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Re: Painful Shoulder
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Re: Painful Shoulder - April 30, 2004 10:33:00 AM
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PTstud
Posts: 86
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From: Texas
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carolcollom,
It is clear its not a rotator cuff tear since his strength is 5/5 in ER and IR directions with full ROM. Im pretty sure its some type of capsular instability (pain w/ post inf glide)leading to bursitis, some type of labral impingement, or neural tissue irritation(charliehorse pain), try the post instability tests in the MLPP and progress to the MCPP.
chiroortho, you doubt it might be capsular instability because apprehension tests in full ER were -? That would be true for anterior instability but the symptoms were present with a post inf glide-the direction of post instability tests.
This patient's injury seems to be extremely irritable. I would perform grade 1 traction mobs to shoulder (for pain relief) and go easy for a week. I would then start a shoulder strengthening program for posterior stability, staying away from end range IR movements.
Mike
[This message has been edited by PTstud (edited April 30, 2004).]
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Re: Painful Shoulder - April 30, 2004 12:50:00 PM
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sprite
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PTstud what is "MLPP and progress to the MCPP" as I am not familiar with the abbreviations.
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Re: Painful Shoulder - April 30, 2004 1:01:00 PM
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chiroortho
Posts: 655
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PTstud, how would the patient develop capsular instability so acutely? His accident was 6 years prior, otherwise if I recall correctly he was atraumatic and otherwise negative history of anything that would have led to instability.
And a patient with a partial-thickness tear could certainly have 5/5 strength and full ROM!
------------------
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 2:15:00 PM
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Jon Newman
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Joined: April 24, 2004
From: Amherst, WI
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Sprite, your case study is interesting as I had arbitrarily made up just such a case some time ago for purposes of discussion. Here you have someone who is strong with full AROM but painful. Sorry I don't have any suggestions only some questions.
1. What was the patient told was wrong with him (by the referral source)? Was any information on management given to the patient by the referral source(lifting restrictions, no overhead activity, etc)? The referral source seemed to feel that this must represent an inflammatory condition based on the decision to administer a cortisone injection.
2. What does the patient feel is wrong? Is he concerned that he is misdiagnosed? Does he feel this is related to the MVA he sustained in 98?
Just curious.
jon
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Re: Painful Shoulder - April 30, 2004 3:05:00 PM
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sprite
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Jon, The referring family MD did not offer the pt. a dx other than what was on the PT referral "R shoulder pain". He was given no restrictions on activity. Also was given Vioxx once daily. Pt. has no idea what is causing his pain.
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Re: Painful Shoulder - April 30, 2004 4:30:00 PM
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Jon Newman
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From: Amherst, WI
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Sprite or anyone, what sort of time frame would be typical for an inflammatory condition to resolve? By resolve, I'm referring to the chemical irritation (hence the cortisone and vioxx) responsible for pain associated with inflammation. If there is no more chemical irritation then it would seem likely that the patient won't get relief from injection or vioxx. That leaves mechanical irritation for peripheral causes of symptoms. Many suggestions have been made in regard to this.
To review, this patient has full AROM, full strength, acute idiopathic pain. The tissue trigger is subtle enough to escape an obvious diagnosis. It would seem that a PT would have just as good of a chance to make matters worse as to make them better depending on approach to movement prescription and on what we lead the patient to believe we know bout their pain. Imaging could be performed to try to see the tissues we cannot diagnose manually. With full AROM and strength, is surgery a likely option (I am asking this honestly. I don't know) if an MRI shows tissue issues?
Lastly, I'm willing to bet that the patient has some concept of why he hurts. Most everyone in pain comes up with what might be wrong, it is our nature. Perhaps,your patient likely has suspicions that have not set up sufficiently to call beliefs. People are often suseptible to suggestion at this stage. What you tell them makes a difference.
jon
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Re: Painful Shoulder - May 1, 2004 6:24:00 AM
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PTMAN
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From: Pine Ridge, SD USA
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Sprite, I agree with everyone who suggests neural involvement. Have you asked him about numbness? Does straining or Valsalva manuever affect his symptoms? Does raising his hands over his head influence pain?
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Dwight Baldoman
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Re: Painful Shoulder - May 1, 2004 7:37:00 AM
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Bill Egan
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From: Newton, MA
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Greg,
Sorry, my friend, but I disagree with you. It is too early to get the MRI.
With the limited physical exam, we still do not have enough information for an accurate differential diagnosis.
The MRI should be used to confirm what we already suspect.
The only exam findings given by Sprite that implicate the RTC are the location of pain and tenderness of the RTC insertion. As you know the location of pain can mislead us into thinking there is local patholgy in the underlying structures.
There is no weakness, he has FAROM, and we do not have any impingement test information.
I will have to look this up, but I would suspect that full to partial thickness RTC tears on MRI are common in asymptomatic shoulders.
Finally, in my opinion, an MRI should be considered a surgical planning tool. Are we ready to scope this guy at this point, if he did in fact have a relevant RTC lesion ?
Bill
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Re: Painful Shoulder - May 1, 2004 9:21:00 AM
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sprite
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PTMAN, no c/o numbness/tingle but did say on a couple of occasions he had pain down into the 2nd and 3rd digits. Primarily he says pain is in shoulder and upper arm. Unsure of when straining. Reported slight increase in pain at end-range of all shoulder movements.
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Re: Painful Shoulder - May 1, 2004 10:37:00 AM
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chiroortho
Posts: 655
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Bill,
Fair enough. And I would agree that P/T and even F/T tears could be asymptomatic, so yes, that would have to be part of the algorithmic process I suppose.
What would really be interesting would be to see how this poor patient makes out in the end...what was wrong, what was his pain generator, what needed to be done to fix it.
Thanks for your ideas and comments.
Greg
------------------
Greg Priest, DC, DABCO
Diplomate, American Board of Chiropractic Orthopedists
Fellow, Academy of Chiropractic Orthopedists
www.drpriest.com
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Re: Painful Shoulder - May 1, 2004 7:20:00 PM
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PTstud
Posts: 86
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From: Texas
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Sprite,
MLPP and MCPP are abbvs. for maximum loose packed position and maximum closed packed position of the shoulder. These positions are the positions of a joint where the joint is either capsularly and ligamentously at its tightest (for shoulder its full ABD and ER) or loosest (55degreesABD, 35 Flex, and 15 IR).
Chiro guy, As far as it being a RTC partial tear, you are correct they may still have 5/5 strength, but I do not recall any pain with the ER/IR resistive tests. Since these tests isolate the RTC tendon, I do not see how a post-inf glide can be painful and these tests be negative (if in fact its a RTC lesion). Perhaps I should have elaborated more last time.
Have you tried axillary nerve tension tests?
Mike
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Re: Painful Shoulder - May 1, 2004 8:39:00 PM
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coloradojulie
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From: colorado usa
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The last time a patient of mine presented with the feeling that his shoulder was disconnected was with a spinal accessory nerve palsy. I have seen them surgically induced as well as traction induced.
Scapular mechanics begin to fail gradually as the entire trapezius muscle begins to atrophy. Shoulder pain arises from improper scapular biomechanics (strain and impingement). Is there any change in scapular mechanics or trapezius atrophy?
Secondly, if all his motion tests are essentially negative and this is truly sudden non-traumatic in origin he could also have an underlying condition such as PMR in the shoulder. Any blood work or history of RA or autoimmune stuff in his family?
The pain could also be referring from a primary internal source. Any changes in bowel and bladder function etc.?
He could be heading into adhesive capsulitis. Has there been any recent illness?
He could have sustained an annular disk tear in the MVA that the imaging studies missed. Perhaps he has certain postural tendencies which gradually created a weakness in the disk and subsequent pathology.
The loss of the cervical lordosis commonly seen after whiplash injury could be accelerating cervical disc degeneration and he may have foraminal narrowing or spurs.
Rotator cuff tears typically hurt more at night and most people can't lay on them. FTRTC tears will present weak. Scapulohumeral biomechanics are often changed with muscle compensation to less than ideal movement ratios.
Muscle testing can be approached by isometric maximums, graduated force, and rep outs.
Posterior inferior glides in certain positions will be moving into the posterior inferior glenohumeral ligament, which when tight will force the humeral head into elevation as the arm abducts or flexes. If he has a posterior capsular insufficiency, he could have, over time created an anterior capsular laxity, an uncentered humeral head with resultant irritation of the long head of biceps. Over time this could create strain and in extreme cases a SLAP lesion.
Assess capsular mobility ratios between posterior and anterior capsule in abduction with the humeral head stabilized. Internal rotation should not be much less than 20 to 25 degrees that of external rotation, particulary if external rotation is hypermobile, as it often is in the dominant hand. Home sleeper stretch if so.
Pain increases from supine to sit without using his arms to assist...wonder what this looks like. I am thinking he might be overengaging his SCMs at this point creating an anterior shear at the base of the C/S. Does he have Forward head posture...what happens to his symptoms with supine to sit if you have him hold a "chin tuck". Does his pull go away when he is in this position and goes through the C/S ROM stuff. Weak deep neck flexors. FHP can have a significant role in shoulder muscle dysfunction (levator scapular, upper traps, etc).
What does he do for a living? What in his life has changed in the last month? Jobs? Bed? New exercises? Treatments? etc. Stress?
What does he do to relieve his pain when it comes on? Are there any positions of comfort?
All of these things are at the top of the pyramid of rule in/rule out, along with the other ideas listed previously. Travel the path to eliminate or include these hypothesis with appropriate questioning and thorough evaluation. You can't treat s SHOULDER. You must look at the patient as a whole and discover what other elements might be contributing.
Pain in a joint can be representative of it being the weak link in a kinetic chain or series of movement patterns that are repeated over and over. Can you identify any that are relevant to this fellow?
Keep your mind open and consider all avenues. Horner's syndrome, CA etc. You can narrow your focus later...but for now you need to consider all possibilities and note significant findings. Use these to lead you into the right direction. Never assume a pattern, even if you think you have seen it a hundred times.
Curious to hear more about this guy!
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Re: Painful Shoulder - May 1, 2004 10:37:00 PM
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nari
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From: Australia
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I would like to hear more as it evolves, too.
Sorry to labour a point, but increased pain moving from supine to sitting, or increased anyway in supine and AT REST is highly indicative, from clinical experience. of neurogenic/neuropathic pain.
This can arise a long time after an insult (eg whiplash, a fall) to the person; even years. A sudden start might mean a trigger of some kind occured, but that would be very difficult to find- there are so many around.
Any more useful clues to his functional activities?
Nari
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Re: Painful Shoulder - May 2, 2004 6:06:00 AM
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chiroortho
Posts: 655
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I know I'm the lone voice here in favor of ordering an MR, so I'll try to summarize my reasons:
-young, atraumatic patient
-last known significant injury 6 years prior
-vague pain localized to shoulder
-no radicular signs
-pain on palp of RC posteriorly (if I recall correctly?)
-pain very disruptive to ADLs and becoming real issue for pt.
-no solid instability signs (even if there were, MR would be helpful-SLAP, Hill-Sach's, etc. show up nicely on MR)
-RC injection gave some relief, though limited.
So, sometimes we have to make decisions (actually almost always) with incomplete information.
Do I think MR is a screening tool? Of course not. Do I think that we can over-assess, over-worry that we're ordering a scan prematurely? Yes.
Have I ever been wrong? You betcha. But eventually this patient is going to get tired of waiting while we perform 3,000 tests over a 6-week period while he continues to go down the tubes. I say we make a decision, and if we don't know what we have that's okay. Let's do the scan and find out if our educated guesses are right.
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 May 02, 2004).]
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Re: Painful Shoulder - May 2, 2004 10:25:00 AM
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eam
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From: New York, NY 10028
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Just a few additional thoughts here to add to the already long list of insightful suggestions. How is his accessory mobility of the cervical/thoracic spine? Any segmental restrictions (flexion, ext, sb, rot)? When you assess this, are his symptoms reproduced? Does pain come before resistance etc? Keep us updated. Good luck!
Erica
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Re: Painful Shoulder - May 2, 2004 12:18:00 PM
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Alex Brenner PT MPT OCS
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From: Kentucky
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Hi Greg,
How would the findings on the MRI change the way you would treat him now? Even if the MRI shows a partial RC tear, that doesn't necessarily make him a surgical candidate. Lets give conservative care a try first (addressing all the things listed above) before we start ordering additional tests. If conservative care fails then an MRI would be warranted with a consult to ortho. I don't think we need the MRI right away, maybe we can fix this guy with PT and save a few bucks that would be wasted on an MRI that would not change the treatment plan anyway. As always, just my thoughts.
Army
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Re: Painful Shoulder - May 2, 2004 12:24:00 PM
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chiroortho
Posts: 655
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Army I can certainly buy that, but a couple things bother me about this guy...such acute onset for no apparent reason, and the amount of pain he's in...
Normally, the patient presents with an identifiable precipitating incident, or lacking that, they typically report chronic intermittent pain that develops slowly and goes away with/without treatment.
He's kind of the opposite of both, and that causes my eyebrows to raise a millimeter or two.
But again, I could be wrong...
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Greg Priest, DC, DABCO
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Re: Painful Shoulder - May 2, 2004 12:40:00 PM
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Alex Brenner PT MPT OCS
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From: Kentucky
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Greg. Good points. It will be interesting to see what they find out.
Army
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Re: Painful Shoulder - May 6, 2004 5:53:00 PM
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Jon Newman
Posts: 1707
Joined: April 24, 2004
From: Amherst, WI
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Well, one more change to get used to. I have to admit liking the old format..but I'll get used to it.
I've been wanting to ask the following questions for a while now.
We have more than 10 hypothesis for a diagnosis to test. My question is what would people do in the mean time. The patient's chief c/o is pain. Do we keep testing and testing? Do we tell him what we think is wrong with him? Do we have him strengthen his RTC? Do we have him shake a body blade? What would the movement that you select to resolve his pain, look like?
I'm very curious?
Jon
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Re: Painful Shoulder - May 6, 2004 9:55:00 PM
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Alex Brenner PT MPT OCS
Posts: 1057
Joined: February 29, 2004
From: Kentucky
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Hi Jon. In my opinion his pain needs to be addressed first before we do anything else. It is very difficult to decide what to do without performing my own evaluation on this patient but I guess that is one of the limitations of discussing PT care on a forum. With what little I know about the patient I would start by performing gentle Grade 1 and 2 joint mobs to the shoulder girdle and c-spine. If working at his c-spine was more effective in lowering pain then I would concentrate there. This patient sounds like he has some neural tissue problems so I would also try performing some gentle neural tension stretches with him to help reduce pain. Once the pain was under control I would then try to work on regaining pain free shoulder range of motion and c-spine motion and then move into strength training ie. shaking the body blade :)
ArmyPT
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