Right Shoulder Pain Case Study and Management

INTRODUCTION

This case is about a middle-aged women Annie Cove, she is 48 years old referred to physiotherapy by Dr. Livesey (GP). She has complaints of right shoulder pain. She owns her own shop and works there, and she goes to play badminton twice a week as for recreational purpose. Her pain started 3 weeks ago after a hectic period of work at her shop and gradually worsened over the period. She describes her pain as deep aches and its intermittent, with a numerical rating score (NRS) ranging between 3/10 to 6/10.

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This has led to difficulty in daily activities of her life, such as overhead lifting, activities like work or while playing badminton which she enjoys, there is also an increase in pain while she is sleeping on the right side after changing her position she feels better after 10 minutes, she also feels stiff and sore on the same side while waking up. Her pain eases when she is resting her arm, meditation and hot baths.

When her past medical history was asked, she mentioned that she had done two x-Rays for her left knee 2 years ago and cervical spine 3 years ago apart from that she has no other past medical such as history of heart problem, diabetes, hypertension. cervical symptoms or neurological symptoms like dizziness, dysarthria, diplopia, drop attacks, nausea, paraesthesia and numbness were all negative. Cervical ROM is normal. While asking her drug history she said that she occasionally takes paracetamol and ibuprofen. Her posture was observed in standing and sitting which was bad and increased cervical protraction was seen, and on palpation she had tenderness at anterolateral aspect of acromion.

On further assessment, her active range of motion (AROM), passive range of motion (PROM), end feel, resisted test and special test were conducted and the results were as follows:

Shoulder AROM

Shoulder abduction at right-side had painful arc between 90° to 130°, the supraspinatus tendon passes under acromion and coracoacromial ligament, resulting in irritation and causing pain (Magee 2014).

Shoulder PROM

During PROM, the patient had pain on medial rotation and abduction at the end range which indicates lesion in inert structures (Magee 2014).

Shoulder resisted test

During shoulder resisted tests over right side, abduction, medial rotation and lateral rotation were strong and painful suggestive of musculotendinous lesion (Magee 2014).

A study by Michener et al., (2009) reported the accuracy of tests used for diagnosing SIS. 55 patients with shoulder pain were included. The tests were performed by a board certified orthopaedic surgeon and a physiotherapist. Prior to the study, training of the tests were given to standardized before the starting of the study (Michener et al. 2009).

Thus, all the clinical features and the special test points towards subacromial impingement syndrome along with supraspinatus tendinopathy as the diagnosis.

PATHOPHYSIOLOGY

Problem in rotator cuff is very common reason for shoulder pain among which supraspinatus tendinopathy being the most prevalent. Shoulder impingement occurs due to the following soft tissue injury at the shoulder joint (Magee 2014). Around 44-66% of the complaints around the shoulder are due to impingement syndromes (Michener, Walsworth and Burnet 2004). Patients with Supraspinatus impingent syndrome (SIS) usually point their pain at anterolateral region of the shoulder (Taha Faruqi, 2019). Extrinsic factors are those which cause compression of RC muscles which includes anatomical changes in acromion, biomechanical changes which causes reduction in the subacromial space. Type two and three acromia is mostly associated with supraspinatus pathology (Kisner, Colby and Borstad 2018). Intrinsic factors comprise of vascularity, trauma, repetitive overload and overuse. Trauma to the RC muscles can hinder with the stabilization of shoulder, resulting the humeral head to move superiorly which causes reduction in the subacromial space (Atkins et al. 2010). In Rotator cuff pathology, 80% cases are due to supraspinatus tendon (Gerdesmeyer L et al, 2003) which holds the subacromial space by compressing the head of humerus to avoid superior displacement while abduction and elevation (Copeland 1993, Atkins et al. 2010).

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The pathophysiology of the supraspinatus tendinitis can be due to the inflamed subacromial bursae, resulting in high fluid and collagen formation by the cells producing synovial fluid in the bursae (Taha Faruqi, 2019). The impingement syndrome is characterised by inflammation and oedema of the subacromial bursae, thickening and fibrotic changes; subsequent to partial or complete tear of rotator cuff (Atkins et al. 2010). Tendinopathy occurs after recurrent injury to RC inducing a cascade of pathological cycle which results in acute on chronic tendinitis ultimately leading to partial or full thickness tears to varying degree of tear. The exact pathology remains unknown; however, most clinicians agree that tendinopathy is a result of play between both extrinsic impingement and degeneration of intrinsic structures within the tendon (Wang et al. 2003).

Neer’s classification (Khan et al. 2013):

Stage-I Occurs in patients under 25 years of age. Characterized

by oedema and haemorrhage of the subacromial bursa and rotator cuff. It is reversible and can be treated by traditional methods.

Stage-II Found in patients between ages 25 to 40. Tendinitis occurs which causes increased friction and irreversible changes, such as fibrosis.

Stage-III Common in patients above 40 years of age. Results in partial or full thickness tear of the rotator cuff.

MANAGEMENT

A randomized clinical trial (RCT) by Vallés-Carrascosa E et al., (2018), compares the effect exercise protocol performed with by recording pain (<40 mm) in Visual Analog Scale (VAS) and without pain, in subjects with SIS on pain, AROM, and shoulder function for 4 weeks. 30 subjects were invited for the study out of which 4 subjects were excluded as two did not meet the inclusion criteria & two subjects refused to give consent for the study. 26 subjects were randomized into a not-painful EE group and a painful EE group, with a 50/50 allocation to each group. The AROM was measured using a goniometer; and shoulder function using modified Constant-Murley Score (CMS) before and after intervention. The results of this study were that rotator cuff EE protocol, scapular stabilizing exercises, and stretching of upper trapezius are equally effective in minimising pain, improve function, and AROM in the short term, whether performed with pain (VAS < 50 mm) or without pain.

The positives of this study were that it had randomized the subjects and had clear focused issue to be addressed, which was the comparison of the effectiveness of painful and painless EE in terms of improving pain, AROM, and shoulder function in SIS. All subjects who fulfilled the inclusion criteria finished the trial successfully. The metrics used to measure the above were statistically significant and were based on quantitative measures. These estimates were based on a confidence interval of 95%.

The smaller sample size and no long-term monitoring after the intervention period of 4 weeks are the limitation of the study. A blinded approach was not used nor was a placebo subject cluster and there was only one researcher/evaluator who was not blinded while undertaking all the assessments for this study, so a bias can creep in to the viability of this study (Vallés-Carrascosa et al. 2018).

A single blinded RCT by Fatima A et al., (2017) compares the effectiveness of routine physical therapy with and without eccentric strength training in subjects with rotator cuff (RC) tendinopathy for 12 weeks. 50 subjects diagnosed with rotator cuff tendinopathy were included in the study. The subjects included in the study were randomly allocated by using computer generated design into two groups; one group was treated with routine physiotherapy treatment, the second were trained with eccentric loading exercises along with routine physiotherapy treatment. Outcome measures such as Visual Analog Scale (VAS) to measure pain intensity and, functional outcomes were measured by a Disabilities of arm, shoulder and hand (DASH) questionnaire.

The results of this study were that Eccentric exercises along with routine physiotherapy manoeuvres gave better results in reducing pain intensity and improving functional outcome in subjects having rotator cuff tendinopathy vs. subjects just having routine physiotherapy treatments. 99.9% confidence interval (CI) was used for VAS and DASH.

The positives of this study were that it had a clear focused issue to be addressed, which was to determine if eccentric exercise program for the RC muscles along with routine physiotherapy better than standalone routine physical therapy in subjects with RC tendinopathy. The sample size was adequate to draw conclusions and the subjects were all the target age group which exhibited these symptoms (mean age ~ 52). Annie Cove belongs to the same age group as included in the study.

The metrics used were statistically significant and were based on quantitative measures. These estimates were based on a confidence interval of 99.9% a p value of 0.001, a single blinded clinical trial was undertaken. All subjects who fulfilled the inclusion criteria finished the trial successfully. A few instances which could have improved this further study and made this study even better were, a long-term monitoring was not used (Fatima and Ahmed 2018).

An RCT by Holmgren T et al., (2012), aimed to assess if a specific exercise strategy, targeted to the rotator cuff and scapula stabilisers, improves shoulder function and pain more than unspecific exercises in patients with subacromial impingement syndrome. This study was conducted on 102 patients with long term persistent SIS (>6 months), all were recruited through orthopaedic specialists and had unsuccessful results in earlier conservative treatment. The subjects were randomized into two groups, one group received specific exercises and the other received control exercises. The subjects in both groups received 5-6 individual guided treatment sessions for 12 weeks. In between these supervised sessions, the subjects performed home exercises once or twice a day for 12 weeks.

The primary outcome was the Constant-Murley shoulder (CMS) assessment score evaluating shoulder function and pain. Auxiliary outcomes were patients’ global impression of change because of treatment and decision regarding surgery using a DASH score obtained via a questionnaire and a visual analogue scale (VAS) was used 24 hours prior to each assessment to measure the patient’s perceived pain intensity at rest, during arm activity, at night; and EQ-5D and EQ VAS to evaluate health related quality of life (HRQoL).

The targeted exercise group (24 points (95% confidence interval 19 to 28.0) had greater CMS than control exercise group v 9 points (5 to 13); mean difference between group: 15 points (8.5 to 20.6)). The specific exercise group had better outcome in DASH score due to the treatment: 69% (35/51) v 24% (11/46); p<0.001. Only 20% (10/51) patients in the specific exercise group chose surgery in the latter stage.

The positives of this clinical trial were that it had a clear focused issue to be addressed, if strengthening eccentric exercises for the rotator cuff and concentric/eccentric exercises for the scapula stabilisers, is effective in reducing pain and increase in shoulder function in patients with persistent SIS. The sample size was of 102 which was adequate to detect a mean 10-point difference between the groups, all patients were chronic, exhibiting the long-term shoulder pain (mean of 41 months). Outcome measures which were used in the study were CMS, DASH, VAS to assess shoulder function at baseline and after a period of 12 weeks with a 95% CI. Randomization was performed by an independent physiotherapist and the assessor (orthopaedic specialist) was blinded. There was no placebo group as all patients were chronic and needed an alternative treatment, given all conventional methods had failed. The inclusion criteria were quite virtuous, all patients with primary subacromial impingement syndrome as their diagnosis, from an orthopaedic specialist and on the waiting list for arthroscopic subacromial decompression were included. A three-month follow-up was done for all participants, which was best practise given a time to surgery of 3 months. The dropout rate was very low (3% to 5%) for each group.  80% of patients in specific exercise group opted out of surgery. In addition, this exercise strategy reduces the need for arthroscopic subacromial decompression within the three-month timeframe. A few aspects which could have been improved were only one physiotherapist was involved in treatment and was not blinded to group assignment also the interaction with the physiotherapist was similar in both groups of patients (Holmgren et al. 2012).

CONCULSION

This case can be managed by strengthening eccentric exercises, as there is a strong evidence based on clinical trials (Holmgren T et al, 2012; Fatima A et al, 2017; Vallés-Carrascosa E et al, 2018) that strengthening eccentric exercises are effective in improving shoulder function, reducing pain and fixing functional

impairment in the affected tendon for subjects having subacromial impingement

syndrome and supraspinatus tendinopathy.

In addition, all clinical studies have a strong methodological strength and they show an objective and statistically proven improvement in strength, functionality, range of motion and management of the pain management. Hence, eccentric exercise therapy should be included as a treatment, there by potentially avoiding any surgical procedure to take place.

BIBLIOGRAPHY

• Atkins, E., J. Kerr, E. Goodlad & M. Kesson. 2010. A practical approach to orthopaedic medicine: assessment, diagnosis and treatment.Edinburgh: Churchill Livingstone Elsevier.
• Copeland, S. (1993) Throwing injuries of the shoulder. British Journal of Sports Medicine, 27, 221-227.
• Fatima, A. & A. Ahmed (2018) Effectiveness of Routine Physical Therapy with and without Eccentric Loading Training for the Rehabilitation of Rotator Cuff Tendinopathy. Annals of King Edward Medical University, 23, 452-456.
• Holmgren, T., H. Björnsson Hallgren, B. Öberg, L. Adolfsson, K. Johansson, i. Ortopedi och, u. Linköpings, m. Institutionen för klinisk och experimentell, o. o. c. Centrum för kirurgi, h. Institutionen för medicin och, L. Östergötlands Läns, Hälsouniversitetet, Sjukgymnastik & L. Ortopedkliniken i (2012) Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study. BMJ, 344, 15-15.
• Khan, Y., M. T. Nagy, J. Malal & M. Waseem (2013) The painful shoulder: shoulder impingement syndrome. The open orthopaedics journal, 7, 347-351.
• Kisner, C., L. A. Colby & J. Borstad. 2018. Therapeutic exercise: foundations and techniques.Philadelphia: F.A. Davis Company.
• Magee, D. J. 2014. Orthopedic physical assessment.St. Louis, Missouri: Elsevier.
• Michener, L. A., M. K. Walsworth & E. N. Burnet (2004) Effectiveness of rehabilitation for patients with Subacromial impingement syndrome: a systematic review. Journal of Hand Therapy, 17, 152-164.
• Michener, L. A. P. P. T. A. T. C., M. K. M. D. P. T. Walsworth, W. C. M. D. Doukas & K. P. M. D. Murphy (2009) Reliability and Diagnostic Accuracy of 5 Physical Examination Tests and Combination of Tests for Subacromial Impingement. Archives of Physical Medicine and Rehabilitation, 90, 1898-1903.
• Taha Faruqi, Tara J. Rizvi. (2019) Subacromial bursitis, [ONLINE] [Accessed on 25 th November 2019], StatPearls Publishing.
• Vallés-Carrascosa, E., T. Gallego-Izquierdo, J. J. Jiménez-Rejano, G. Plaza-Manzano, D. Pecos-Martín, F. Hita-Contreras & A. Achalandabaso Ochoa (2018) Pain, motion and function comparison of two exercise protocols for the rotator cuff and scapular stabilizers in patients with subacromial syndrome. Journal of Hand Therapy, 31, 227-237.
• Wang, C.-J., K. D. Yang, F.-S. Wang, H.-H. Chen & J.-W. Wang (2003) Shock Wave Therapy for Calcific Tendinitis of the Shoulder: A Prospective Clinical Study with Two-Year Follow-up. The American Journal of Sports Medicine, 31, 425-430.