Introduction

This case report will outline the relevant subjective history and discuss the relevance of the objective examination. Then the analysis behind the rationale for the clinical diagnosis is reviewed. This is followed by an outline of the treatment plan and the discussion and evaluation that led to its formation. Why the objective markers were chosen is discussed, followed by how the treatment progressed and an explanation of why modifications were made. Lastly a reflection on the effectiveness of the treatment is given including the impact of the orthopaedic medicine course on the treatment approach and improvements for the future are presented.

History (Subjective Examination)

 

The patient was a forty five year old male architect who additionally works in academia. His lifestyle is sedentary but he does play tennis and is right handed. He complained of pain locally over his right shoulder under the acromium. He stated the pain had come on gradually whilst playing tennis four weeks ago and went after playing. It was initially only 2-3/10 serving. Since then it has got a little worse each time he has played tennis and is now at 4-5/10 when playing. He only gets the pain coming on when he serves but it is now taking longer for the pain to subside. The pain abates when he finishes playing. The patient has no past medical history of note and is not taking any medication.

Examination (Objective Examination)

On observation there were no changes in facial expression or gait. He had a visually obvious tennis posture with an increased thoracic kyphosis, increased lumbar lordosis and a forward head posture.

On inspection, postural assessment showed a thoracic curve of 50 degrees, where 35 degrees is considered normal. In addition he had a 6cm forward head posture, where 0-3cm is considered normal. These two findings combined suggest a significant upper cross syndrome, which limits thoracic extension. The limitation in thoracic extension may also limit shoulder flexion predisposing to shoulder injuries. The right acromium was 11cm from table in supine compared with 7cm on left. In addition in standing the right scapula demonstrated a pseudo-winging and significant pronation of the right shoulder. There were no colour changes, wasting or obvious swelling. At rest he had no pain.

On examination by selective tension active cervical extension, rotations, side flexions and flexion were all clear. Shoulder flexion test produced pain at end range but the patient was willing to go to end range. Passive flexion was less painful. Active abduction was painful from 90 degrees onwards, with possibly a little relief at the very end of range. All passive movements were pain free. Passive lateral rotation was 70 degrees right, 80 degrees left pain free. Passive abduction was full bilaterally with no pain. Medial rotation was pain free but limited to only 10 degrees from the back on the right and 20 degrees on the left. The capsular pattern was therefore not evident.

Resisted abduction produced the patient’s pain on the right. All other resisted tests were pain free. On the Oxford scale abduction scored 4-/5 on the right, 4/5 on the left. Infraspiantus scored 4/5 on the right, 5/5 on the left. Subscapularis scored 5/5 bilaterally. The scarf test was negative and the Trott/Maitland test (Turner 2001) was also negative, the distraction did not reduce the pain on resisted abduction. On palpation the right supraspinatus tendon was significantly more painful, than the left. There was no pain on palpation of the muscle belly and no active trigger points were present.

Analysis of his tennis serve showed his limited thoracic extension meant he was using lumbar extension to get the racket past vertical in concert with putting excessive flexion in to his shoulder. In addition a lack of rotation was also evident although on assessing his trunk rotation in sitting he had 35 degrees right trunk rotation and 30 degrees left. Whilst 45 degrees or more is ideal he was not using the range he had, possibly due to poor stabilisation or poor technique.

Clinical Diagnosis

 

The history suggests a chronic injury of cumulative microtrauma (Tozzi 2012). There is nothing to suggest a metabolic disorder and it appears mechanically driven being related to playing tennis. Active cervical movement was clear suggesting no cervical involvement. The pain at end range active and passive shoulder flexion suggests a sensitive structure getting compressed at end range. That passive shoulder flexion was less painful suggests the lesion may be in an active structure. All passive movements being pain free suggests no passive structure is involved. Active abduction was painful past the 0-30 degrees the supraspinatus is primarily active. However, the load on the supraspinatus is greater at 90 degrees so whilst the deltoid is the primary mover the supraspinatus still has a significant load. Resisted abduction producing the patient’s pain suggests the lesion is in the supraspinatus. With confirmation on palpation of a painful site in the tendon and no decrease in pain with decompression and resisted abduction the diagnosis is a supraspinatus tendinopathy.

As with most rotator cuff tendinopathy pathogenesis is not precisely known but a multifactorial etiology is likely (Mehta et al 2003, Soslowsky et al 2002). In addition to this lesion the patient’s posture is a contributing factor. His thoracic kyphosis and tight right pectoralis minor is likely to be effected by his working ergonomics and him being right handed. The increased thoracic kyphosis and tight pectoralis minor as shown by the distance of the acromium from the table in supine mean the shoulder joint is not centrated functionally (Antoniotti et al 2011). Placing the supraspinatus in a more stretched position. This makes it relatively weaker and increases the load the muscle has to handle as it is at a mechanical disadvantage (Soslowsky et al 2002). Further this position brings the supraspinatus forward in the sub-acromial space increasing the chance of repetitive impingement leading to tendinopathy (Neer 1983, Soslowsky et al 2002).

Treatment Plan

The aim of treatment was to return the patient to pain free tennis within four weeks and reduce the likelihood of future episodes. To achieve this the goals were to eliminate pain on resisted abduction and active abduction. The longer term goal was to reduce the patient’s thoracic kyphosis to 35-40 degrees, his forward head posture to 3cm or less, his pectoralis minor test to 7-8cm and for him to achieve 5/5 strength on the oxford scale for the supraspinatus and infraspinatus bilaterally (Ludewig and Reynolds 2009). A subjective goal of improving the quality of his tennis serve was also set. As such the primary asterisk signs used were resisted abduction, active abduction. The secondary asterisk signs were his thoracic kyphosis, forward head posture and pectoralis minor test.

To achieve this deep transverse frictions (DTF) were applied for 10 minutes past numbness to the lesion (Kesson and Atkins 2005). Primarily to create traumatic hyperaemia to improve circulation, decrease levels of substance P and thus reduce pain levels (Chamberlaine 1982). In addition the DTFs provided physiological movement of the tendon, which is theorised to break scar tissue and improve physiological movement of the tendon (Chamberlaine 1982). Following this resisted abduction and active abduction were pain free. At this point I wrote to patient’s general practitioner (GP) to update them with my diagnosis and treatment plan.

This plan and strategy was discussed with the senior physiotherapist in my clinic. He agreed with my planned use of DTF and a corrective stretching and exercise programme. He suggested the addition of an exercise to more aggressively reduce the patient’s thoracic kyphosis and the horse stance decompression. I felt the patient could progress to a more aggressive thoracic extension exercise once he had some experience with the foam roller longitudinal as he had done very little stretching previously. I agreed with the horse stance decompression as an exercise to teach improved thoracic and upper quarter alignment, strengthen the serratus anterior, teach scapula positioning and strengthening the paraspinal stabilisers.

The following day the patient returned to be taken through their grade A mobilisation. This took the form of a structured rehabilitation programme shown in Appendix A. Resisted and active abduction were pain free meaning resisted abduction exercises could be started. The patient was instructed in how to do each exercise and repeated them himself for a full set each with prompting on correct technique where appropriate.

Specifically the patient struggled with scapular positioning during the external rotation and abduction exercises, especially as he fatigued. However, with the use of a mirror he was able to correct any excessive use of the upper trapezius or pectoralis minor. During the prone cobra the patient used excessive lumbar extension and needed prompting to extended through the thoracic spine and keep the lumbar spine neutral.

As the patient was independent with his exercise programme and the primary asterisk sign was now clear he was encourage to continue with the exercise programme on alternate days for 2 weeks and then return to attempting some serving on his own in a practice situation. He was instructed to update the physiotherapist after this session. At which point a decision could be made about returning to playing recreationally, the need for any further DTF and progressing the rehabilitation programme.

 

Re-assessment

 

The patient returned for a follow up appointment four weeks after he had been given his rehabilitation programme. He had not made any contact in the interim. He informed the physiotherapist he had done the rehabilitation programme four times on alternate days and was feeling better so he agreed to play with a friend. Fortunately he played symptom free and has been playing regularly since and doing his exercises two or three times a week.

On assessment his thoracic curve had reduced to 42 degrees, his forward head posture was 3.8cm, his pectoralis minor test was 9cm. On the Oxford scale his infraspinatus was 5/5 on the right and his supraspinatus was 4+/5 right and left. Resisted and active abduction were pain free. Anaylsis of his tennis serve showed some improvement in his thoracic extension and rotation.

The patient was advised to continue with the rehabilitation programme with the band exercises progressed from a medium difficulty band to cable machine at his gym with the weight adjusted set by set so that he achieves fatigue within the given repetition range with the ability to do two repetitions remaining. In addition it was recommended he contact a tennis coach for guidance on improving his service.

 

Discussion and Evaluation

The programme overall produced a positive result. The patient’s aim of returning to tennis within four weeks was achieved. Further the patient made good progress in reaching the postural objectives set. Whilst the programme produced the desired result in the short term it is possible the result could have been achieved faster. Further at follow up the postural goals had not been achieved although good progress had been made.

There is evidence scapular kinematics can play a role in rotator cuff pathology and should be addressed prior to rotator cuff strengthening (Ludewig and Reynolds 2009). Furthermore, Ludewig and Reynolds suggest strengthening the serratus anterior and lower trapezius muscle. The serratus anterior is the only muscle that can produce all three desired scapula motions (Ludewig and Reynolds 2009). Upward rotation, acromioclavicular joint external rotation and acromioclavicular joint posterior tilting (Dvir and Berme 1978, Fey et al 2007, van der Helm 1994). Further, the literature (Lin et al 2005, Ludewig and Cook 2000) shows that reduced serratus anterior activation is associated with shoulder pain and impingement. As such an exercise like the push up plus could have been included as it activates the serratus anterior but minimally activates the upper trapezius (Ludewig et al 2004).  The evidence would support the use of side lying should flexion to 135°, side lying external rotation and prone horizontal shoulder abduction with external rotation to activate the lower trapezius (Cools et al 2007). However, there is conflicting evidence as to whether scapula kinematics can be improved empirically (Kluemper et al 2006, McClure et al 2004, Wang et al 1999).

The patient therapist relationship was not optimal. A successful result was achieved in that the patient returned successfully to playing tennis but with the lack of contact and the patient going it alone the outcome is fortunate.  The patient either did not listen to the advice given or felt so much better they could ignore the advice. It may be the advice would have been better heeded if it had been given in writing as well. It would help therapists greatly to have a system to sub categorise patient personality types and classify the optimal way to provide treatment and advise. Such a system could utilise the A, B and C personality types. However, this structure may need further sub dividing as I have seen type A personalities that follow advice to the letter in an almost obsessive compulsive fashion and others like this patient, that will pick and choose the advice they follow.

In this instance I only communicated with the patient’s GP and the senior physiotherapist at my clinic on this case. I was right to inform the patient’s GP and should ensure I continue to do this in future. Potentially I could have gained more insight by consulting with additional professionals at the clinic I work in. This could have provided differing opinions and more chance for debate and professional development. In particular it would have been prudent to discuss the case with a college experienced in the application of injection techniques. As a physiotherapist not qualified in injections techniques I am always likely to think frictions is the best treatment where a doctor may use a cortisone injection. I must ensure I use the resources available to me to provide optimal patient care.

In time I may begin to employ more specific nutritional and functional approaches. For example, anti-inflammatory nutrients such as omega 3 fatty acids or bromelain might be prescribed to aid the anti-inflammatory effect after a successful local cortisone injection. Adrenal function tests might be employed to assess natural cortisol production where local cortisone injection is indicated. A specific postural rehabilitation protocol based on specific measurement may be prescribed for conditions known to be associated with poor posture such as rotator cuff pathology (Ludewig and Reynolds 2009). For example, a sub acromial impingement patient with increased internal rotation on shoulder flexion should benefit from pectoralis minor stretching and serratus anterior strengthening in concert with reduction of an excessive thoracic kyphosis.

Conclusion

This case history shows a patient presenting with shoulder pain on serving during tennis, which has got progressively worse. On assessment their pain was produced with active and resisted abduction and there was pain on palpation of the supraspinatus tendon. The diagnosis was supraspinatus tendinopathy. After assessment ten minutes of DTF past numbness were applied to the tendon. Active and resisted abduction was then pain free. The patient’s care was discussed with the senior physiotherapist at the clinic and the patient’s GP was informed. The patient failed to follow the advised time off from tennis or maintain contact with the physiotherapist. Fortunately the patient returned to tennis without aggravation and on re-assessment he had made good progress in improving his posture and muscle balance.  On reviewing the evidence there is an argument treatment could have been more focused on scapula kinematics however whether this can be altered remains to be proven empirically.

References

Antoniotti, S.A. LeBeau, J.A. Mackner, J.H. Tarpoff, J.A. and Wiltgen, B.A., 2011. Short term efficacy of reflex stimulation on the ability to facilitate activity in serratus anterior with secondary relaxation of the upper trapezius.  Chesterfield, MO: Logan College of Chiropractic.

Chamberlaine, G., 1982. Cyriax’s friction massage: A review. Journal of orthopaedic and sports physical therap, 82, 16-22.

Cools AM, Dewitte V, Lanszweert F, et al. Rehabilitation of scapular muscle balance: which exercises to prescribe? Am J Sports Med. 2007. pp. 1744–1751.

Dvir, Z. and Berme, N., 1978 The shoulder complex in elevation of the arm: a mechanism approach. J Biomech, 11, 219–225

Fey AJ, Dorn CS, Busch BP, Laux LA, Hassett DR, Ludewig PM. 2007. Potential torque Capabilities of the trapezius. J Orthop Sports Phys Ther. 37, A44–A45.

Kesson M, Atkins E, 2005 Orthopaedic medicine – A practical approach. 2^nd Ed. Elsevier: Oxford.

Kluemper M, Uhl TL, Hazelrigg H. 2006. Effect of stretching and strengthening shoulder muscles on forward shoulder posture in competitive swimmers. J Sport Rehab, 15, 58–70.

Lin JJ, Hanten WP, Olson SL, et al. 2005. Functional activity characteristics of individuals with shoulder dysfunctions. J Electromyogr Kinesiol, 576–586.

Ludewig PM, Cook TM. 2000. Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. Phys Ther. 80, 276–291.

Ludewig PM, Hoff MS, Osowski EE, Meschke SA, Rundquist PJ. 2004. Relative balance of serratus anterior and upper trapezius muscle activity during push-up exercises. Am J Sports Med. 32, 484–493.

Ludewig, P.M. and Reynolds, J.F., 2009. The Association of Scapular Kinematics and Glenohumeral Joint Pathologies. Journal of orthopaedic and sports physical therapy, 39 (2), 90-104.

McClure PW, Bialker J, Neff N, Williams G, Karduna A. 2004. Shoulder function and 3-dimensional kinematics in people with shoulder impingement syndrome before and after a 6-week exercise program. Phys Ther, 84, 832–848.

Mehta S, Gimbel JA, Soslowsky LJ. 2003. Etiologic and pathogenetic factors for rotator cuff tendinopathy. Clin Sports Med, 22, 791–812.

Neer CS., 1983. 2nd Impingement lesions. Clin Orthop Relat Res, 70–77.

Soslowsky LJ, Thomopoulos S, Esmail A, et al. 2002. Rotator cuff tendinosis in an animal model: role of extrinsic and overuse factors. Ann Biomed Eng. 30, 1057–1063.

Tozzi, P., 2012. Selected aspects of fasci in osteopathic medicine. Journal of osteopathic medicine, Epub ahead of print. Available from; http://www.sciencedirect.com/science/article/pii/S1360859212000629 [Accessed 30^th August 2012].

van der Helm FC. 1994. Analysis of the kinematic and dynamic behavior of the shoulder mechanism. J Biomech. 27, 527–550.

Wang CH, McClure P, Pratt NE, Nobilini R. 1994. Stretching and strengthening exercises: their effect on three-dimensional scapular kinematics. Arch Phys Med Rehabil, 80, 923–929.

 

Appendix 1

 

 

 

 

 

 

Always stretch first!

 

No	Exercise	Rest Period	Intensity	Repetitions	Tempo	Sets
	Horse stance decompression	60s	-1/ side	4-6/ side	10/5	1-22.
	Prone cobra	60s	-10 secs	6	30 secs hold/ 15 secs rest	180 secs total
	Band resisted abduction	60s	-2	8-12	4-1-2	1-3/ side
	Band resisted external rotation	60s	-2	8-12	4-1-2	1-3 Right only

* Number 3 only started once resisted abduction was pain free.