November Journal Club Case

[Justin Pretlow]

19 y.o. male, cc of left shoulder pain, off and on for 2 years

Subjective Asterisks
MOI: Overhead Dumbbell presses, Golf season during Senior year.
Sx location: anterolateral GH jt. Nature: Ache, rubbing symptoms while walking
NPRS C 5/10, B 2/10, W 8/10
Aggravating factors: Overhead motion, top of backswing golfing(golfs as a leftie)
Easing factors: limiting arm swing, rest

Objective Asterisks:
Cervical A/P/R negative
Palpation: Mild TTP anterior and lateral GH joint, infraspinatus, pec minor, long head biceps tendon
Scapulohumeral Rhythm Normal. Mild winging with scapular endurance testing
AROM IR functional reach R T4, L T7 AROM WNL Flex, Abd, Scap, ER w mild pain noted at endrange Flex
Special Tests: Sulcus neg. Load and shift neg. Neers neg. Hawkins Kennedy neg. Biceps Load II neg. Apprehension neg.

For consideration – pt reports he received a cortisone injection to the bursa for his diagnosed bursitis of left shoulder 6 months ago, attended PT, symptoms improved. Re-aggravated left shoulder with overuse while Right arm was splinted for 6 weeks due to a fracture of distal radius. Received cortisone injection to glenohumeral joint 3 weeks ago, symptoms improving until he aggravated it helping to carry a drunk friend up the stairs.

Primary Hypothesis: Secondary Impingement w Scap dysfunction
Differential list: biceps tendinitis, SLAP lesion

Interventions and Outcomes of Treatment
I.E. Scapular Strengthening Elevation with Tband for HEP. Review of rotator cuff ER/IR with tband that he was already performing from previous episode of PT. Education – posterior tilt of scap, avoiding impingement like positions

Day 2
Scapular strengthening – horizontal abduction multiple planes
PNF diagonals with tubing(added to HEP)
Posterior cuff MET, Subscap STM
Subjectively – decreased pain with walking
Day 3
Scapular Upward rotation ball on wall
Lat stretching
Lower Trunk rotation, standing rotation warm up
Posterior cuff MET, Subscap STM
Subjectively – decreased pain with daily tasks

Discussion questions:

This patient has had 2 injections and an MRI revealing an intact labrum with some possibly fraying. How would you address his concerns about the MRI findings?

On the first day, this patient was reporting rubbing/achey symptoms of his shoulder with typical arm swing while walking. Described as getting more sore as day goes on. Do you associate this mechanical symptom with a particular diagnosis?
Does it bring up any special questions to ask as follow up?

With the patient having a recent injection to the GH joint, does this make you weigh the information gathered from objective tests any differently? Does it impact your management of this patient in any way?

As shoulder symptoms improve, I would shift my focus to his golf swing and mechanics. Are there key areas or movement patterns you’d like to assess considering this patient’s complaint at the top of his backswing? Or does anyone have any general advice on assessing golf mechanics?

Attachments:

You must be logged in to view attached files.

[Michael McMurray]

Primary Hypothesis: Secondary Impingement w Scap dysfunction

Special Tests: Sulcus neg. Load and shift neg. Neers neg. Hawkins Kennedy neg. Biceps Load II neg. Apprehension neg.

Justin please discuss your asterisk signs: There is not very clear reasoning.

If this is your primary hypothesis – what findings lead you to that hypothesis?

Please be more specific with scapular findings.

[Justin Pretlow]

I was trying to be brief and not list too many findings, but I think I was too brief. I see what you mean that those asterisk signs do not point to that hypothesis.

My findings from the initial eval did not fit a clear clinical pattern, and left me somewhat confused about the diagnosis. I classified it as impingement based on pain at endrange flexion, description of MOI, medial to inferomedial scapular winging and fatigue with scapular endurance test at wall, and lack of a clear clinical pattern pointing to a more specific diagnosis.

After the 2nd weekend VOMPTI course, and reviewing some of the slides, I thought it made more sense to call this secondary impingement, based on his age, scapular winging/fatigue, and training error/overuse contributing to onset.

At second and third visit, Scapular Assist Testing has provided a decrease in pain symptoms at endrange flexion and scaption. Scapular upward rotation at the wall was pain free at times and symptom provoking at times, making me consider scapular dysfunction as having a role.

[Tyler France]

Hey Justin,

Interesting case. Did you happen to assess thoracic mobility, particularly into rotation? If his thoracic rotation is limited, that would certainly stress the L shoulder of a L handed golfer more at the top of his backswing and would likely lead to decreased distance on his drives. Additionally, we discussed some research studies during the second weekend of the course series regarding thoracic mobilization and manipulation as an intervention for patients with impingement.

As far as addressing his MRI findings, I would try to explain to him that studies have shown that a high percentage of people have evidence of labral tears on MRI that never experience shoulder pain. I’ve attached one of the more recent articles discussing that.

There is no specific diagnosis that I associate with shoulder pain with simple arm swing. May sound weird with a patient with shoulder pain, but did you asses his gait? If he has differences in arm swing bilaterally or abnormalities with trunk motion, it could potentially stress the shoulder differently (just grasping at straws here).

Attachments:

You must be logged in to view attached files.

[Justin Pretlow]

Thanks for the SLAP tear/imaging article, Tyler. That will come in handy for explaining lack of correlation between imaging and symptoms.

I haven’t assessed his thoracic mobility, but I have added some trunk rotation warm-up and lower trunk rotation stretching. His left side appears tighter with LTR. I will take a closer look at thoracic mobility next time. It makes sense that left rotational thoracic limitation could increase the stress to the shoulder at the top of the backswing.

[Jennifer Boyle]

Hey Justin! Thanks for the patient case and article. I think your first question would be nicely addressed with utilizing some of the conversation points Gail Deyle expressed to us during our imaging course. It may be beneficial to communicate to this patient that imaging is not the gold standard of determining where pain is originating from. Maybe by using the article Tyler posted and relaying that even though an abnormality (fraying) is seen on an image it is not necessarily the cause of the specific pain that patient is experiencing can help ease the patients concerns.

With the recent injection to the GH joint I would anticipate a potential increase in tolerance to activity. With this I would take note of objective finding taken with the injection in comparison to without the injection but this would not impact the management in my care. I would still progress this patient as per subjective and objective asterisk findings for each follow up session.

I also agree with Tyler in assessing Thoracic spine mobility and possibly implementing some of the side lying techniques that Jake Magel showed us this weekend to help increase overhead motion during the shoulder sweep on the floor.

[Justin Pretlow]

Thanks Jen,
I think I’ve gotten a little better at addressing patient concerns about imaging findings since the Gail Deyle course. In hindsight, I think I was more alarmed that he’d had an MRI already and multiple injections, so I wanted to make sure I didn’t play into any unnecessary fear or anxiety about imaging findings.

This patient has been tolerating progression of exercises fairly well while reporting decreased symptoms with ADL’s. So I do think the injection has allowed a window of facilitating more movement with less pain.

I could picture this patient when Jake was demonstrating the manual techniques thrown in with the sidelying shoulder sweep. I’ve added in mobility and stretching to the patient’s HEP, and I think using some of the manual techniques to facilitate that motion will be a helpful piece to add.

Thanks

[Author]

Posts