LAPORAN KASUS

Frozen Shoulder

Disusun oleh:

Iva Pinasti C111 11 366

Andi Erdiankuneng C111 11 370

Supervisor

dr. Husnul Mubarak, Sp. KFR

DEPARTEMEN KEDOKTERAN FISIK & REHABILITASI

MEDIK
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 handed
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
Cervical
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
Trunk
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
Shoulder
Flexion Full(0-1800)/limited (0-1000) 5/5
Extension Full (0-600)/limited (0-500) 5/5
 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
Elbow
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
Wrist
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
Fingers
Flexion
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
Thumbs
Flexion
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
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
Knee
Flexion Full/Full (0-1350) 5/5
Extension Full/Full (135-00) 5/5
Ankle
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
Toes
Flexion
MTP Full/Full (0-300) 5/5
IP Full/Full (0-500) 5/5
Extension Full/Full (0-800) 5/5
Big Toe
Flexion
MTP Full/Full (0-250) 5/5
IP Full/Full (0-250) 5/5
Extension Full/Full (0-800) 5/5
Neurological Examination

DTRS : BPR +/+ KPR +/+

TPR +/+ APR +/+
Local Status Regio 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, pendulum
shoulder exercise, overhead pulley, shoulder wheel
Modality : - USD rotator cuff
- TENS (Transcutaneous Electrical Nerve Stimulation)
Education plan : dont carry any heavy thing. Change sleep position. Do exercise
at home
 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, hypothyroidism, parkinsons 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 typically 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