Joseph is a forty-year-old firefighter who fell and hurt his right shoulder three years ago. Joseph hurt his shoulder when he fell hard while playing rugby league and was diagnosed with a sprain and partial dislocation of his right acromioclavicular joint at that time. The condition seemed to improve with time though never really healed and now Joseph is left with a shoulder that is hard to rely upon. His shoulder aches, makes cracking sounds and after he uses his shoulder a lot he finds that he can’t raise his arm fully.
Over the past few months Joseph finds that his shoulder is deteriorating. It aches more frequently, the pain is more intense and the shoulder feels weaker. Joseph’s sleep has become disturbed by his inability to sleep on that side for long periods. Therefore Joseph saw his GP who arranged an ultrasound of his shoulder and this showed that his rotator cuff is worn. Joseph typically exercises regularly but has cut back some time ago because of his shoulder. Having said all this, he does still manage to work okay but is worried how long his “shoulder will last”.
Examination of Joseph’s posture showed that his right shoulder is unlevel compared to the left. It is lower and more forward. There appeared to be a loss of muscle bulk on the outer edge and the back of the shoulder. These changes are found in people with loss of specific muscle mass in key muscles. We watched Joseph move his right arm: he couldn’t quite raise it as far as he should and it moved like a ratchet; he couldn’t push his right hand very far up behind his back; when he crossed his right arm across his chest it elicited pain at the tip of his right shoulder and this could be increased if we applied slight overpressure to the arm. Further examination showed limited internal rotation and ability to fully lengthen the right pectoral muscles.
Observing Joseph’s functional movements showed he was weak performing a push-up with associated ‘winging’ of his right shoulder blade and the same occurred in a plank position and a side-plank position. Test’s for the patency of the supraspinatus and biceps were near-normal but weakness was observed in resisted muscle tests of serratus anterior and infraspinatus (a scapular stabiliser muscle and a rotator cuff muscle.)
Palpation of his shoulder revealed thickening of the ligaments and tissues on and around his right acromioclavicular joint with associated tenderness and the same type of situation but to lesser degree in his right sternoclavicular joint. The glenohumeral joint (the ball and socket’ one) could not fully translate to move into full abduction movement to get the arm up as high as possible.
When we examined Joseph’s spine, his neck movements were stiff and limited to a degree in most directions. His upper back was even more restricted in extension and right rotation. Segmental examination revealed joint restriction and signs of vertebral subluxations at C6/7, T 2/3 and T4/5.
Some imaging examinations, that Joseph brought with him, – X-rays and a recent ultrasound examination were reviewed. They showed a mild degree of degeneration at the right acromioclavicular joint and a partial thickness tear of the right supraspinatus tendon. There was also thickening of the right subscapularis tendon.
We discussed the examination findings with Joseph and offered the following advice: We agreed that his shoulder complaint – though somewhat challenging was not something to be concerned about. We thought it unlikely that his deterioration would continue if we could help him find ways to overcome the symptoms. Given that he looks after himself so well, that his shoulder should respond to a combination of corrective exercises and chiropractic treatments. The insufficiency and implications of the scapular stabilisers and the rotator cuff muscles were explained to Joseph and that exercises would be taught to specifically address these imbalances.
Having identified the cervicothoracic and right acromioclavicular joint dysfunction, it provides a platform that as chiropractors to work from. Having only a few muscle dysfunctions will make the task of exercising to improve Joseph’s shoulder easier. These are some of the reasons we would approach Joseph’s condition with confidence. Adding up-to date information and evidence on shoulder complaints will aid Joseph in his understanding and adherence for his recovery.