Help!!Shoulder assessment/treatment

hi all, first post & been forced into musculoskeletal after many years away so go easy!! have a lady in her late 40's referred with Left "frozen shoulder" (italics are mine, not the docs!) whom I saw for the first time last week. She says that this pain probably did start last year & was "severe" in September forcing her to go on anti - inflammatories for a time but had no loss of function and a reduction in the pain over time (I didn't go into this history enough now I realise). She came for review with me as she wanted to review the exercises her GP had given her (which all provoked pain ++). I guess I'll summarise main findings:

Pain area: anterior area of top 1/3 of humerus
Aggs: Sudden movements, especially near end of range, carrying heavy bags, sleeping on shoulder (usually wakes at night), putting on/off top or cardigan
Pain lasts for < 10 minutes, usually ~5mins

Posture: both humeral heads sitting v anterior, "poking head" posture, mild winging of both scapulae

Movement: long story short movements in all directions limited actively and passively by pain, abduction, HBB and External rotation most painful (in order - ie abd most painful). Lots of use of upper traps for flexion/abduction with what I thought looked like less humeral head depression than was normal & humeral head remaining v anterior
flexion 135 + pain on left (vs ~170 on R) , abduction worst at 90 on L (vs 180 on R), External rotation 1/2 rom on left
Passively felt like ER and abduction were limited but also conscious of her pain so didn't push beyond an extra ~ 5 degrees
Strength same L = R (but in mid range)

Impingement tests - only Hawkins provoked some mild pain
Lift off test: increased pain from HBB position

Other findings: Reduced AP glide GHJ
Poor recruitment of lower traps (using ++ lat dorsi)

so I guess I was thinking "inflammatory, ? irritable Rotator cuff exacerbated by movement dysfunction" but now I'm wondering does this tally with pain in all directions?
Also wondering how much I can push/mobilise to gain increased range? I did some physiological movments (flexion/abduction/ER) with glenohumeral glides & some GHJ APs but only got an extra 10 degrees abduction and flexion, she was however able to put on her top & cardigan & draw curtain back without pain which she was pleased with...

Would really appreciate any thoughts on pathology (or does it indeed matter) & treatment
Thanks a million

Hey there, for being out of the MS game for a while I reckon you have done pretty well.

I agree some further drilling down during the subjective would have been useful i.e activity history, occupation, contributing factors, MOI.

In the 40+ age group shoulder pain usually evolves following an overloading incident no matter how innocuous. Less commonly from a de-loading episode.

The bursa is usually involved acutely and the cuff can develop a reactive style tendinopathy.

As time passes, inflammation, scarring, cuff and scapula neuromuscular dysfunction and muscle patterning compensation ensues.

There may even be some central sensitivity involvement here as well.

It seems from you Ax that she doesn't have a true FS just suffering from the sequela of the above potential scenario??


However, FS (of varying degrees) is a clinical diagnosis.

So if you feel that she is restricted and painful in all directions and you cannot make a positive change either with a manual or self correction
or improve muscle patterning and cuff activation then she may indeed have the dreaded FS.

In saying that, I have seen many seemingly FS resolve quickly with correct, consistent and facilitated shoulder rehab programs.


My advice, think about what is required for normal shoulder but more importantly hand function?

Focus then on what you can correct or improve upon. One positive reaction or improvement in range for example may feed into another improvement elsewhere.

Re-engage the scapula and cuff stabilisers through conscious (patient centred) activation, even if it is in the lower ranges of abduction and ER.

Positive correct input is essential both locally and centrally at a higher cortical level.

All the while provide the hand, arm, scap and cuff with feedback i.e. touch, load, visual self correction, manual therapy, correct muscle activation etc etc.


Finally, just have a crack at it.

Trust your instincts and test and measure always.

But most of all educate your client, they have to be able to tell you what they feel, where they are now and where you want them to go.

Good Luck!

Luke

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Thanks for the above Luke, have had a read through your previous posts & found some equally great nuggets of information. sounds almost bobathey - that I can cope with!
Progress is slow and I guess I feel like I am perhaps winging it a bit... Do get more pain free range with realigning scapula throughout abduction (though still not near the other arm) but don't feel like I have been adequately able to depress her humerus to see if that makes a difference to her range.. So is it true mechanical impingement, me no know... I just keep thinking normal movement normal movement to avoid having a big old freak out! Will post back if I fail/succeed spectacularly!