Shoulder Case Study
A 39 year old female nursing assistant (Ms G) presented to physiotherapy with a 6 month history of right sided shoulder pain. This had come on for no apparent reason and was gradually worsening. She denied having any neck pain, no paraesthesia, but had noticed reduction in her grip on the right side. Her pain was aggravated by lifting and pulling activities and she struggled to lie on her right shoulder. She was waking from her sleep regularly. She had had a reduction in pain by keeping her arm supported, avoiding the aggravating activities and using ice and Panadol or Mobic.
6 months prior to the onset of pain, in May 2016 Ms G had a C3 – 6 laminectomy and left sided decompression for left sided radiculopathy. Her left sided symptoms had resolved following this and she had had no post-operative physiotherapy.
Ms G had limited shoulder range of motion to 90 degree flexion and abduction, hand behind back to L5, external rotation to ¾ Rom and pain with all rotator cuff strength tests, however, no weakness evident on testing. Ms G also had global limitation to her neck range of motion, with significant loss to extension and with retraction reproducing pain to the shoulder. A positive upper limb tension test reproduced her shoulder symptoms.
Ms G had had an ultrasound scan showing limitation of external rotation suggestive of adhesive capsulitis not bursitis, calcification in the bursa overlying subscapularis tendon, degenerative changes in ACJ. However, using Mckenzie repeated retraction exercises, she had an improvement in her shoulder range of motion and decreased aching in her shoulder at rest, which would not fit with an adhesive capsulitis. This would be more consistent with pain of cervical origin and nerve sensitivity which is aggravated by upper limb movement, which tensions the neural tissue and requires some low cervical and upper thoracic range of motion, which she was lacking.
Intervention and Restoration of Function
Ms G was prescribed a combination of Mckenzie retraction exercises along with cervical rotation exercises to improve her general cervical range of motion and to start to mobilise the neural tissue around the neck and shoulder. In addition to this, she has progressed to thoracic extension mobilising exercises and shoulder range of movement exercises for regaining the remaining shoulder flexibility. Ms G also had some pectoralis major tightness secondary to adopting her habitual comfortable posture with the right upper limb, which was restricting her right shoulder movement slightly and stretching exercises to help improved flexibility and enable her shoulder function to return to normal have also been added.
Following surgery, Ms G had not been given any advice on whether or not to move her neck and as she did not have any follow up rehabilitation, although her left radiculopathy had improved well, her neck range of motion gradually deteriorated as she spent longer not moving her neck. Education that she was fine to start to move more normally has had a significant impact on her neck function, as well as helping to reduce her symptoms.