This patient came to our office from his PCP with an already established diagnosis of Severe Adhesive Capsulitis in the right shoulder, a.k.a. Frozen Shoulder.
The patient is a 55-year-old owner of a small pool-cleaning company. He had started to feel pain in the right shoulder approximately 4 months earlier, and eventually the pain became so bad that he wasn’t able to work anymore due to severe restrictions that had recently formed in the shoulder joint.
Previously, the patient had been treated with physical therapy, dry needling, steroid injections and muscle relaxants, and all modalities had failed to produce stable clinical results. The only option offered to him was joint manipulation under anesthesia. In this case, the patient is put to sleep while the orthopedic surgeon tries to forcefully tear up capsular adhesions in the joint and restore range of motion. The problem with this treatment is the excessive immediate damage to the already shortened joint capsule and the soft tissues around the joint caused by the forceful manipulations. Very frequently, patients end up with even worse symptoms.
EVALUATION
The video below illustrates the patient’s active abduction in the shoulder joint during the initial evaluation. Besides feeling pain, the patient also reported a physical obstacle that wasn’t letting him lift his arm farther. Thus, the active movements in the right shoulder joint were greatly restricted, and it was a sign of Active Contracture due to Adhesive Capsulitis.
Next in the evaluation was an examination of his passive movements. This is a very important piece of data, since if the patient’s active movements are restricted while passive movements are within the normal range, recovery is usually quicker and shoulder function is restored relatively easily. The presence of active and passive contractures at the same time significantly complicates and prolongs the therapy.
The video below illustrates our efforts to test the patient’s passive abduction in the shoulder joint. As you can see, even significant efforts on the practitioner’s side didn’t significantly increase passive abduction compared to the active one. A similar degree of restriction in active and passive movements is called Non-compliant Contracture or Fibrosis, and, as we mentioned above, the restoration of ROM in this case is a very complex process.
Evaluation of passive and active ROM confirmed the presence of a non-compliant contracture, but before therapy on his shoulder started, we had to examine the origin of the shoulder’s innervation.
- The Vertebral Compression Test ruled out acute cervical disk pathology.
- The application of Wartenberg’s Test, to examine possible irritation of the brachial plexus by the anterior scalene muscle, indicated the presence of mild tension there, but there wasn’t any sign of direct compression of the brachial plexus by the ASM.
- The final piece of data was possible irritation of the brachial plexus by the pectoralis minor muscle. As soon as even a mild Compression Test was applied to the anterior shoulder, the patient immediately reacted with pain and withdrawal. He also mentioned that the pain he felt spread throughout his entire right shoulder.
- The Sensory Test over his right shoulder also confirmed a decrease in skin sensitivity over the right shoulder compared to the left one.
At this point, it was obvious that, besides Non-compliant Contracture (a.k.a. ‘Frozen Shoulder’), the patient had developed severe tension in the pectoralis minor muscle, which in turn directly compressed the brachial plexus located under it. It was impossible to say what came first: restriction in shoulder ROM or irritation of the brachial plexus by the pectoralis minor muscle. It could be determined only by the patient’s reaction to the therapy.
THERAPY
A positive Compression Test for the pectoralis minor muscle means that treatment of Non-compliant Contracture and restoration of the ROM must be postponed until the same test becomes negative. Thus, we started with the MEDICAL MASSAGE PROTOCOL for the Pectoralis Minor Muscle Syndrome on Friday. The contracture wasn’t even addressed during the first therapy session or with homework.
The intensity of pain was significantly higher on Saturday than before the first session; the patient started to feel better on Sunday, and by Monday morning the pain intensity had subsided. The patient also felt less tension, or ‘grip’ as he described it, in the shoulder itself. That was a very interesting and unexpected development!
The Pectoralis Minor Muscle Protocol was applied for four more sessions (Monday, Wednesday, Friday and the following Monday) without any significant work done on the right shoulder. By the fifth session, the patient had full range of motion, but he felt mild to moderate pain in the right shoulder at the end of the movements.
The Compression Test became negative. The video below illustrates the application of the Compression Test to rule out irritation or compression of the brachial plexus by the tense pectoralis minor muscle. Pay attention to the position of the hand.
The video below illustrates the cumulative effect of 5 sessions of the MEDICAL MASSAGE PROTOCOL for the Pectoralis Minor Muscle Syndrome on the patient’s ROM in the right shoulder joint.
For two more sessions, we added the combined MEDICAL MASSAGE PROTOCOL for the Deltoid Muscle and Rotator Cuff Syndromes to decompress residual tension in the right shoulder joint and eliminate remnants of the previous tension. It has been almost 5 months since his last session, and the patient continues to be without pain, with full ROM, and he is very busy with his pool-cleaning business during the summer pool season in Arizona.
LESSONS
- Initially, the patient exhibited a 100% clinical picture of adhesive capsulitis, a.k.a. ‘Frozen Shoulder’, and he was treated by several health practitioners accordingly. However, the real cause was compression of the brachial plexus by the pectoralis minor muscle, which completely mimicked Adhesive Capsulitis, since it irritated the axillary nerve, which is the main source of innervation for the deltoid muscle and other soft tissues.
- The real trigger was identified by simple application of the Compression Test on the pectoralis minor and by the nature of the patient’s work, which requires constant vertical motions against water, which is a thicker medium.
- It didn’t make sense to waste the patient’s time and money working on his shoulder, since the origin of its innervation, i.e., the axillary nerve, was obviously compromised on the anterior shoulder by the pectoralis minor muscle. Thus, the only correct treatment strategy was to decompress the brachial plexus first, before addressing the consequence of its compression in the form of ‘Frozen Shoulder’. Any other treatment protocol would be a mistake, which had already been made several times by other health practitioners who targeted the consequence rather than the initial trigger.
- This case is a perfect illustration of the great necessity for correct evaluation prior to the treatment application. It doesn’t matter how many techniques and modalities the therapist accumulates; a deficiency in evaluation skills will lead him or her to develop an incorrect treatment strategy, and it will always affect practice.
Category: Blog
Tags: JMS 2019 Issue #3
