Case Studies



Case Studies



Introduction


This chapter serves as a brief summary of the muscle testing performance concepts presented throughout this book. Concepts are amplified using a series of case studies that illustrate the need for various forms of muscle testing. Each case features a real patient with a need for specific data to verify clinical findings and understand functional deficits. An overview of the problem-solving approach used by the therapist is presented for each.


The variety of tests available to therapists is illustrated in these case studies. The diagnoses presented are common and each case is intended to highlight the rationale for specific muscle test selection. The cases are unique in both their presentation and the clinical data they require, thus providing a glimpse into the decision-making required to thoroughly evaluate the range of muscle performance deficits seen in various patients.



image Case 1. Shoulder Pain


The patient was a 56-year-old male investment banker who developed right shoulder pain after a weekend of working with his arms extended over his head while painting and wallpapering his home. On examination, he presented with Grade 3 strength of the right external rotators (teres minor and infraspinatus). Abductor strength, when tested in 15° of abduction, was weak (Grade 4) and painful. Internal rotation, flexion, and extension strength were all Grade 5 and nonpainful. Given his pattern of pain and weakness, shoulder joint impingement with supraspinatus tendonitis was suspected.


Attention to scapular function became the focus of evaluation. Because glenohumeral joint movement is only possible if the scapula moves simultaneously, muscle testing of the scapular stabilizers was performed as a key element of his problems.


The scapular retractors (middle and lower trapezius, rhomboids); downward rotators (also middle and lower trapezius, rhomboids); and muscles that perform upward rotation (serratus anterior, pectoralis minor, upper and lower trapezius) were tested. In this patient example, the retractors and downward rotators were graded at the 4 level. The upward rotators were a Grade 3. Active and passive shoulder movement revealed tightness of the pectoralis minor (Grade 3).


Treating the muscles only at the glenohumeral joint will not resolve this patient’s problem because a major cause of his pain is weakness of the scapulohumeral muscles, specifically the serratus anterior and lower trapezius, and tightness of the pectoralis minor. Strengthening of the serratus and lower trapezius and stretching of the pectoralis minor opens the sub-acromial space, allowing more freedom for the supraspinatus to slide beneath. This decreases the impingement and may ultimately resolve the patient’s complaints and prevent a recurrence.


This case example reflects a typical patient who is referred to physical therapy. The original symptom was pain, but the patient’s discomfort was the consequence of muscle weakness coupled with diminished muscle length. Knowledge of anatomy, kinesiology, and manual muscle testing enabled the therapist to isolate the root causes of the patient’s painful condition.



Clinical Comments




• Pectoralis minor tightness is a common clinical finding that often is a significant contributor to impingement at the glenohumeral joint.1,2 Tightness of the pectoralis minor and weakness of the serratus anterior and lower trapezius results in a downward and forward position of the acromion. The downward and forward position decreases the sub-acromial space and results in an impingement of the rotator cuff muscles that ordinarily slide freely under the acromion during overhead activities.3 Repetitive impingement causes irritation of the supraspinatus portion of the rotator cuff, resulting in pain and decreased strength.1,2


• To confirm an inflamed supraspinatus tendon, alternate the position of the supraspinatus and the infraspinatus (posterior rotator cuff muscles for internal rotation with arm at the side) to test only the contractile tissue. If these muscles are strong and testing does not cause pain, progress to the manual muscle positions of external rotation and shoulder flexion. If pain results from the alternate position, do not use the traditional test position (which involves more torque).


• If supraspinatus tendonitis exists, shoulder abduction and flexion muscle tests will often cause pain and reveal weakness. If the scapula downwardly rotates during shoulder abduction and flexion, it will cause compression of the humeral head into the acromion process and impinge the supraspinatus tendon (painful). Downward rotation of the scapula per se is not usually painful or weak. If the scapula moves into downward rather than upward rotation, it is not properly positioning the humerus, and the supraspinatus becomes compressed. This condition is often seen in patients who have kyphotic posture and in men and women of all ages who stand with rounded shoulders.



image Case 2. Compromised Gait and Function Secondary to Muscle Weakness


The patient is a 68-year-old retired man. One weekend he went to the movies with his wife and after 2 hours of sitting found he could not get up from the chair without a great amount of effort. This embarrassing incident prompted him to seek help and he referred himself to an older adult wellness clinic.


Evaluation revealed a pleasant appearing gentleman with flexed hips (~20°) and knees (~15°) when standing upright. He was of average height (68 in.) but was overweight, stating that he weighed about 240 pounds at the time of initial evaluation (body mass index = 36, which is obese). He clearly had difficulty rising from the standard 17-in. chair in the treatment area, as evidenced by using his arms and rocking back and forth several times. Gait evaluation revealed the following: slow gait speed (2 mph or 0.9 m/s), forward trunk lean during the entire gait cycle, slight pelvic drop bilaterally during the stance phase (exhibited by a “waddling” gait), no flexion at the knee (exhibited by failure to flex the knee at loading), and no heel rise at the end of the stance phase as exhibited by a flat foot and shortened stride. These observations suggested possible weakness of the following muscle groups: back extensors, hip extensors, hip abductors, knee extensors, and plantar flexors. Thus, additional muscle testing was done.


Because this man was large, it became immediately apparent to the therapist that manual muscle testing was not feasible given the therapist’s size in relation to the patient’s. Therefore alternative testing using the leg press and the one repetition maximum (1-RM) method was chosen. The patient was also tested using the standard 25× heel rise test for plantar flexors (described in Chapter 6, page 254).



Total Lower Extremity Extension


The leg press provides a composite value for total lower extremity extension (ankle plantar flexion, knee extension and hip extension). If it is suspected that there is weakness in the entire kinetic chain, wider testing to get a general idea of patient capability is useful as an index of general lower body strength. The leg press is ideal because norms are available for men and women of all ages (see Chapter 8). The patient was seated on a leg-press device that was adjusted to a position of comfort that was compatible with the patient’s leg length. A 68-year-old man should be able to complete a leg press equivalent to approximately 1.4 times his body weight (see Chapter 8).


Because of this patient’s difficulty rising from a chair, a functional task that requires a minimum of 50% of the body’s weight, that is, a weight stack of 150 pounds was chosen (60% of body weight); however he could not move the weight stack. The amount of resistance was adjusted downward to 110 pounds (40% of body weight) based on his inability to move the stack or rise from a chair. The patient did complete a full leg extension with 110 pounds. Thus, another 10 pounds was added (120 pounds) and another full leg extension elicited, which he completed, but barely. To confirm the 120-pound maximum, a final 5 pounds was added to the weight stack and then he could not complete leg extension.


If one considers the fact that this 240-pound man could leg press only 120 pounds, it is no surprise he had difficulty getting out of a chair. To provide a different context, on a manual muscle test, if enough resistance could realistically be applied, he would have scored a maximum of Grade 4. It is unreasonable to believe that a therapist can apply sufficient resistance to discern the difference between Grade 4 and Grade 5 for total lower extremity extension, particularly when a leg is so large and heavy. Thus, manual testing is not appropriate to determine the leg strength required to rise from a seated position.


For a more thorough understanding of this patient’s weakness, it is essential to determine the strength of specific muscle groups, particularly those that evidence weakness in the gait cycle. Thus, specific selective resistance tests were done in addition to the leg press (e.g., leg extension, knee extension, and plantar flexion).

Related posts:

Relevance and Limitations of Manual Muscle Testing Alternatives to Manual Muscle Testing Testing the Muscles of the Neck Testing Functional Performance Testing the Muscles of the Trunk and Pelvic Floor Testing the Muscles of the Upper Extremity

Stay updated, free articles. Join our Telegram channel
Tags:
Aug 25, 2016 | Posted by in RHEUMATOLOGY | Comments Off on Case Studies

Full access? Get Clinical Tree
Get Clinical Tree app for offline access