Shoulder Derangement with an Underlying Dysfunction from a MDT Perspective

1. Shoulder Derangement with an Underlying Dysfunction from a MDT Perspective KeeleyGarrou Regis University

2. Objectives • Audience will be able to differentiate derangement and dysfunction in terms of Mechanical Diagnosis and Therapy by end of presentation • Audience will be able to list possible treatment interventions for rotator cuff tendinopathy by end of presentation • Audience will be able to apply the literature and physiology of tissue remodeling to physical therapy exercise by the end of presentation

3. Meet Sammie • 15 year old female softball player • Plays 1st base • Has been playing softball since she was six • Cannot remember the last time she has had time off of playing softball • Right shoulder pain

4. Many people, both young and old suffer from shoulder pain from no traumatic mechanism of injury • At any point in time, 6.9-26% of people have shoulder pain • Lifetime prevalence is from 6.7-66.7%2

5. Mechanical Diagnosis and Therapy • Comprehensive and logical step-by-step process that classifies patient conditions by level of pain or limitation that results from certain movement or positions10 • Three steps10 • Assessment • Treatment • Prevention

6. Mechanical Diagnosis and Therapy • Assessment • Algorithm that leads to classification of disorders which is based the “relationship between historical pain behavior as well as the pain response to repeated test movements, positions and activities during the assessment process10”

7. Mechanical Diagnosis and Therapy • Assessment Continued • The assessment is a systematic progression of applied forces and responses to separate patients into defined subgroups to guide treatment • Two of the basic classifications for the extremities are • Derangement: Anatomical disruption or displacement within the motion segment • Dysfunction: End-range stress of shortened structures (scarring, fibrosis, n.root adherence)10

8. Mechanical Diagnosis and Therapy • Treatment - most treatment is with repeated motion, with a progression of unloading, clinician overpressure, mobilization and manipulation as needed10 • MDT emphasizes patient education and involvement so that the patient can manage themselves without having to come in and be dependent on the clinician10 • Goals – to reduce pain quickly and restore function and independence10

9. Purpose • The purpose of this case report is to illustrate and describe the assessment and treatment for shoulder pain using the Mechanical Diagnosis and Therapy method

10. Initial Evaluation • History: • Pt came in with the complaint of right shoulder pain • Pain started in March after a double softball practice • Currently, shoulder aches all the time; heavy lifting increases pain • Pain is not that bad when playing softball but it aches afterward • Pt has practice once per week with tournaments approximately every other weekend playing up to five games • Pt received MRI – negative for tears but did show swelling in her shoulder • Pt was prescribed an anti-inflammatory; she reports she does not take them as prescribed • She often takes Advil or Tylenol for pain • Pt reported no other co-morbidities

11. Initial Evaluation Examination • Measured AROM with large goniometer • Measured IR behind back with palpation of spinous process • to measure ROM limitations which then translate into functional limitations • In order to reference improvement • PROM in supine: No pain

12. Initial Evaluation • Special Tests • Anterior instability and impingement are common in baseball and have been linked to decreased in IR and concurrent increases in ER,7 therefore wanted to test for impingement and instability

13. Initial Evaluation • Strength Testing(MMT) • Abduction • Could not test secondary to pain • External Rotation • 5/5 with pain • Scapular dyskinesia • Initial Treatment • Attempted mobilization with movement with shoulder abduction to increase ROM with reduced pain4 • Results – patient could not tolerate secondary to pain • Kinesiotape to reduce shoulder pain • Results – patient reported reduced pain with movement and resistance • Evidence6 • Thelen M, Dauber J, Stoneman P. The clinical efficacy of kinesio tape for shoulder pain: a randomized, double-blinded, clinical trial. • Investigated efficacy of kinesio tape when applied to college students diagnosed with rotator cuff tendonitis/impingement • Conclusion: Kinesio tape may assist clinicians in improving pain-free AROM immediately after taping

14. The Patient-Specific Functional Scale • Primary Functional Goal: Sammie will score 8.8/10 or greater on The Patient-Specific Functional Scale indicating improvement in overall function • Minimum detectable change for average score = 25

15. Visit 2 • Beginning ROMs: R shoulder Abd 124° with pain, Flex 152° • Used MDT for assessment and treatment: Repeated shoulder extension and repeated shoulder extension with clinician overpressure • Instructed patient to extend her arm, palm facing up, as high as she can • Patient was instructed to repeat 10 times • Rechecked abduction – less pain but still painful • Patient repeated 4 sets of shoulder extension until pain had reduced to a constant • Then, patient extended shoulder and clinician gave overpressure • Continued extension with overpressure for 4 sets of 10 repeating it until she had no pain with abduction • Post treatment: Abd 163° with no pain

16. Visit 2 • The abolishment of symptoms lead to the MDT diagnosis of reducible derangement because the symptoms were decreased with repeated movement (extension) and then abolished with therapeutic loading strategies (extension with overpressure) , which was accompanied by improvements in the mechanical presentation (ROM)3 • Began therapeutic exercise to improve muscle performance • Home Exercise Program – Patient instructed to perform 10 repeated extensions every 2-3 hours, particularly before and after softball games and when she felt pain

17. Visit 3 • Assessment: Sammie presents with no shoulder pain and no significant loss of ROM allowing for increased function with daily activities. Sammie requires further monitoring and strengthening to return to prior level of scholastic athletics. • Plan: Continue/alter/progress extension principles; assess response to softball practice, continue therapeutic exercises for strengthening for return to sport

18. As treatment continued . . . • Sammie reported that shoulder no longer hurt during the day but would still hurt after softball practice • Repeated extension always reduced pain with movement however there was an underlying pain when given resistance with external rotation at 0° and abduction at 90° • Hypothesis: Sammie presents with a reducible derangement with an underlying soft tissue dysfunction • Reasoning: Sammie had pain consistently with resisted abduction at 90° and external rotation at 0° but with no other positions. Pain would subside once the force was removed

19. Tendinopathy • Tendon injury can occur from acute trauma or repetitive loading from overuse • Of all injury related physician visits, almost 7% are from overuse injuries • The most common site for an overuse injury is at the osteotendinous junction • Tendons are predisposed to hypoxic tendon degeneration from the low blood supply to the tendon insertion8

20. Treatments for Tendinopathy • Goal of treatment • Reduce pain • Return to function • Most common and effective treatments8 • Relative rest of affected area • Stretching • Ice • Analgesics

21. Visit 8: ASTYM • ASTYM is “‘a stimulation’ of the body’s healing response, which results in the remodeling/resorption of scar tissue and the regeneration of degenerated tendons.9” • ASTYM restarts the body’s inflammation process which can then start healing/tissue remodeling • PT certified in ASTYM performed an assessment and treatment on Sammie’s right upper extremity and noted increased tissue texture in right anterior shoulder, AC joint and long head of biceps • This finding helped confirm the hypothesis that Sammie had an underlying soft tissue dysfunction in the shoulder with scarring and fibrosis

22. Therapeutic Exercise to Promote Tissue Remodeling • Eccentric External Rotation • With green TheraTube in doorway with towel under elbow • Fast external rotation with slow eccentric internal rotation • 4 sets of 15 repetitions • Scaption • At 45° angle lifting to approximately 90° • 3 lb weights • 2 sets of 15 repetitions with slow eccentric lowering • Bicep Curls • Bicep curl palms up, lower with palms down • 3 lb weight • 3 sets of 15 repetitions with slow eccentric lowering • This will help remodel the tissue to resolve the dysfunction • Mechanotherapy – load is used therapeutically to stimulate tissue repair and remodeling in tendon, muscle, cartilage and bone1

23. Visit 10 – Last Available Visit • The Patient-Specific Functional Scale average score = 8.3 • Abduction AROM 175° with no pain • Sammie reported minimal pain with softball games • No joint mobility restrictions • Continues to have pain with resisted external rotation demonstrating tissue dysfunction requiring further treatment for tissue remodeling • Sammie will benefit from up to 4 more treatments for ASTYM for tissue remodeling and to progress her to an independent home exercise program

24. Summary of Case • Sammie presented with shoulder pain and decreased ROM • Pain was reduced and ROM increased with repeated shoulder extension reducing the derangement • Sammie continued to have residual pain with resisted movement consistent with soft tissue dysfunction • ASTYM assessment and treatment confirmed dysfunction • Dysfunction was treated by continued ASTYM and repeated eccentric loading to remodel tissue and resolve dysfunction

25. Limitations • Did not record PROM measurements • Did not record initial strength measurements for all shoulder motions • Physical Therapist Student not certified/proficient in Mechanical Diagnosis and Therapy method • Not generalizable to all patients • Did not perform intra-rater reliability • Some missing data collection • Patient not yet discharged

26. Were you listening? • What MDT diagnosies am I demonstrating? • What is the theory behind ASTYM? • What type of exercises are best for tissue remodeling?

27. Questions?

28. References • Khan K, Scott A. Mechanotherapy: how physical therapists' prescription of exercise promotes tissue repair. British Journal of Sports Medicine [serial online]. April 2009;43(4):247-252. • Luime J, Koes B, Heridriksen I, et al. Prevalence and incidence of shoulder pain in the general population; a systematic review. Scandinavian Journal of Rheumatology [serial online]. March 2004;33(2):73-81. • McKenzie R, May S. The human extremities mechanical diagnosis and therapy. New Zealand: Spinal Publications Ltd; 2000. • Mulligan BR. Manual Therapy 'Nags'. 'Snags', -MWM'. etc. 4'"ed. Wellington, New Zealand: Plane View Series Ltd, 1999. • Stratford P, Gill C, Westaway M, Binkley J. Assessing disability and change on individual patients: a report of a patient specific scale measure. Physiotherapy Canada. 1995;47:258-263. • Thelen M, Dauber J, Stoneman P. The clinical efficacy of kinesio tape for shoulder pain: a randomized, double-blinded, clinical trial. Journal of Orthopaedic & Sports Physical Therapy [serial online]. July 2008;38(7):389-395. • Thomas S, Swanik K, Swanik C, Huxel K, Kelly IV J. Change in Glenohumeral Rotation and Scapular Position After Competitive High School Baseball. Journal of Sport Rehabilitation [serial online]. May 2010;19(2):125-135. • Wilson J, Best T. Common overuse tendon problems: a review and recommendations for treatment. American Family Physician [serial online]. September 2005;72(5):811. • www.astym.com • www.mckenziemdt.org