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Shoulder Doozy - Advice
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Shoulder Doozy - Advice - September 22, 2007 10:17:46 AM
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dscouras
Posts: 27
Joined: January 27, 2007
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I have a wild shoulder lady. This lady has had sh pain since last February. Was seeing an AT with mixed success until early June when it began to correct. She was involved in an MVA in July where she was strapped leant over and tried to protect her son, L arm on wheel (scapular plane flexion at 90 degrees, and other arm abducted and 90 degrees while leaning over.
Instant pain after MVA and came into clinic2.5 months later exhibiting these results.
42 year old active with fantastic physique except, great definition R U/E
L scapular wasting
AROM PROM pain migrates down mid bicep
fwd flex 90 120 palpable pain at deltoid insertion
Abd 80 100 and at the suprsp. tendon insertion
ER 45 80 increased tone subscap, infra, UFT
IR 50 80
Hor Add 1/2 1/2
Was originally MRI'd with result of subdeltoid bursitis
Now when therapist actively moves arm there is a block at the above ranges of mov't but they are boggy (like fluidy)
Some mobilisations and we can get a rushing out feeling of fluid and her range improves untill she works it or sleeps on i etc. Other times working and releasing subsc, infra etc will improve her ROM...but only temporarily
Too much strengthening and it irritates etc etc...
I will add more info if asked but help would be appreciated cause we are all stumped here 6 therapists
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RE: Shoulder Doozy - Advice - September 22, 2007 10:39:50 AM
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bonmar
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From: Boston, MA
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I am assuming the L arm is the symptomatic one.
Is there pain with PROM of the L shldr? Impingement-type? You say "when the therapist actively moves the arm..." Do you mean passively moves the arm?
Pain at rest?
CROM? a/p...pain?
Scap stability?
When you say that strengthening irritates, what are you focusing on strengthening that irritates it?
Sensory changes?
Keep us posted
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RE: Shoulder Doozy - Advice - September 23, 2007 10:27:28 AM
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dscouras
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Joined: January 27, 2007
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Yes L arm is the symptomatic one.
There is pain with the mov't of the arm starting at about 90 degrees when she is having an allright day, and pain starting at 30 dgrees or so if she is having a rough day. With PROM there is still pain starting at about 90 degrees on a rough day with a odd block in there.
We can mobilise the block and get full ROM with some end range pain. On a good day we can mobilise close to full with little pain.
The block as described by client releases at times with a swishing like feeling. I liken this to the suction effect when relocating a dislocation of said joint. The release hurts for a few seconds and then full range is there.
Posterior mobs help, as does deep tissue massage (DTM), and some light pulley work. Lady was doing a course of strengthening exercises form a different clinic that I asked her to stop as she kept aggravating her shoulder.
It is that swishing feeling that I am concerbed about. My suspicion is that there is a labral irritation or tear in there but an old MRI prior to her MVA showed only subdeltoid bursists. Can a bursitis get so chronic/bad that it begins to block ROM and then release with some encouraging? I have never seen this...?
Hope this adds a bit to the situation. Any other questions I will answer cause this has us all stumped
Thanks
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RE: Shoulder Doozy - Advice - September 24, 2007 12:44:23 PM
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Shill
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From: Madison WI USA
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I cant see how a subdeltoid bursitis would limit movement, unless by sub they mean subacromial. If it is the deltoid bursa near the deltoid insertion, this should not really affect PROM. Could you elaborate on the scapular wasting?
What about her neck? I would suggest a full neck evaluation, not just a screen, and see what that brings about.
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RE: Shoulder Doozy - Advice - September 24, 2007 3:09:38 PM
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AdamP
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There is some communication of the bursa to the joint capsule, but it is unlikely the culprit. I agree with the previous reply. Check the neck real well and then move to the scapula. Are there specific muslces wasting? This would cause strange limitations in ROM. You could also check scapular rhythm and compare on good days to bad days. I wouldn't rely too heavily on an older MRI. Good luck and keep us posted! Thanks for the interesting case.
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RE: Shoulder Doozy - Advice - September 24, 2007 9:39:06 PM
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dscouras
Posts: 27
Joined: January 27, 2007
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Thanks guys for the brainstorming.
I have checked and worked on the neck. She has a congenital fused C4-5 Left transverse process with noticable calcification. ROM is full rot'n and side flexion = bilateraly with fwd flexion to 1 inch from the sternum. I am not sure if it is a complete fused joint/complex or if it is just the one side. Problem is that whenever I treat the lady she gets better for the day and sometimes 2 days. She just bought a new bed and that has helped with her pain levels and her sleeps are better.
Having said that she still gets her pain at the deltoid insertion region when flexing or abducting her arm to 90 degrees. Except when we get to swish whatever it is out then we get better ROM and painfree (this is all active). Also a posterior pressure on the humeral head helps reduce the pain and increase her ROM passively. When still locked (boggy) without this posterior mob her arm shakes when trying to raise it actively above 90 degrees.
Is it possible that after this long she has some major scarring in and around the subdeltoid bursa, or thickening of the ligaments or tendons causing the blockage? Could there be a slight labral tear or even worst a supraspinatus tear that was missed by the old MRI or just occurred in the new MVA?
As for the wasting of the scapular area, it is not just one muscle that is affected. It is th ewhole general area that is atrophying because of her inability to strengthen that area for the last 7-8 months...
Hope this adds more to her story!
Thanks everyone
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RE: Shoulder Doozy - Advice - September 25, 2007 1:11:53 AM
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bonez
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Is there significant wasting in the supraclavicuar fossa? This would be expected with a significant tear in supraspinatus. My experience is that the squishy crepitance can occur with a tear here when doing tissue release work especially in that 70 to 110 range of abduction.
An ortho I work with is always concerned about nerual injury with significant periscapular wasting. How about suprascapular nerve entrapment for the scapular muscle wasting.
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RE: Shoulder Doozy - Advice - September 26, 2007 12:16:23 PM
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pappawheelie
Posts: 40
Joined: September 19, 2007
From: Vermont
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Sounds like she could use an MRI of her shoulder (if she hasn't had one after the MVA), and even a neuro consult.
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RE: Shoulder Doozy - Advice - September 26, 2007 3:47:16 PM
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TLB
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From: Arizona
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You should always check C5-7 unilateral, you'll be surprised what you find.
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RE: Shoulder Doozy - Advice - September 28, 2007 7:09:05 AM
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Chocco
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I would continue to look at her neck, don't ignore her clavicle either both at sc + ac joints. Because abd and horizontal abd and flex are limited more than external rotation and internal rotaion It seems less like post capsule. I would try mobilizing the clavicle in a sup & post direction with shoulder flexon preferable active and monitor her pain. You can also try mulligan mobes for shoulder flex and abd to stabelize the gh joint and prevent ant. translation. Taping Her Scapulas into a retracted position would open up the subacromial space in case there is a gross hypertrophy of the bursa and improve her thoracic + cervical posture if there is cervical invovlment. That is if she could tolerate the taping. Just some more ideas to throw at you .
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RE: Shoulder Doozy - Advice - September 28, 2007 7:44:55 AM
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spaniard
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Just another idea in the same lines as above. Is there any tenderness, any symptoms elicited to the palpation at the supra-scapular fossa? I'd hate to miss a case of supra-scapular nerve compression.
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RE: Shoulder Doozy - Advice - September 28, 2007 8:10:12 AM
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dscouras
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Spaniard, (I love that name lol)
Palpation does not really cause any problems to the suprascapular region. Also there is no gross atrophy in that same area. I do not think we are looking at the suprascap nerve as a problem.
However Chocco, I will try the post/sup glides of the clavicle. Her neck is a possible culprit but does not explain the swishing feeling she gets when we get the release in her shoulder. This is also followed by instant ROM improvement and pain decrease. I have taped her scaps into retraction to help open up the subacromial space and she tolerates it well.
If there is more ideas keep em coming cause I will try these out. The mulligan mobs I will have to research before I do em.
Thanks guys/gals
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RE: Shoulder Doozy - Advice - September 28, 2007 10:52:33 AM
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pappawheelie
Posts: 40
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From: Vermont
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I'm curious about what tests you have done to r/o a RCT or even a labral tear. Also, what is the strenght of the rotator cuff, lower trap and serratus anterior?
And call me crazy, but I have had a couple of shoulder patients that after applying sustained pressure their shoulders will release with a squishy feel, but I attributed it to muscle relaxation.
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RE: Shoulder Doozy - Advice - October 11, 2007 4:50:35 AM
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ginger
Posts: 660
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From: Melbourne Victoria
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I'm with Shill, AdamP, TLB and Chocco. Don't waste time confusing yourself further , untill a comprehensive analysis of the cervical spine has been carried out to exclude the most likely of all phenomenon, referred events from spinal joints/nerves. It will not be sufficient to perform active movement tests ( of any structure or group of structures ) hoping to produce upper limb symptoms, neither will dural stretching on it's own reveal the likely central origin of these symptoms.
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RE: Shoulder Doozy - Advice - October 16, 2007 2:01:24 AM
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dscouras
Posts: 27
Joined: January 27, 2007
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Please tell me how to mobilize a congenitally fused C5-C7 joint?
I have mobilised her AC and her SC joints with varied success. Her best results have come from working her C-spine, Mobilising her shoulder and adding some traction. With some ER and traction and some occilations (30 secs at a time), we have been able to get and hear an audible crack/pop etc relieving her pain. My suspicion is that there is a labral tear in there and the MRI has been ordered. Unfortunately this is Canada and we may be able to get her in late Nov or earlt Dec. if are lucky.
I have not felt the squishy feeling client has mentioned that improves her ROM etc. Hard to get a true test in there d/t her limitations in mov't and pain.
However Obriens test was positive up to certain degree (keeping above in mind). SLAP test did not decrease pain but...above. Pain provoation test (client assessed in sitting with her arm in 90° abduction, arm passively externally rotated with forearm in pronation) was positive.
We have been treating as mentioned before with Taping retraction in scaps and mobs, Cspine and shoulder, and light exercise to promote retraction rather than protraction with releif for 2- days at a time. Her schedule of training and work aggravaes her shoulder.
Bed time for now getting tired
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