Case of the Week 1-30-12: If It Looks Like a Rotator Cuff Strain and Moves Like a Rotator Cuff Strain... | Modern Manual Therapy Blog

Case of the Week 1-30-12: If It Looks Like a Rotator Cuff Strain and Moves Like a Rotator Cuff Strain...


History: Just this past weekend I had an interesting case, and I don't even work on the weekends! My wife's cousin was visiting from sunny Toronto and asked me to take a look at his right shoulder. One month ago, he lifted something heavy and his right shoulder had been hurting with all elevation activities and general use. In that time, his complaints had not improved. The pain was located around his coracoid process, supraspinatus, and deltoid insertion and was intermittent. His complaints were worse with all elevation activities and he was actively unable to elevate past 90 degrees. He was better with rest.

Objective:
Initial cervical screen was negative for right shoulder pain. Cervical ROM appeared to be WNL in all planes.Shoulder elevation was painful and limited with 90 degrees abduction/scaption. He visibly substituted and recruited his upper traps during elevation with initial movement without setting his scapula.

Resisted shoulder ER, IR, flexion and abduction were all weak and painful, rated around 4/5. I found it strange that all motions were weak and painful.

Neer's and Hawkins and Kennedy's impingement signs were both positive, and reproduced his right shoulder pain.

Shoulder IR was moderately limited, painful and had a hard end feel.
Shoulder elevation was limited on the right by about 20%, was painful, and limited with a hard end feel (passively compared to left)

Grade 2 (moderate) restrictions in right 1st rib inferior glide.

Assessment: Signs and Sx consistent with subacute rotator cuff strain.

Treatment: initially focused on IASTM with the EDGE to right lateral upper arm, supraspinatus, infraspinatus. Also performed functional release of subscapularis. This improved his AROM abduction to about 120, with much less pain.
Strength still tested weak and painful with no real changes.
30 degrees improvement in elevation, and would have been call it a day with some HEP in the clinic.... BUT.... this was my wife's out of town/country cousin who would only be here for 24 hours AND... his PCP just referred him for physio and ultrasound....

I tried postural correction again, which slightly improved his elevation more, about 10 degrees. Then I tried aggressively overcorrecting his normally severe forward head. I held him passively in an overcorrected cervical retraction position. In this position, which only felt extremely tight in his subcranial area, he was able to abduct to almost 180 nearly pain free.

Reassessment of cervical PIVM found C4-5 downglide restriction with hard end feel grade 2.
One informed consent, and premanipulative hold later, I performed a cervical downglide thrust.
He was able to abduct his right UE completely pain free. His strength tests were 5/5 strong and painless in all planes. I instructed him on postural correction (which I was going to give him anyway), and cervical retraction exercises. The entire next day, his shoulder was still pain free in elevation and his strength was still normal. Reassessment: Signs and Sx consistent with subacute cervical derangement.

It was just a hunch/MDT training that made me try the sustained retraction. I'm also sure that repeated cervical retraction and postural correction would have yielded similar outcomes. But hey, who has time for that with only 1 visit? Similar to the recent JOSPT article, cervical thrust works faster than cervical mobilization within the first 48 hours.


2 comments:

  1. Great case study. Thought provoking.
    Question the initial cervical screen. Does your screen include over pressure and quadrants to clear? I have a Maitland background which is different that your training and just looking for clarification in my practice model. Thanks. Please keep doing the case studies, I feel these are very beneficial.

    ReplyDelete
  2. I don't find the quadrant test useful as I normally use PIVM, so I find that redudant. I did overpressure him into cervical SB to the right (involved side) and away, but it did not reproduce his complaints strangely enough. It's possible repeated motions with overpressure in that direction would have also improved the shoulder motion.

    ReplyDelete