Thoughts from the journey… Excerpts from a day in the life of Sherry McLaughlin

8Oct/091

Adhesive Capsulitis (and a weak shoulder)

For anyone that has ever had a "weak" shoulder, this case might really help you out.

For the lay person, here is the major point: Weakness with lifting your arm up may be due to your shoulders not being the same level (check this in the mirror!) and a trigger point on your infraspinatus muscle (lower angle of your shoulder blade), which you would only notice if someone poked it. The good news is, it's fixable! But it takes some corrections in places nowhere near your shoulder... like your hips and your thoracic spine and maybe even your ankles.

For the clinician: I had the opportunity to evaluate a Marine who had sustained a gunshot wound that pierced his left 6th intercostal space and exited through his right external oblique. After 15 months of multiple surgeries and rehab, he is now complaining of left shoulder weakness and limited range of motion. He had a soft tissue endfeel at approximately 140 degrees of elevation.

Visual observation reveals his R shoulder significantly higher than his L. He stands with his L foot slightly externally rotated. (This is a classic Leaning Tower R scenario, for all of you Missing Link alumni) - R leg more supinated, L leg more pronated.

His range of motion is limited to about 140 degrees of elevation by a soft tissue restriction. Isometric MMT revealed 4 flexion and 4 abduction strength with mild pain noted in the posterior shoulder region with resistance.

Trigger points were palpated in the R upper trapezius, L iliopsoas, L piriformis and L quadratus lumborum.

Here is the assessment of his three key rotational spots:

Hips: Tight hamstrings bilaterally (90/90 test approx. -40 degrees); (+) R FABERs test (hip won't externally rotate); Normal piriformis test bilaterally.

Thoracic spine: 50% rotation bilaterally. R limited primarily due to hip and thoracic spine limitations (restored with piriformis inhibition, ITB release, thoracic NAGs and posterior rib mobilization). L limited primarily due to hip restrictions (restored with piriformis inhibition, ITB release and lateral hip mobilization).

Ankles: L>R tightness on the gravity drop; Severe hypomobility of the L>R subtalar joints into eversion. Incidentally, prior to his injury he had a history of L ITB friction syndrome and has used Brooks Beast shoes (their most stable motion control shoe) for years.

He presented with R SI joint dysfunction. I corrected an inflare and a posterior rotation, L on R sacral torsion.

Following correction of all of the above, his shoulder height was symmetrical. He still had mild pain/weakness with resisted shoulder abduction (4 MMT).

I palpated a significant trigger point on the L infraspinatus (inferior angle of the scapula). After counterstraining that tender point, his MMT was 5/5 and pain-free.

How did that happen?

Well, if you look at a picture of the infraspinatus, you will find that a trigger point in the inferior angle would have to be caused by one or m0re of the following:

1. An upwardly rotated scapula which would put the supraspinatus and deltoid in a long/weak position

2. An abducted scapula (which would put the rhomboid in a weak position

3. Or an elevated scapula (which was not the case here).

Normalization of shoulder strength after counterstrain to the infraspinatus would lead us to believe that the first scenario was the case. The deltoid/supraspinatus were weak because the infraspinatus trigger point was creating upward rotation of the scapula, placing them in a long/weak position.

The manual therapy fixes were mentioned above, primarily to normalize his posture and rotational movement patterns and inhibit the infraspinatus.

The exercise fix:

1. Strengthen the rhomboid in the short position. By they way, this gets compromised with abnormal rotation of the opposite hip.

2. Lower the opposite shoulder by encouraging thoracic rotation: backstroke, prone alternating arm lifts, plyoball throws, prone sky reaches, STEMs, etc.

3. Get that L hip to work! Shoulder flexion drives off of the L hip, which in this case was shown to be a major cause of his postural asymmetry (remember the trigger points in the iliopsoas, quadratus lumborum and piriformis?). Those trigger points will all inhibit the gluteus maximus.

Try some anterior cone reaches, pulley low rows (hip dominant), wall airplanes, the yoga warrior series to wake up that L hip.

4. Normalize ankle dorsiflexion with the gravity drop, downward dog, BOSU or foam roll rockers, Warrior I.

5. THEN put the shoulder to work with all the ways you normally do that.

Well, that's a lot of stuff to work on, so I'll let you get to it.

Have a great day.

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  1. Thanks so much for doing this blog. I love reading these case studies. I am really trying to work some of these into my treatment with my patients.


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