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Dear All,
This is a follow up e-mail for a case study that I had difficulty with a while ago. I posted two e-mails (reproduce below) requesting advice and assistance on the case study. The patient went on to gathering a second orthopaedic opinion on her shoulder that diagnosed an isolated 90% tear of infraspinatus on MRI. Hmm, bone scan and CT reports ?missed this! She is now awaiting surgery for this. I think that no doubt there are neural signs in this patient but more than likely these appear secondary to compensatory positioning of the shoulder adopted to 'guard' this tear. I am providing you with this follow up information for your learning. Once again, thank you for your input.
Regards,
Brendan Valente
Snr Physiotherapist
Fremantle Hospital
Fremantle, Western Australia

FIRST POSTING.........
Dear Colleagues, (what a wonderful resource you all are!!!!)

I am wondering if any people can give me advice on a patient of mine who I
am having slow progress with.....

A brief history: She is a 25 year old female who sustained a depression
injury to the right shoulder after a fellow basketballer fell down onto her
shoulder 1 year ago. She continues to experiences pain under the pec minor
insertion to the coracoid process, nerve roots of the lower cervical region
and medial arm regions. The pains are tight, occasionally sharp but also
aching in nature. A CT and bone scan ordered through an orthopaedic surgeon
showed a small tear in the upper trapezius muscle and some bursitis. With
pins and needles in the MF and RFingers though, I feel that her pain is has
neural origins........

Objectively, she stands with a depressed and protracted shoulder. Her
cervical range is full but with a 'muscular' tightness at the end of range
all directions. She has painful shoulder flexion and abduction greater than
90 degrees due to a pull in the inner arm. NTT: ulnar and median nerve
tightness. Upper limb muscle strength and reflexes appear preserved. There
is a positive Hawkins and Kennedy test and most special tests of the
shoulder aswell.....quite a complex and vague, very painful and irritable
picture.

Treatment has consisted of neural glides (stretches), elevation taping,
upper traps strengthening, TENS applied to the nerve root through to the
coracoid process and anti-inflammatory tablets.....and she is improving, but
slowly.

I welcome any comments on her condition or my treatment. Advice on any
treatments or assessments that have been overlooked would also be
appreciated. (I have been bias in my presentation of her objective findings
but if you wish to know more, please ask.)

Many regards for the assistance and your time,
Brendan Valente
(A/Senior Physiotherapist)
Physiotherapy Department
Fremantle Hospital
Western Australia.

SECOND POSTING......

Steve,
Thanks very much for the time you have spent to help me with this patient. Here is the additional information......

1) Any more detail on aggravating and easing factors?
Eases: rest, hand held supported across abdomen, taping into shoulder retraction and elevation. Positions provide almost instant relief from infra-clavicular pain but an ache remains in the shoulder joint area.
Aggravating: most aggravating action is 'shoulder shrugging' which pulls through behind the clavicle, also carrying objects, pushing and pulling doors and turning the steering wheel aggravate the pain.

2) Does she have full active range of motion (AROM) of flexion/abduction/internal rotation/external rotation? How does this compare to passive ranges (PROM) How does the onset of pain and resistance compare? (Is external rotation more limited in neutral compared to 45 or 90 degrees abduction, this appears to be commonly the case in subscapularis tightness which leads to restricted elevation)
Right Shoulder ACTIVE ROM: (P1 and R1 are initial onsets of pain and resistance respectively)
Flexion: 95deg P1 infra-clavicular pain and posterior shoulder
Extension: Full ROM no pain (R=L)
Abduction: 135deg P1 infra-clavicular pain (movement pattern includes scap depression!)
External Rotation: 85deg P1 infra and supra-clavicular pain (R 10deg < L)
Internal Rotation (HBB): T7 P1 supra-clavicular pain (L=T3)

PASSIVE ROM: (P1 and R1 are initial onsets of pain and resistance respectively)
Flexion: 95deg P1 infra-clavicular pain. (*****No change with Cx sideflexion)
Extension: Full ROM no pain (R=L)
Abduction: 100deg P1 infra-clavicular pain, 'pull' in axilla and medial arm
*****with contralat Cx rotation: 70deg P1 same pain area!*****
External Rotation: 85deg P1 infra and supra-clavicular pull. No difference in range when tested in abduction (Subscap).
Internal Rotation (HBB): T7 P1 supra-clavicular pain (L=T3)

3) Is thoracic spine rom into extension full and does the patient exhibit
a forward head posture?
This patient is posturally quite kyphotic through the thoracic region but has full thoracic extension ROM.

4) During arom into abduction / flexion, does the onset of pain alter with contra or ipsilateral cervical side flexion? Are there any other movements you can use to alter the onset of pain and or restriction?
See part two*****

5) Which resisted tests are painful? nil!!! (So I guess PRE's will only be of use for postural re-education.)

6) What are the glenohumeral accessory movements like?
a) P-A and A-P GH joint glides are stiff compared to the left but she tells me that her shoulder has felt stiff following the first episode of shoulder pain.
b) Interesting, in standing, passively elevating the shoulder+ girdle through a force applied only through the elbow leads to sharp shoulder pain but isolated cephlad compression of the GH joint does not lead to pain. hmmmmm....another pathology?
c) AC joint shears cause pain in the anterior shoulder joint but I feel this may be due to hand pressure.

Many thanks again,
Brendan Valente
(A/Senior Physiotherapist)
Physiotherapy Department
Fremantle Hospital
Western Australia