Initial Evaluation – Ultrasound indicated inflammation and thickening of (R) supraspinatus tendon, subacromial bursitis and anterior acromion spurring – Chronic neck, shoulder and wrist pains suffered from work activities. Afraid to act in case of workplace ramifications – Mild hypertension (currently managed through dietary intervention) Diagnosis (R) supraspinatus tendonitis Symptoms – Constant (R) anterior shoulder, upper cervical and thoracic pain (VAS 5/10). VAS increases to 8/10 with overhead reaching and shoulder abduction. – Relief from symptoms with rest, heat packs and medication Mechanism of injury Process line worker conducting repeated upper limb tasks – Heavy (10kg) overhead lifting, repetitive transfer of 5-7kg boxes from waist to floor level for up to 2hr intervals, screwing bottle lids, quality control assessment and packing boxes. – Possible aggravation during household tasks i. e. cleaning, cooking and washing Observation Anxious about using (R) shoulder and protective against further injury Psychological & Pain Testing – OMPQ score of 120 – DASS questionnaire: depression=5, anxiety=13, stress=20 Function – Limited ROM during abduction and overhead reaching – Reluctant to use right shoulder unless necessary
List of problems – Pain in (R) Shoulder, cervical and thoracic regions – Decreased (R) shoulder ROM (abduction, overhead movement) – Decreased (R) shoulder flexibility – Decreased strength in (R) shoulder Prioritise problems 1. Pain 2. ROM 3. Flexibility 4. Strength Additional issues – Mild Hypertension – Increasing stress and anxiety levels – Home environment – disabled husband and children no longer at home Supplemental Information – No palpitations or special testing was conducted; as this injury is deemed chronic and it was felt further testing was not necessary Long-term goals 1.
Return to work (12 weeks) performing modified or full range of tasks with minimal pain 2. Return to full ROM in 6 weeks 3. Regain full strength in 12 weeks Short-term goals 1. Reduce constant pain to 2/10 at rest 2-4 weeks; reduce active pain to 4/10 4-6 weeks 2. Increase abduction to 180o in 6 weeks 3. Introduce closed chain kinetic exercises in 4 weeks Treatment/RTW/Activity plan (2-3 days/wk in clinic + home program) Stretches and ROM exercises will commence as passive motion whilst pain remains present, and progress to active motion as the client becomes stronger and regains free movement of the injured shoulder.
Exercises will initially be performed with no resistance and with a high degree of caution. As rehabilitation progresses, theraband and wands will be utilized to increase muscle stability, function and strength: ?Internal and external rotation ?Flexion below 90o and extension ?Abduction below 90o and adduction ?Passive neck stretches (flex/ext, rotation) ?Abductor stretch ?Chest stretch ?Shoulder flexion with pulley for passive stretch Strengthening exercises will develop when appropriate to include a power component: ?Shoulder shrugs ?Protraction/Retraction of scapula Internal and external rotation ?Flexion and extension in sagittal plane ?Wall push-up ?Four point kneel ?Swiss ball exercises (i. e. pelvic circles & leg raises) ?Lateral raises w/ dumbbell (progress to sitting on Swiss ball) ? Standing row w/ theraband (progress to sitting on Swiss ball) Cardiovascular maintenance will also be included in rehabilitation to improve overall physical fitness levels. At each session the client will perform up to 30 mins of moderate intensity walking, increasing the time and frequency of these walks as the program progresses.
Specific interventions by week or post-injury phase / Theory and Evidence of Effectiveness: The program provided in this case study is based upon a logical progression through rehabilitation phases, each setting the groundwork for the phase to follow. This series of progression is re-enforced in the many journal articles that examine the systematic approaches to musculoskeletal injuries, such as O’Connor et al (1997) and Stark (2006). The phases used within this case study have been set out below, including evidence for its inclusion:
Phase One: Early pain reduction – Maintaining exercises in pain free planes of motion to prevent recurrent inflammation on the subacromial bursa and tendon through a combination of NASD’s and ice. Phase Two: Integration of Kinetic Chains into rehabilitation – Weakness, muscular imbalances and inflexibility of rotator cuff musculature should be addressed before formal strength rehabilitation exercises are commenced (Kibler 1998). Passive and active ROM exercises should be started as early as permitted to avoid a loss of motion and prevent further complications such as frozen shoulder (Fongemie, Buss & Rolnick 1998; Lyons & Orwin 1998).
Phase Three: Scapular Stabilization – Due to the multiple roles the scapula plays in normal shoulder rotation and upper limb movement, it is important that the scapular is stabilized within the shoulder as early as possible to decrease the risk of re-injury (Kibler 1998). When injured scapular positioning can be altered to accommodate injury patterns or due to the change of biomechanics to reduce pain and prevent further injury (Kibler 1998). Shoulder retraction exercises can assist with the redevelopment scapular stabilization through the retraining of co-contractions within the rotator cuff (Kibler 1998).
Phase Four: Early Achievement of 90o Abduction – As many of our upper limb movement patterns occur between 80-110o abduction, early achievement of 90o abduction is necessary to allow for normal biomechanical patterns to be rebuilt (Kibler, 1998). The progression within this phase should be slow whilst in the healing phase as to prevent recurrence of the injury, but may become more intense after 3 weeks of treatment (Lyons et al 1998; Kibler 1998).
Phase Five: Closed Chain Rehabilitation – Closed chain exercises are recommended throughout the rehabilitation literature used within this study, as weakness of the muscles making up the rotator cuff can pre-determine a recurrent injury around the shoulder (Lyons et al 1998; Kibler 1998). The rotator cuff muscles can be overshadowed by the deltoid due to their small size, and when not developed simultaneously clinical symptoms in shoulder injuries are not relieved (Lyons et al 1998; Kibler 1998; Fongemie 1998).
Closed chain exercises emphasise co-contractional forces occurring at the scapulothoracic and glenohumeral joints allowing the rotator cuff to stabilize the centre of rotation within the shoulder (Lyons et al 1998; Kibler 1998). Open chain exercises produce greater forces and require larger movements, making them ideal in the later phases of rehabilitation for development of power (Kibler 1998). References: 1. Fongemie, A. E. , Buss, D. D. , & Rolnick, S. J. (1998). Management of shoulder impingement syndrome and rotator cuff tears. American Family Physician. 57(4), 667. 2. Kibler, B. W. (1998).
Shoulder rehabilitation: principles and practice. Medicine and Science in Sport and Exercise. 30(4), 40-50. 3. Lyons, P. M. , & Orwin, J. F. (1998). Rotator cuff tendinopathy and subacromial impingement syndrome. Medicine and Science in Sport and Exercise. 30(4), 12-17. 4. O’Connor, F. G. , Howard, T. M. , Fieseler, C. M. & Nirschl, R. P. (1997). Managing Overuse Injuries : A Systematic Approach. The Physician and Sports Medicine. 25 (5) 88-113. 5. Stark, T. W. (2006). Introduction of a pyramid guiding process for general musculoskeletal physical rehabilitation. Chiropractic & Osteopathy. 14 (9) Online Edition.