full/Full (0-800)
5/5
Extension
Full/Full (0-700)
5/5
Radial Deviation
Full/Full (0-200)
5/5
Ulnar Deviation
Full/Full (0-350)
5/5
MCP
Full/Full (0-900)
5/5
PIP
Full/Full (0-1000)
5/5
DIP
Full/Full (0-900)
5/5
Extension
Full/Full (0-300)
5/5
Abduction
Full/Full (0-200)
5/5
Adduction
Full/Full (200-00)
5/5
MCP
Full/Full (0-900)
5/5
IP
Full/Full (0-800)
5/5
Extension
Full/Full (0-300)
5/5
Abduction
Full/Full (0-700)
5/5
Adduction
Full/Full (50-00)
5/5
Opposition
Full
5/5
Elbow
Wrist
Fingers
Flexion
Thumbs
Flexion
Hip
Flexion
Full/Full (0-1200)
5/5
Extension
Full/Full (0-300)
5/5
Abduction
Full/Full (0-450)
5/5
Adduction
Full/Full (0-200)
5/5
Ext. Rotation
Full/Full (0-450)
5/5
Int. Rotation
Full/Full (0-450)
5/5
Flexion
Full/Full (0-1350)
5/5
Extension
Full/Full (135-00)
5/5
Plantar Flexion
Full/Full (0-200)
5/5
Dorsi Flexion
Full/Full (0-500)
5/5
Inversion
Full/Full (0-1500)
5/5
Eversion
Full/Full (0-350)
5/5
MTP
Full/Full (0-300)
5/5
IP
Full/Full (0-500)
5/5
Full/Full (0-800)
5/5
MTP
Full/Full (0-250)
5/5
IP
Full/Full (0-250)
5/5
Full/Full (0-800)
5/5
Knee
Ankle
Toes
Flexion
Extension Big Toe
Flexion
Extension Neurological Examination
DTRS : BPR +/+
KPR +/+
TPR +/+
APR +/+
Local Status Regi o Shoulder - Inspection
: deformitas (-), udem (-), atrofi (-)
- Palpation
: pain in shoulder muscles
Special examination
Drop hand test (-)
Empty cane test
Diagnosis : frozen shoulder Functional Examination :
Impairment
: pain at left shoulder Limited ROM Adhesive capsulitis
Disability
: limiting on self care (daily life activity)
Handicap
: Difficult to doing her activity as a houswife
Problem list
Surgical : -
Medical : - adhesive capsulitis
Planning of Medical Rehabilitation
Therapy plan
:
Exercise : ROM – Streching, finger ladder exercise, towel exercise, pendu lum shoulder exercise, overhead pulley, shoulder wheel Modality : - USD rotator cuff - TENS (Transcutaneous Electrical Nerve Stimulation)
Education plan at home
: don’t carry any heavy thing. Change sleep position. Do exercise
Prognosis
Advitam = bonam
Sanationam = bonam
Etfungsionam = bonam
Case Review •
a woman aged 57 years came with complaints of pain in the left shoulder since the month of February 2016. The patient began treatment to rehabilitation medic in March 2016 . Today, patient has got 6 therapies. Patients admitted difficulty moving his left arm and it is very painful when moved. Pain in the left shoulder felt spread quickly to the upper arm. Patients no history of DM, no HT, arthritis gout (+) but controlled. On physical examination after receiving 6 times the therapy, ROM in the shoulder get limited but there have been improvements in flexi and abduction but not full yet. There are no signs of inflammation or crackles. On the arm drop test in getting a negative result. Muscle spasms in the shoulder were also obtained.
Tinjauan Pustaka
Frozen Shoulder Definition
Frozen shoulder, also called adhesive capsulitis, causes pain and stiffness in the shoulder. Overtime, the shoulder becomes very hard to move. In frozen shoulder, the shoulder capsule thickens and becomes thigt.
Etiologi dan Patofisiologi
The causes of frozen shoulder are not fully understood. There is no clear connection to arm dominance or occupation. A few factors may put you more at risk for developing frozen shoulder. 1. Diabetes 2. Other disease (hyperthyroidism, hypothyr oidism, parkinson’s disease, cardiac disease) 3. Immobilization
Klasifikasi 1. Freezing : in the freezing stage, you slowly have more and more pain. As the pain
getting worse, your shoulder loses the ROM. Freezing t ypically lasts from 6 weeks to 9 months. 2. Frozen : painful symptom may actually improve during this stage, but stiffness remains.
During the 4-6 months of the frozen stage, daily activity may be very difficult. 3. Thawing : shoulder motion slowly improves during the thawing stage. Complete return
to normal or close to normal strength of motion
Clinical Manifestation
-shoulder pain when moved - limited ROM
Supportive examination
Physical Examination
-
ROM : active ROM or passive ROM
-
Drop arm test to see there is some tear in rotator cuff tendon or not.
-
Empty cane test
Radiology Examination 1. MRI 2. USG
Planning
-
Exercise
-
USD
-
TENS
-
Farmakologi : corticosteroid injection
-
Surgery
:
manipulation
under
anesthesia,
shoulder
arthroscopy