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Painful Shoulder - April 29, 2004 9:09:00 AM

sprite

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Looking for suggestions on this one. Has had R shoulder pain x 10 days. He describes the pain as a constant 'charlie horse' and feeling that arm is 'disconnected' around the entire GH jt. Started for no apparent reason and progressively got worse. Given an injection on 4/25 with minimal relief. Pt. has full A/PROM, 5/5 strength ER/IR/ABD/Flex. Pain with post, inf glide. States long axis distraction feel better. + scour. Hx of MVA in 1998 with Cervical pain and ulnar nerve intraptment which was surgically corrected. MRI of c-spine - in 1998. All cervical motions except flexion give 'muscular pull' in R upper trap, with no reproduction of shoulder sx. States this pull has been since MVA. Ice aggervated and heat with temp relief. Pendulum ex increase pain. Had to limit exam to above due to irritation of sx's. Any idea?

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Re: Painful Shoulder - April 29, 2004 6:42:00 PM

advsportrain

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how does long axis distraction makes him better and pendulums make him worse ? Maybe some weird labral pathology.

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Re: Painful Shoulder - April 29, 2004 6:48:00 PM

carolcollom

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From: Las Vegas, Nevada
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I would suggest an MRI. I am a massage therapist, but it sounds to me like it could be a torn rotator cuff in one or two areas. I would stay away from ice and utilize ultrasound, mild stretching and progressively more facilitated and self stretching of area, then weight bearing to regain strength. Neuromuscular massage techniques and trigger point therapy on a regular basis can also help if patient has adequate financial ability or insurance.

Carol Collom

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Re: Painful Shoulder - April 29, 2004 7:10:00 PM

Bill Egan

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From: Newton, MA
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This gentleman's presentation and history sounds like he could have at least a component of neural tissue irritation.

Check the neural tissue provocation tests, and pay careful attention to how the cervical component modulates any symptoms. Also see how the elbow movement effects the symptoms if he has had previous surgery there.

To check for more of a compression sensitive problem, try Spurling's A and B. Sometimes with these you have to sustain the position for awhile to illicit a response.

Palpate along the cervical roots and brachial plexus for tendernes.

Palpate the lower cervical segments, upper thoracic, and upper ribs for tenderness, stiffness, and tissue texture changes.

It sounds like you assessed for any local dysfunction at the shoulder, did you check the stability of the GH joint ?

Any red flags ? General health ? Is he diabetic ?

Hope this helps, let us know what you find.

Bill

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Re: Painful Shoulder - April 29, 2004 7:15:00 PM

CHENGER

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From: Stamford, CT
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In his own words, what does he do to aggravate it? And what does he do to relieve it? Some of the findings are inconsistent, ie distraction helps yet pendulums doesn't. Is he doing them right? Does head position have anything to do with it/maybe relief with manual traction? Did you test Empty Can? How are his reflexes and did you check TOS? These are a few things you might want to check out to rule RC pathology/Neurological issue. Remember many of the most common tests are just provocative but not specific. While there are so many things one could check, again I find the best and easiest way to find out the answer is to ask the patient "What do YOU do to make it worse, and what do YOU do to make it better" and take it from there. Have fun.

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Re: Painful Shoulder - April 29, 2004 9:47:00 PM

Alex Brenner PT MPT OCS

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From: Kentucky
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Hi Sprite. I would agree with Bill Egan. With your description I feel it is most likely neural tissue. Was his neural exam normal (reflexes, sensation, myotomes)? I would not tend to think it is a torn rotator cuff or labral tear without some type of mechanism of injury, plus the fact that all of your manual muscle tests of the shoulder were 5/5. Take a closer look at the c-spine and try placing the patient into some upper limb tension positions to reproduce pain. If you place him into the Spurlings positions and hold him there can you reproduce his shoulder pain? You also may want to try placing the patient prone and do some graded PA glides on the c-spine to see if you can reproduce his shoulder pain. The relief of pain with shoulder distraction may also mean that he has some neural tissue irritation. Let us know how it goes!

ArmyPT, OCS

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Re: Painful Shoulder - April 29, 2004 9:49:00 PM

Alex Brenner PT MPT OCS

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Whoops, sorry Bill. I basically just repeated almost everything you said. I guess we think alike. [IMG]http://www.rehabedge.com/forums/smile.gif[/IMG]

Army

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Re: Painful Shoulder - April 30, 2004 12:33:00 AM

CuriousPT

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Sorry, somebody might haver mentioned this earlier, but have you done over-pressure in the cervical spine to really clear it?
Is his pain continous? If it is, the cervical jt might be more of a source than suspected- especially with a previous hx of possible whip lash injury... A C5 nerve root irritation would cover the area wouldn't it? Would be interested to see result of your neurological testing.
Good luck!

[This message has been edited by CuriousPT (edited April 30, 2004).]

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Re: Painful Shoulder - April 30, 2004 1:20:00 AM

nari

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I also echo Bill and Army. Investigate a neural component; the ease with distraction is a clue.
Why do pendular exercise with normal ROM??
It is likely to aggravate neural tension if that is shown to be present.

Look at slump +/- neck F/E then ULNTT.
Include cervical LF and rotation in ULNT if the straight ULNTT is negative.

I am curious - what is charley horse???

Nari

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Re: Painful Shoulder - April 30, 2004 4:14:00 AM

chiroortho

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Could be partial thickness supraspinatus tendon tear in region of relative hypovascularity just proximal to insertion on humerus.

May have type 2 acromion with subacromial spur, can cause irritation of tendon without tear. MRI needed to assess.

May be referred pain from c-spine but very unlikely based upon your limited info. C-spine HNP wouldn't result in pain on pendulums.

Yes it's possible that glenohumeral instability due to capsular injury/laxity is present but very unlikely. Would have + apprehension on full ER if present.

You didn't mention anything about tenderness on palpation.

Lastly, subacromial/subdeltoid bursitis could be an issue. Again, MRI needed.

Upper trap "pulling" could be secondary to muscular guarding w/RC tendinopathy.

MVA in 1998 would not cause abrupt onset of these sx aside from very idiosyncratic factors.

In summary, sounds like tendinopathy, fairly acute flareup, which would show up on MRI. You don't mention shoulder xrays, but doubt that they would be of any help. The fact that recent injection gave him any relief at all, even "minimal" suggests local problem. If it was referred from c-spine injection wouldn't have made any difference whatsoever.

Suggest MRI and go from there. If tendinopathy is ruled out, check for triggers in posterior RC. If all else fails, send to ortho.

Greg

------------------
Greg Priest, DC, DABCO
Diplomate, American Board of Chiropractic Orthopedists
Fellow, Academy of Chiropractic Orthopedists [URL=http://www.drpriest.com]www.drpriest.com[/URL]

[This message has been edited by chiroortho (edited April 30, 2004).]

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Re: Painful Shoulder - April 30, 2004 4:22:00 AM

chiroortho

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BTW,

Very impressed with all of your posts.

Great job.

Greg

------------------
Greg Priest, DC, DABCO
Diplomate, American Board of Chiropractic Orthopedists
Fellow, Academy of Chiropractic Orthopedists
www.drpriest.com

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Post #: 11

Re: Painful Shoulder - April 30, 2004 4:26:00 AM

Alex Brenner PT MPT OCS

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From: Kentucky
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[QUOTE]Originally posted by sprite:
[B]Started for no apparent reason and progressively got worse......Pt. has full A/PROM, 5/5 strength ER/IR/ABD/Flex. [B][/QUOTE]

With no mechanism of injury and full strength on manual muscle testing it would be hard for me to believe he has a rotator cuff tear. Current MRI results of shoulder would be interesting. Current MRI results of c-spine would be even more interesting.

Shoulder plain films would reveal if there is a subacromial spur. Take a look at those if you can.

Does he have a positive Drop Arm or Empty Can to suggest a RC tear or supraspinatis involvement?

ArmyPT

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Re: Painful Shoulder - April 30, 2004 5:04:00 AM

mike71

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From: Atlanta,USA
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I agree with armyPT and Bill. Check

1. ULTT
2. cervical capsular pattern? ( flexion least restricted?)
3. Spurling's
4. cervical spine palpation and glides.

Any sensory symptoms(dermatomal)?
MRI would be of help ( considering the history of MVA)
It can be even a cervical facet problem.( unilateral symptoms,restricted movements).
check for any radiculopathy ( interscapular pain?)
Check out thoracic area too.

Mike

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Re: Painful Shoulder - April 30, 2004 5:15:00 AM

Bill Egan

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To all who mentioned an MRI. What are you trying to rule in or out ? Would the results of this study change your treatment, especially if it did not match the clinical findings ?
I think we open a can of worms just doing an MRI, unless we are trying to answer a specific question. As you all know, MRI's are very sensitive and typically are going to show something that may or may not be relevant.

Bill

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Re: Painful Shoulder - April 30, 2004 6:03:00 AM

Shill

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From: Madison WI USA
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Chiroortho,
I agree that pendulums shouldnt cause problems from C-spine referral, BUT, there are many times that patients will protrude their necks during this movement, or maintain flexion of the cspine during the pendulums, thus generating a worsening effect.

Sprite,
see if scapular protraction with horizontal adduction of the arm across the body with rotation of the head away from the painful side increases symptoms. This is a recommendation for checking for suprascapular nerve entrapment.
Taken from Neurologic Clinics Volume 17, Number 3, August 1999
Tenderness of the scapular notch is sometimes present, as is weakness of the SS, IS, and occasionally deltoid atrophy due to disuse.
Its rare, but it happens, and I would be suspect of "weird neuro stuff" (the correct medical term) in someone with previous neurologic surgery for entrapment.

Rehab for this is similar to that for an unstable shoulder, with some neuromobiliations thrown in, if helpful in symptom control.

Good luck, let us know how it turns out.
Steve PT, Madison WI

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Re: Painful Shoulder - April 30, 2004 6:03:00 AM

Shill

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From: Madison WI USA
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Re: Painful Shoulder - April 30, 2004 8:52:00 AM

Bournephysio

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I agree with everyone who suggested looking at the neck and neural tension. R sideflexion should not cause a muscular pull in the right trapezius. One quick test I like is to get the patient to perform a movement that is painful (you didn’t give that info) and try it with and without cervical traction. If cervical traction decreases the pain there is likely a neck component to the problem. Pain relief with injection does not rule this out. First the relief could be placebo and secondly, the neck problem could have caused an actual shoulder problem to develop.

You mentioned that you stopped the exam secondary to pain. What in particular caused this pain?

Capsular instability is likely. Full er in 90 abd is not specific enough to rule out instability so er in neutral wouldn’t be either. Both only test anterior capsule anyway. This may be more posterior. You need to carefully check all portions of the capsule.

What is this subject’s scapular position and mobility like? Even a couple of degrees of downward rotation can negatively impact glenohumeral stability. The neck problem can alter scapular control which would impact the shoulder.

How old is this patient?

What does the patient mean by “charlie horse?” I have always been taught that a charlie horse is a thigh contusion. When I worked in Michigan any patient who used the term thought it was a cramp as SJ said.

I agree with Bill. There is no reason to get this person an mri. A full clinical exam hasn’t even been done yet.

If I suspected a rotator cuff tear I WOULD NOT STRETCH it.

Why did he have an injection within 10 days of having a problem? That is atrocious.

Doug

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Re: Painful Shoulder - April 30, 2004 9:22:00 AM

chiroortho

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Army, I disagree that a patient can't have normal MMT w/RC (partial-thickness tears, especially). Despite the empty can testing position, it's still very hard to isolate the SS muscle. I know textbooks say otherwise, but I see it almost every day.

Bill, I did explain what we're looking for on the MRI, and unfortunately I disagree with you too. This much pain localized to the shoulder, injection failed, stated clinical findings inconclusive...RC tear needs to be R/O and that can only be done via MR. Yes it's sensitive, and that's why we do the MRI studies for shoulders because RC tears are extremely easy to see if full thickness w/tendon retraction, and partial thickness tears are also easy to Dx, especially in an acute shoulder where it would be accompanied by a fluid signal within the tendon. Again, I've seen the scans countless times myself.

IMO we already have plenty of history and clinical info to justify an MR of the shoulder.

So does this guarantee that I'm right? Of course not. But this is what the forum is for, right? Sharing clinical insights, ideas and recommendations.

Respectfully,

Greg

------------------
Greg Priest, DC, DABCO
Diplomate, American Board of Chiropractic Orthopedists
Fellow, Academy of Chiropractic Orthopedists [URL=http://www.drpriest.com]www.drpriest.com[/URL]

[This message has been edited by chiroortho (edited April 30, 2004).]

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Re: Painful Shoulder - April 30, 2004 9:44:00 AM

sprite

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Pt. is a 44 yo male. Negative apprehension; pain with grade II GH inferior and post glide; slight tenderness RTC insertion but is also wher he was injected 3 days prior; horiz. add negative. By the charlie horse he meant cramping and also has a deep bone ache. States his pain is the worst at rest and with supine to sit transition (he did not use UE support with supine to sit and had significant pain in the clinic). I tried supporting his arm with a pillow while in sitting to take any traction off arm but he said it felt worse. The activites he says make it worse are pulling, pushing, weight bearing through the arm, supine to sit with no UE assist. From the A/PROM, MMT, and other tests all together aggervated his shoulder and that is why I stopped. And with U/S 20% .8 w/cm over the RTC make pain worse.

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