Treatment of Shoulder Pain

We are going to go through the examination and treatment of female athlete in her 40’s for misdiagnosed shoulder pain.

A problem that I see when treating orthopedic conditions is a lack of proper assessment.  It’s important to understand that where the patient feels the pain isn’t necessarily where the problem is. Many individuals continue to needlessly struggle with pain and the prescription of unnecessary treatments, medications, and surgeries due to a failure to properly assess and diagnose the underlying (root) cause of the patients condition.

The patients main complaint was limited and painful Range Of Motion and during snatches, overhead activities  and pushing activities. These movements produced a deep pain in the anterior shoulder.  The patient had been referred to another therapist and was diagnosed with bicipital tendonitis. The patient was treated with ‘dry needling’ combined with corrective exercises for over a month with minimal improvement. Through proper orthopedic testing and palpation we were able to diagnose the cause of the problem and resolve the injury in 3 treatments. (How Many Treatments Will I need?!)

How We Diagnosed the Patients Shoulder Pain

1. We had patient reproduce the pain through their daily movements and painful arc test.
2. We measured and compared ROM between the two shoulders – noting which movements caused the patient pain.
3. We utilized the proper orthopedic tests to differentiate referred pain (symptom) from the root cause of pain.

Patients Test Results

1. Patients pain was reproduced through internal rotation of the shoulder during weight lifting activities. Patients pain reproduced during ‘bench press’. Pain Reproduced when extending shoulder and lifting over-head.
2. During the ROM tests we found that the patient had limited internal and external rotation which caused pain deep in the anterior area of the shoulder.
3. Due to the previous diagnosis we tested the patients Biceps tendon both long and short heads and also proximal and distal origins and insertions. We found these tests inconclusive and although the patient had palpable pain near the biceps tendon attachment found that this was most likely due to a referred pain pattern. This called for further orthopedic testing to ensure proper diagnosis and treatment.

To properly assess this patients condition we performed the following Orthopedic Tests.

‘Speeds Test’ – This test is used to check the ability of the transverse humeral ligament to hold the biceps tendon in the bicipital groove. In my experience this test isn’t the best indicator of bicipital tendonitis. Regardless, this test was negative.

Yergensons Test – Great Diagnostic test for Biceps Tendonitis. The patients pain wasn’t replicated.

Neers Impingement Test – which tests for supraspinatus tendinopathy, bicipital tensosynovitis, and or subacromial bursitis. We found some replication of the patients pain with this test, however still inconclusive.

Hawkins-Kennedy Test – This test asses Supraspinatus pathology and the potential involvement of the biceps brachia long head tendon.   Reproduced some pain.

Infraspinatus Test – Self explanatory. Reproduced some pain.

Full/Empty Can Test –  Tests for Supraspinatus pathology.  Both tests were positive.

Diagnosis & Treatment

Through orthopedic testing we were able to deduce that the issue is the patient is having issues with subacromial impingement and pathology of both the Supraspinatus and Infraspinatus. As a result we chose to treat all rotator cuff muscles through  Acupuncture, Orthopedic Acupuncture (dry needling), exercise prescription, and the application of Evil Bone Water.

After a short-course of 3 acupuncture treatments, adherence to proper corrective exercises, and the application of a topical analgesic the patients pain was resolved.

Conclusion 

Assess don’t guess. It’s important to have the patient go through the proper testing process which gives the patient the best chance at a full and fast recovery. Last, but not least, where the pain is (symptom) isn’t always where the problem is.