Case of the Week 12-26-11: Eclectic Management of Frozen Shoulder | Modern Manual Therapy Blog

Case of the Week 12-26-11: Eclectic Management of Frozen Shoulder



I am treating a patient who is married to a PT, yet she chose to refer her husband to me as a result of him having an extremely restricted left shoulder and moderately restricted right shoulder in all planes.

Quick history: Had pacemaker implanted 6 months ago, since then noticed progressively worsening left shoulder flexibilty. In the last 2 months, his wife also noticed decreased right shoulder mobility. Left shoulder flexion was 45/hard end feel, IR 10/hard, ER 0/hard, abd 55/hard. Right shoulder flexion 90/hard, IR 35/hard, ER 65/hard, abd 90/hard. All motions more painful at end range on left > right. These were all PROM.

Five visits later, he has left 160 abduction, 45 ER, 55 IR, right is almost WNL for elevation, IR and ER and has nearly no pain with ADLs.

This is his treatment program

IASTM to:

Functional Release to:
Mobilization with Movement 
Thrust Manipulation
  • upper and mid thoracic - made the BIGGEST difference in regard to left UE elevation, as I test and re-tested after each technique and while there were marginal improvements after each, on the 2nd visit went from 55 scaption to 95 after two thrust techniques
HEP
  • pt holds scapula with opposite hand, observes for improper firing of upper traps, sets his scapula then moves into only pain free range of scaption several times/hour
  • self distraction several times/day
  • thoracic rotation in sidelying "open book"
The HEP is surprisingly simple and works on several levels. He is working in the pain free range which decreases anxiety about movement; it demonstrates movement does not have to be painful and decreases CNS sensitivity. It also keeps remodelled tissues and capsule moving in the new range after plastic deformation. The light inflammation that is caused by IASTM causes healing and the repeated motions cause remodelling in the new range.

3 comments:

  1. Erson,

    Great results for a diagnosis that is particularly hard to treat! I would add that Trigger Point Dry Needling has become a very effective treatment modality for me in working with patients with Frozen Shoulder. Needling the subscapularis in particular increases ER ROM quickly. It also saves my fingers from trying to do the deep manual releases, and yields a longer lasting result. I wrote about dry needling on my blog:
    http://bit.ly/uZqwHH
    Happy New Year!
    Ann

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  2. Erson, How did you manage a upper or mid thoracic thrust with limited shoulder flexion/abduction?

    I have a patient with frozen shoulder who I've progressed quickly* from 30deg flex/abd to 120deg after surgical neck # months ago.

    I have used PA thrust for the Thx spine, but would have liked to use the two thrust techniques available in your vids under the 2 links above early in the treatment.

    I think the superior/AP glide for the mid thoracic thrust would be too painful for my pt still, and upper thrust requires at least 90deg shoulder elevation (which I can now hopefully attempt on the next consult).

    *NB: using the Edge for this pt has been very useful to improve range (their delts/tris/bis/RC/PMin were like bricks!!!) and improved my feel of the tool. Thanks for putting this tool out there for us!

    Thanks,
    J

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  3. It does not require a lot of shoulder flexion, in fact, it's shoulder extension for both supine techniques. You have to take up all the shoulder slack by pushing both arms into their chest and the thrust is not only A/P but also superiorly. I'm glad the EDGE is working out for you, I knew it would!

    Thoracic thrust works great for frozen shoulders, a recent study showed that as well!

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