Hi Everyone! Looking forward to seeing you all this weekend! Here is my case for next week.

Subjective:
Patient is a 65 yo F, retired attorney, with a chief complaint of right shoulder pain that began at the end of September. Reported that she woke up one morning with pain. No specific MOI, had felt aches prior, but not this level of pain. Reported that she had been very busy the week before cleaning and caring for her mother who lives in an assisted living facility. When pain first started, she felt it in anterior shoulder from mid-clavicle to acromion, along superior and posterior aspect of the shoulder and along the lateral aspect of the upper arm. In the past few weeks (was evaluated on 10/23) pain now more localized to superior shoulder and lateral arm (about mid-way to elbow) that is described as a stabbing, achy pain, constant but variable in intensity. Denies any N/T. Also reporting a constant, variable intensity upper to mid thoracic “stiffness” that is made worse by time on her phone (not a new symptom for her). Her favorite activities are playing games on the computer and iphone and reading.

PMH: history of headaches made worse by stress and when she spends hours on her phone. Bankart repair on left shoulder in 1995, h/o DM, hypercholesterolemia, and depression. X-Ray for right shoulder was normal (per pt report) and she had a subacromial cortisone injection on 10/3/17 with no significant relief of symptoms.

Aggs: lifting overhead, lifting any object out away from her body (can be light weight) and reaching behind her back. Both exacerbated if done quickly and she feels pain immediately. Prolonged cellphone use as she often holds it in her right hand. Biggest agg: lifting her mother’s transport chair and/or Rollator into and out of her car.
Eases: rest with arm at her side, biofreeze.

Pain: Best: 3/10 Average: 5/10 Worst: 8/10
Severity: Mod-Severe (pain 8/10 at worst with moderate interference with ADLs and more limited with lifting tasks associated with being caregiver for mother)
Irritability: Mild-Mod (Able to reproduce symptoms quickly, but alleviates to baseline quickly (a few minutes) with rest.
Nature: Mechanical/ somatic
Stage: Acute
Stability: Worsening

Objective:
– Posture: forward, rounded shoulders, forward head
– Negative for cervical pain or reproduction of symptoms with cervical AROM + overpressure.
– Negative Spurling’s, distraction, and Negative neuro screen
– Shoulder AROM: Full on left, about 165 degrees flexion and abduction on right feeling pain at end range and reporting “weakness” into abduction. Pain and “tightness” reproduced at 150 degrees PROM flexion as well.
– TTP of pec minor, subscapularis, upper trapezius, biceps.
– Speed’s, Drop Arm were Negative. Hawkins and Full Can were Positive for pain reproduction, + Painful Arc.
– MMT: good strength, but painful with resisted RTC testing (supraspinatus, infraspinatus (mild), and subscapularis).
– Joint Mobility: GH: Hypomobile posterior capsule, ST: hypomobile ER, posterior tilt, upward rotation (pain relieving with mobilization), T-spine: hypomobile upper to mid-thoracic (and later assessed hypomobile 1st rib on R).
– FOTO: Intake 51 (predicted final score 63)

– Primary hypothesis: primary impingement, rotator cuff tendinopathy.
Asterisks:
*+Painful arc/Hawkins/Infraspinatus, positive full can for pain reproduction
*Hypomobility of posterior capsule
*Decreased thoracic mobility, poor posture
*Pain relief with scapular mobilizations, repositioning

Treatment:
Day 1 at Eval:
-Scapular mobilizations for pain relief followed by scapular PNF (rhythmic initiation, slow reversals) in side-lying with re test of forward flexion (resulting in slight decrease in pain).
-Shoulder ER isometrics with arm at side, starting with 5 second holds for 10 repetitions, once daily.
-Education on relative rest due to acute phase, use of ice for symptom management, and activity modification (discussed phone usage and strategies for her to get assistance lifting assistive devices for her mom).

Day 2:
Patient reporting increased stress and pain after having to take her mom to multiple doctor’s appointments, left her AD (14lbs), etc.
-Continued discussion on activity modification strategies (getting help from front desk for chair, deferring unnecessary trips with her mom, use of pillows for sleep positioning, computer/phone ergonomics).
-Started with MT: MFR upper trapezius, scapular mobilizations into posterior tilt, external rotation, upward rotation. Followed by PNF and AAROM flexion and ER with cues for scapular setting first. Re test of forward flexion, inc from 164 deg to 172 deg with pain at end range.
-Continued isometrics, now pain-free with arm at side.

HEP:
-ER isometrics
-UT stretches
-Scapular retractions

Future components to investigate:
–GH joint mobilizations, Effects of thoracic manual therapy (due to poor posture, complaints of thoracic spine stiffness)

PICO:
In patients with shoulder impingement, does the addition of thoracic manipulation result in a greater reduction of pain in less time than a treatment plan consisting of mobilization and exercise, as indicated by their numeric pain rating scale?

Discussion Questions:
1) With the acute nature and irritability level of this patient (and those like her), what are your immediate strategies for pain relief? Further, what are some of the strategies you like to use when discussing activity modification with the patient who is a caretaker for others or may have a physical job?
2) When evaluating a patient with shoulder pain, is there any further subjective information you would have liked to have day 1? Would you have looked at something differently on her objective exam?
3) There is a body of evidence showing thoracic manipulation can be effective for pain relief and perception of disability (though results can be inconclusive or reported to be just as effective as the alternate treatment with higher level evidence, i.e. systematic reviews). My question is, do you consider thoracic manipulation in your shoulder impingement patients, and if so, what subjective and objective asterisks are you looking for in your decision-making? At what point in the rehab process would you consider manipulation?
a. Mintken et al. developed a CPR to identify patients with a primary complaint of shoulder pain who will have a favorable response to cervical and thoracic thrust manipulation…however, in a secondary analysis done in March 2017, the results of the current study did not validate the previously identified prognostic variables.
4) What are some treatment strategies do you find effective in this patient population in conjunctions with therapeutic exercises? (i.e. taping, educational tools, muscle energy techniques, etc.)