The latest COTW illustrates patterns of treatment and presentation despite having two "different" conditions.
Both cases are males in their late 20s. The first had insidious onset of right shoulder pain, had been to various other PTs and only given exercises without any manual therapy. He had pain with elevation and difficulty lifting.
The second patient (a friend of the first who was referred after he noticed improvements after 2 visits), also had difficulty lifting, but had a mechanism of injury. He was in a fight with his brother, who ended up falling on his left arm, the patient quickly pulled his arm from under his brother's body weight and felt and heard a large "pop" accompanied by pain deep within his shoulder. His other brother was a former PT student of mine who treated him for a bit, but then left on a travelling PT assignment. Like most family members, the brother was most likely not listening 100%, plus he also did not receive manual treatment.
It's an old fashioned compare and contrast, one of the worst assignments we used to get in school!
Evals are as follows
Insidious
Subjective: Pt reports onset of R anterior and deep shoulder pain 2-3 years ago. Sx have improved in the past 3 months due to PT and home exercise program. Sx are intermittent and rated 1/10, however he is unable to perform pushups, bench press, or lift anything overhead greater than 5-10#.
Objective: fair sitting posture, moderate forward head
key: F = functional (WNL), D = dysfunctional, N = non-painful, P = painful, PDM = pain during movement, ERP = end range pain, LRF = lat rotation and flexion, MRE = med rotation and extension
ROM
Cervical screen all FN
Thoracic
Rotation Left FN Right FN
Shoulder
LRF Left FN Right FN
MRE Left FN Right DN, mod winging
MMT
Shoulder all motions 5/5 except R shoulder abduction 4*/5 - painful
Myofascia: moderate restrictions in R lateral upper arm, cervical and upper trap patterns
Special tests: repeated shoulder extension increases R shoulder motion and shoulder strength with less pain
Traumatic
Subjective: Pt reports getting into a fight with his brother, who eventually landed on his L UE. The pt pulled his L UE out from under his brother's body weight and felt a “tear.” Since then he has tried various forms of PT and chiropractic and has improved at least 80%. Currently c/o L upper trap. MRI arthrogram results show posterior labral tear.
Objective: fair sitting posture, moderate forward head
key: F = functional (WNL), D = dysfunctional, N = non-painful, P = painful, PDM = pain during movement, ERP = end range pain, LRF = lat rotation and flexion, MRE = med rotation and extension
ROM
Cervical
flexion DN
extension FN
Rot/flex Left DN Right DN, mild bilaterally
Thoracic
Rotation Left DN Right FN
Shoulder
LRF Left FN Right FN
MRE Left DN Right DN, L > R winging (mod vs min)
Myofascia: moderate restrictions in L cervical, upper trap, levator scapula, lateral upper arm patterns
Contrasts
- insidious versus traumatic
- crepitus versus none
- positive MRI findings on left shoulder for torn posterior labrum, negative on right shoulder patient
- trauma patient needed education on the insignificance of MRI findings of minor posterior labral tear
Similarities
- both cases are "almost there" but stuck at higher level activities - resistance training
- loss of functional shoulder IR
- similar mobility loss in upper quarter tissues - cervical paraspinals, upper traps, levator scapula, lateral upper arm, pec minor, subscapularis
- repeated shoulder extension MDT reset both slight PDM during the movement, better as a result
- both had significant scapular dyskinesis in shoulder elevation and WB on the involved UE
- ther ex given for HEP
- supine kettlebell rotations for proprioception and stability training progressed to first unweight baby get-up position
- repeated shoulder extension in standing
- kettlebell carries
- Tx - IASTM to the restricted patterns, functional release to the shoulder to improve IR, first rib and thoracic mobilization/thrust manip
- both were 100% better with slight modifications to their programs
I thought both of these cases were interesting not because they were difficult, because they certainly were not. They both exhibit the importance of looking for and treating patterns, such as loss of IR, similar soft tissue restrictions, and using similar correctives and resets to improve mobility and stability. They even swap kettlebells for their HEPs. So what's the lesson learned here? After months of stability exercises, with no functional improvement (or change in stability), time to change up the program and at something a bit more functional and a little manual to improve some loss of shoulder IR.
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