Rotator Cuff syndrome
The following case study gives you an idea of what treatments may be considered for this patient. This is a brief overview. Any CPD or case study for university would require much more depth and must be evidence based and demonstrate clear clinical reasoning. Many examples of these can be found through Pubmed and these should (alongside university guidelines) be used as your outline for graded work.
A 40 year old man presented with a five month history right shoulder pain VAS 7/10 on the superior aspect of the right shoulder and sub deltoid region. His symtoms appear insidious in onset, with no previous reported trauma to the left upper quadrant, however symptoms have been gradually worsening. They seem to be aggravated at work with over head movements. The patient works as a service engineer which involves repetitive overhead movements and he is required to do some lifting. On further questioning there has been a staffing issue and he has increased his hours to 5 x 10 hour days/ a week. He reported no pins and needles or paraesthesia or red flags.
Mr. M reports that his symptoms can be painful at night however are eased with Ibruprofen and he can then great back to sleep. He sleeps with 2 pillows. Symptoms worsen throughout the day and are at their peak in the evening..
He is a Type II diabetic and reports that since his hours have increased his as been feeing tired and low in mood. His GP has prescribed antidepressants however these do not seem to have helped to date. He reports no other PMH.
The findings of the objective assessment fitted with rotator cuff syndrome. There is no single clinical test which is significant in diagnosing rotator cuff syndrome (Hughes et al, 2008) therefore Hawkins and Kennedy, resisted external rotation and empty can were all completed and positive which strengthened the index of suspicion of a rotator cuff syndrome issue. On AROM the patient demonstrated a painful arc sign with GHJ forward flexion and pain could be eased through range if the clinician provided support. The patient reports pain with GHJ abduction at 30 degrees and 90 degrees. There was also pain with GHJ external rotation.
Muscle atrophy of the supraspinatus on the right and pain on palpation of the muscle belly and tendon. Neck and elbow ROM appeared normal.
No clinical images were advised at this stage because there were no red flags present and it was not felt that they would provide any further clinical information or change management (Bussieres. 2008).
- Treatment goals were discussed and formulated with the patient.
- Reduction of shoulder by 50% in 6/52
- Improve pain free ROM to 60% in 4/52
- Improve strength and biomechanics of the GHJ with 6/52.
Treatment Plan (“Tool box”)
- Contraindications considered (ie PMH)
- Explanation of pathology and self management strategies.
- Address yellow flag issues encourage use of the arm within pain free ranges. Explain that overall there is a good prognosis for this condition.
- Posture re-education: Use of side profile photographs to educate the patient about retraction and optimal posture of the scapula.
- Joint mobilisations (Grade I and II for pain and Grade III and IV)
- Ultrasound (ssp tendon or muscle belly)
- Cyrotherapy [MacAuley (2001) suggested that the optimal method of ice application is wet ice applied directly to the skin through a wet towel.]
The Hawkins-Kennedy impingement sign, the painful arc sign, and the infraspinatus muscle test were chosen as evidence suggests that they yield the best post-test probability (95%) for any degree of rotator cuff syndrome. The combination of the painful arc sign, drop-arm sign and infraspinatus muscle test produced the best post-test probability (91%) for fullthickness rotator cuff tears (Park et al, 2005).
D’Onise et al (2010) and Leclerc et al (2004) have found a correlation between shoulder pain and depression therefore a holistic approach to treatment was adopted. Yellow flags were assessed to see if there were any further barriers to recovery and the patient reported that he was fearful that his symptoms would mean that he would be unable to work and provide for his wife and 6 month old son.
Time was spent to provide clear goals and listen to attitudes of the patient. Opportunities to ‘Dethreaten pain’ were taken and the patient was reassured that his condition usually had a good prognosis and that he would be able to return to full time work with guidance.
Rotator cuff syndrome
Bussieres, A.E., Peterson, C., & Taylor, A.M. (2008). Diagnostic imaging practice guidelines for musculoskeletal complaints in adults- An evidence-based approach: Part 2: Upper extremity disorders. Journal of Manipulative & Physiological Therapeutics, 31(1), 2-32.
Park, H.B., Yokota, A., Gill, H.S., & McFarland, E.G. (2005). Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome. Journal of Bone and Joint Surgery – American Volume, 87, 1446-1455.