Shoulder woes

Hello everyone! One more week to go! Yes!

I am currently on my musculo placement and this entry is on a case of (R) full thickness supraspinatus, infraspinatus and subscapularis tear in a 90 year old lady managed conservatively. Sadly, this lady’s previous improvement has declined and reached a plateau. As I understand from the previous PT’s notes, she was once able to perform Abd and F of 155deg before pain kicks in and during those 3 treatment sessions, trigger point release was the main intervention. Those ranges are indeed more than ‘functional’! However, currently she’s at 90deg for F and 60deg for Abd (passively 100deg for F and 90deg for Abd). The other findings were elevated and protracted shoulder girdles; stiff AP and caudad glide compared to (L) with pain reproduction; multiple trigger points in Utrapz, Levator Scap, rhomboids, teres major, pec major + minor, supraspinatus and infraspinatus. Previous treatment I did included postural practice and trigger point release (but unfortunately, not for all those muscles described above). I reviewed the mechanics of the shoulder girdle and in summary, the rotator cuff is important to provide dynamic stability to the GHJ. So I thought there’s no way this shoulder can be without pain! I had the opportunity to discuss this case with my Curtin tutor and accordingly, a full thickness tear need not necessarily mean total distraction from the attachments; it can be a through thickness ‘hole’ so rotator cuff ain’t entirely gone (I interpreted this as we can still work on them). In addition, the multiple trigger points could be due to frequent muscle guarding with pain; I also think that it could be due to ‘overworking’ of muscles to compensate for the dysfunctional rotator cuff. What I find hard in this case is that the patient does not seem to be compliant towards working on posture and avoiding aggravating activities… I believe I have to keep educating and reinforcing (does anyone have any other strategies to deal with this…?). She also tends to tense up the shoulder. The multiple trigger points is definitely a big issue so I committed my very last session with her to releasing all those which I managed to identify! I also noticed with abduction that pec major appeared to be very taut so I spent quite abit of time working on that as well. She was definitely quite sore post treatment and as expected, there were no improvement in ranges. I then got her to show me her main functional limitations which included combing hair and she was able to do that quite ‘effortlessly’ (I should have assessed this prior as well). I certainly hope that with the extensive work on the trigger points, there will be some improvement by next week… I will also work on providing a HEP next session. If anyone has encountered such presentation before or have any ideas on what else I should assess and treat, I will be really grateful! Thank you!

Cheers, Peiying ~