2 years and 3 elbow injections, all for what?

I recently had this case:

Subjective History: 87 y/o female presents with right elbow pain.  It has going on 2 years or more.  She has had all of the injections should could have in the right elbow (at 3), and now she is told the elbow pain is from the neck.  She has also tried bracing and was treated by a physician for her wrist, which did not help (she was prescribed a wrist brace but it did nothing for her).  Sometimes the pain is so bad that she can’t stand it.  She said her hands can get numb too.  She is also trying to recover from shingles (had in February) that affected under the right arm and across chest.  She cannot elevate the right arm now due to pain from shingles.  She was seeing Dr. ***, who referred to Dr. ^^^.  The last injection that was given gave her relief for 2-3 months.

Relieves symptoms: hot shower.  She denies finding a comfortable position for arm when pain arises.

Location of Arm and Elbow Pain: Mostly in the right elbow but has pain all the way from shoulder to fingers on right side. Pain is aggravated with the following activities or positions: She does not know.  She said sometimes it just “hurts” and does complain of the fingers to get numb. Pain Quality: Dull and just hurts, almost to the point where she can’t stand it.

Pain rating: 5/10 currently, 0/10 at best, 10/10 at worse that can take 1-2 days to ease.

QuickDASH: 65%

Objective
Elbow: Full, pain-free elbow AROM and PROM

Cozen’s Test – Negative

Mill’s Test – Negative

3rd finger extension (ECRB) MMT: Negative (same with 2nd digit for ECRL)—negative for pain and weakness

Cervical Active ROM
Cervical Extension: 20 degrees, Cervical Flexion: 30 degrees with pulling at CTJ (no reproduction of concordant signs), Cervical L. Rotation: 40 degrees, Cervical R. Rotation ROM: 40 degrees

Technically you should put overpressure to ROM to rule-out the neck…but come on she was 87.

Shoulder Active ROM
Shoulder elevation Active Range of MotionL 70 degrees
**Patient says she has had trouble with shoulder elevation since shingles, which came on over a year after her current symptoms**

Considering lack of motion, I did not test functional rotation moments and only tested MMT in neutral by side (in 90/90 position):

Infraspinatus/teres minor: 4 /5
Weakness noted Bilaterally
Subscapularis: 4+ /5

Grip Strength:
R: 30#, L: 25#. No pain.

Note: marked TTP at lateral epicondyle but biggest finding==>Reproduction of concordant symptoms in elbow with ischaemic compression over the infraspinatus and teres minor.

Treatment:

Simple: Ischaemic compression with wiggle using middle phalanx for 20-30 seconds over infraspinatus and teres minor MTrP.  It reproduced symptoms initially but abolished them upon completion.  As taught by the Dry Needling Institute, the main MTrP for infraspinatus muscle is frequently 1/3 of the distance from the middle of the spine of the scapula along a line to the inferior angle of the scapula—so no need to push all around the shoulder—the Institute teaches you specifically where the highest percentage of pain generators are located. This could have been addressed with dry needling too, but unable to perform without MD order in VA. Exercise prescribed: S/L scapula retraction and S/L shoulder ER with towel roll.

Follow-up at 2nd visit:

Right UE symptoms STILL 0/10 but 2/10 at worse in last several days.

SOAP note Impression: Patient’s symptoms have been complex and very irritable for the last 2 years at least, with only short term relief from medical management.  From further assessment today, it appears patient’s symptoms are arising from shoulder girdle complex (see objective above) > cervical spine, but I do not see marked dysfunction of the right elbow (all negative lateral epicondylitis tests) other than tender to palpation at lateral epicondyle.  Considering she did not have symptoms today other than reproduction at MtRPs in the shoulder, we will continue to re-assess our treatment approach.  She is a good candidate for PT intervention.

Blog Impression: Basically no active or passive movement reproduced concordant symptoms (again did not put overpressure at joints but don’t typically for this age).  I was not satisfied with the medical diagnosis of lateral epicondylgia based on 1. Negative 3rd digit (ECRB) weakness and pain & 2. Negative pain and weakness with grip testing.  Only diagnostic sign was tenderness over the lateral epicondyle, which is not unusual for mostly anyone and did not give me any more clinical utility.  She has marked limitation in shoulder girdle function, which was interestingly limited after the onset of symptoms started 2 yrs ago.  I felt her symptoms (wooo nocioception coming from the shoulder) that referred into the upper extremity.  Now one thing I do not know is if she had positive lateral epicondylalgia tests that led to steroid injection initially.

Bottom line: Send to a physical therapist EARLIER in the care for a full musculoskeletal assessment.   A PT could have picked up symptom arising more proximal and actual lead to treatments to abolish symptoms, then a program to address the underlying dysfunction.  This patient could have avoided 3 cortizone injections and not lived with right upper extremity pain for 2 yrs with only relief in short duration by a hot shower.

My question to you’ll:

1. Why do you think the cortizone injection worked? What would be some of the mechanisms?  

2. What led me to the infraspinatus and teres minor muscles specifically?

3. Would you have treated more her cervical spine vs shoulder? Why or why not?

4. What other manual and/or exercise treatment would you have given for day 1?

 

When do you recommend MUA for frozen shoulder?

Ahh, the mystical frozen shoulder.  We have all had our share of patients, with frustration typically steaming out of both parties’ ears.  It is a diagnosis usually made of exclusion, but a proper examination can help rule-in the condition.  The onset is usually spontaneous, the cause of the condition is still unknown and not one conservative intervention has been exclusively shown to be superior.

As physical therapists, we strive for all patients to be treated conservatively.  I do this for every condition and I will say 90%+ of patients should NOT need any other type of medical intervention, including medication & especially surgery.  One that continues to stump me though is the challenging treatment of adhesive capsulosis (frozen shoulder).  One of the main reasons is that if the shoulder is truly ‘frozen’, the average length of symptoms could last up ~30 months (average 1 year to 3 years).  Three stages have been described in the literature, and typically are presented by the following graph:

Frozen Shoulder Time Frame

I like treating orthopaedic cases that have a significant within-visit response and can get instantaneous gratification, even though full resolution will take some time. Besides a few interventions in lower realm of evidence (thoracic manipulation case report and dry needling case report), most of the time the treatment is slow. 

This treatment process can be labeled a “difficult condition and even difficult patients”.  With the deadlock of a condition as frozen shoulder can be, clinicians and patients could consider pulling the trigger SOONER than later to proceed with more risky interventions.  One of the most common interventions is manipulation under anesthesia (MUA).  With that said, the question remains: should MUA be considered earlier in the care for frozen shoulder patients?  This could be a possible proposal to improve ROM, decrease pain and decrease disability in a more speedier fashion, THEN proceed with physical therapy care.

Frozen Shoulder Risk Analysis

Let’s delve into this question further.

Anytime a procedure is performed, a risk:benefit analysis must be weighed.  For the most part, any physical therapy procedure is extremely safe with very little adverse events.  A low risk and over 90% success rate, the first choice for treating frozen shoulder should be physical therapy.  However, the success can depend on what you perceive as a short period of time.  Meaning, do you want to push through ~4 months of rehabilitation or will a MUA get you results sooner and get out of the frozen stage quicker?

For the sake of this post, I’ll skip steroid injections (as this is usually combined with ~12 weeks of therapy) and proceed to manipulation under anesthesia.

The procedure of MUA itself definitely has more risk, especially of possible fracture, rotator cuff tears, and labral tears.  Also, some surgeons will avoid the procedure if the patient is a diabetic (insulin-dependent), which is a risk factor for the condition. This does not include the risks associated with anesthesia, which can be very high, including recently noted to double dementia risk.   The benefit must then be weighed.  I have always heard ~70% success rate with MUA. Let’s look at some more evidence:

In a study of 125 patients by Kivimaki, et al 2007 comparing MUA to HEP had this conclusion,

Manipulation under anesthesia does not add effectiveness to an exercise program carried out by the patient after instruction.

On the other hand, Dodenhoff et al 2000 expressed,

We recommend the use of manipulation under anesthetic in primary frozen shoulder to restore early range of movement and to improve early function in this often protracted and frustrating condition.

Vastamaki & Vastamki 2013 found in a low level study but followed patients a mean of 23 yrs showed,

In this group of patients treatment of idiopathic frozen shoulder by MUA led to improvement in shoulder motion and function at a mean 23 years after the procedure

Farrell et al 2005 looked at long-term (15 yrs) with the following results (however, it was after failure of conservative care),

Treatment of idiopathic frozen shoulder by manipulation under anesthesia leads to sustained improvement in shoulder motion and function at a mean of 15 years after the procedure.

Wang 2007 had this conclusion,

We concluded that manipulation under anesthesia when initial conservative management failed speeds up the recovery of idiopathic, post-trauma and post-surgery frozen shoulders and improves shoulder function and symptoms within a short period of time. 

I would imagine physical therapy would be the most cost-effective intervention, but recent systematic review and cost-effectiveness analysis could not provide a conclusive outcome (no surprise since this is a systematic review!).

So in conclusion, the evidence doesn’t really provide us guidelines of using MUA besides suggesting it after failure of conservative measures.   I could not find any studies that solely looked at performing MUA EARLIER (to then decrease the length of disability).  Would the disability be less and recovery speedier?

My opinion:

I don’t have a true answer here and it all depends (don’t you hate that answer!?).  I will say that I have seen many patients who respond solely to physical therapy services and not need anything more invasive, costly or risky as a MUA.  However, there are ~5% of patients who just do not respond to PT.  These have gone on to have MUA (or lysis) and have come back to PT with a significant improvement in ROM and then get to ~90% of prior function within a month. I am trying clinically to find out if they will respond to my care or will have to have another treatment earlier in the course of care.  Pretty much all of my patients do not want to have another procedure and will rather continue with PT services, even if the course of treatment is slow.  That makes a big difference too in regards to how to approach various treatment options.

What are your clinical judgments in regards to this?  If you had a patient right now with frozen shoulder who has not shown improvement in ROM in the last ~4 weeks, but pain is still mild to moderate (NRPS: 2-4/10), would you continue with physical therapy or recommend MUA?  Or, would you suggest continued care with hopes of  transitioning to the ‘thawing’ stage quicker with further PT services?

At what time-frame do you consider conservative therapy to be a failure?  Do you think physical therapists over-treat this condition and should recommend other measures sooner than later?

To treat a non-traumatic RTC tear or refer out?

I recently received an email from MedBridge entitled, “The Relevance of the Physical Exam for Rotator Cuff Tears” in my mailbox.

We can all (with good confidence) pick out a full rotator cuff tear but the remaining question that always gets to me: should I treat…or refer out for surgery?  I have two patients on my case load just right now with these clinical findings: all of which do not want to have surgery.

I didn’t write the post so can’t claim the contents BUT it brought up a VERY good study and wanted to make sure my readers got the information too (if you are not signed up for MedBridge.)

It included a study by Kukkoen, et al. Treatment of non-traumatic rotator cuff tears: A randomized controlled trial with one-year clinical results. Bone Joint J 2014;  96-B: 75-81.  Unfortunately I can’t get to the full article, even through an academic source, but here it is summarized: it was a trial that randomized patients with supraspinatus tears between just physical therapy, physical therapy and acromioplasty, or physical therapy, acromioplasty & RTC repair.  The Constant Score was assessed at 3, 6 and 12 months between the three groups.  Here is the conclusion:

These results suggest that at one–year follow-up, operative treatment is no better than conservative treatment with regard to non–traumatic supraspinatus tears, and that conservative treatment should be considered as the primary method of treatment for this condition.

I said this study was VERY good for five reasons:

1. it answers (in research) through a randomized trial a question that I have not been able to answer with confidence…

2. it answers questions inquired by Systematic Reviews in 2007 and 2011.

3. it gives high props for physical therapy 🙂

4. it is in The Bone and Joint Journal…not in a PT journal.

5. ROCK ON physio group!

If you are interested in signing up for continuing education through MedBridge, use my icon to your right or click this link.  Honestly, if you don’t get it through me…I don’t care!…just sign up…great information that should be available to all physical therapists.   I have learned a great deal from the instructors and was able to do it in my tighty whities.

Ha, just kidding no that last part…

 

Palpation as diagnostic test for subacromial impingement

Palpation is starting to get a bad name in our field as it is not reliable between clinicians and validity of it’s use is undetermined. However, just as I teach my interns, you have to put your hands on the patient. You have to with a purpose and not just to poke around. I am glad to finally see a research study conclude what I’ve determined for years, palpation does have diagnostic value, especially ruling out conditions. Here is a good example:

Shoulder impingement is very common in any outpatient clinic and honestly can be ‘diagnosed’ quite easily. There is or there isn’t shoulder impingement with other common choices of frozen shoulder, labral tears and/or instability. All of these can really be determined through the history but as the purpose of clinical tests, it is best to finalize your hypothesis through the objective examination.

I have written in the past on how to rule out adhesive capsulosis (shown here ) but let’s get back to shoulder impingement diagnosis.

We know to rule out conditions we need to choose the clinical tests with the highest sensitivity. For shoulder impingement, these have been around for a long time and are Hawkins-Kennedy (here ) and Neer Test (here). We all know how to do this, however, in some instances; patients will walk into our office who do not have the range of motion (due to pain, guarding, etc.) to perform these measures. This is where palpation can be very important.

Toprak and colleagues (article here) just came out with a research article comparing Neer’s and Hawkins-Kennedy Test to palpation for shoulder impingement using sonography. What they found was that palpation to the supraspinatus and biceps tendon have a slightly higher accuracy compared to impingement tests. Pretty good results considering these two impingement tests are our go to guys for ruling – out subacromial impingement due to the high sensitivity values.

The authors recommend (and myself) that you use palpation as a strong tool in your physical examination for subacromial impingement. A positive finding does not tell you much, but if negative, it has significant clinical utility.

Two Ways to Prescribe Self-A/P glide of humeral head for HEP

Okay, long title sorry.

Attached is a video plus pictures on ways to prescribe a self-mobilization of the humeral head for your patients.  It goes along Mulligan’s philosophy of mobilization with movement and seems to work well if the condition does have a true impingement (and not just a CTJ derangement).  I am teaching the Pendulum (or Codmans) MWM to my post-op RTC patients vs the classical way (as shown in a past video below too).

 

Physical Therapy

Here is your classical way to perform Codman’s:

Top 3 Case Reports of 2012

I am a big advocate of my interns reading case reports.  Yes, this is low level research but the last time I read a systematic review, it left me with a big hole in my brain.  Some show interventions directly that help a patient, while some are differential diagnosis and clinical reasoning cases.

This is what I did as a student to give me ideas of how to treat, because we don’t learn this well in school!   It really helped me in the past and I try to translate this knowledge forward to our future therapists.  Makes you think about the picture below provided in AAOMPT conference 2010 by Cook & Sizer.  It is not a bad idea to flip the triangle every once in awhile.

Physical Therapy. Courtesy AAOMPT 2010 by Cook & Sizer

Diagnosis and Management of Ankylosing Spondylitis Masked as Adhesive Capsulitis: A Resident’s Case Problem

Physical Therapy

Written by Chelsea Jordan and Dan Rhon in JOSPT October 2012, I find this report is not only an eye opener of practitioner’s not using clinical reasoning, but a great review of ankylosing spondylitis.  It is well worth your read and will aid in your differential diagnosis of a mechanical vs non-mechanical cause of spinal pain.  Quite detailed, it provides criteria for inflammatory back disease, differential diagnosis based on several features, and the appropriate call to refer out.

I wrote a piece earlier this year (part 1 here and part 2 here) about a patient arriving with positive SIJ pain from combination of provocation tests but had underlying AS.  These two can go hand in hand.

Use of Thoracic Spine Manipulation in the treatment of Adhesive Capsulitis: A Case Report

Physical Therapy

Written by Joshua McCormack in JMMT, this case shows the benefit of thoracic manipulation that was implemented after the 10th visit in a patient who was not showing improvement with typical glenohumeral and scapulothoracic manual therapy and exercise.  I typically incorporate this approach much earlier in my treatments but was a good learning experience for the intern of mine at the time to not give up but go back to the drawing board to find what else can help this patient.  Shoulder elevation improved 25 degrees after this intervention so definitely a ‘boost’ for this patient! This condition is self-limiting yes, but depressing in my opinion in that who wants to wait up to 18 months for it to improve!? Would have been interesting to see results and lower visits if manipulation would have been implemented at day 1 or 2.

We are seeing more and more benefits of thoracic spine manipulation in the literature lately so definitely a good skill to have.

Differential Diagnosis of a patient referred to physical therapy with neck pain

Physical Therapy

Written by Jessie Mathers in JMMT, this is an excellent case report highlighting a simple concept that was missed by prior practitioners (7 visits total prior to referring to PT!) to detect a non-mechanical source of neck pain.  This concept is reproducing the concordant symptom.  We all do this daily and sometimes it seems thoughtless until something does not line up correctly.  This case underlines reproducing concordant symptoms through a clinical reasoning, patient response and assess-reassess model.  All of these will give the therapist the most confidence in determining if a patient is appropriate to continue our services or not.  This is especially important if you do practice under Direct Access.

Oh and even better, this came out of Duke, right down the street from me.  Go Blue Devils!

Did you read a case report this year that is worth sharing? I would like to hear from you.  

Have a Happy New Year!

A/P glide of Humeral Head during PROM

I typically use this technique shown below for many shoulder conditions, but particularly status-post RTC.  These are the circumstances where early PROM is efficacious; especially in external rotation and elevation.  As you know, these individuals are typically very guarded with the humerus adducted and IR’d across torso (hence in a sling position).

My patients typically are never this happy!

 This is adding art to a fairly un-artful and boring (yes, passive range is boring).  You have to have a ‘little give and take’ though with the movement; meaning, you have to only apply the necessary glide posteriorly as the humeral head pushes into your hand.  This may take a little time to get used to if you have only been using a longer level moment by pulling through the elbow.  It is not quite defined as MWM I wouldn’t say as the purpose at this protective phase of rehabilitation is the same as you normally would want with MWM. 

I get quicker results, better results, and more confidence from the patient from performing an arthrokinematic component to an osteokinematic approach.  If you don’t already do this, give it a try.  Let me know what you think!

 

Compression: It’s not that bad is it?

I had a 6 week post-op RTC repair middle-age female patient arrive to my clinic for evaluation just recently on a Monday morning.  The Friday prior, she had returned to her surgeon who doffed her abduction sling completely (6 weeks seemed like a long time but not the point here).  No details were given to me about the procedure (such as size of tear, if he even performed a SAD or DCE; just knew it was an arthroscopic approach).  The patient did tell me that the surgeon said he had to “extract” the tendon so I am assuming a large tear (possibly reason for long sling wear). She had only been performing elbow flexion/extension and Codman exercises as prescribed by her surgeon for the last 3-4 weeks, otherwise, no other specific activity.  She had returned to her desk job a few weeks prior.

She has not had a significant amount of pain per her report since the surgery but pain has exponentially increased since doffing sling (pain rating up to 8/10 on NRPS).  The location of pain was not as typical as I would see around shoulder cap  but mid-brachium anteriorly.   The posture was observed as significant difference in shoulder height on involved side (basically depressed) with guarding of the involved limb across her torso in GH adduction/IR and ante-brachium in pronation.  She had pretty much no voluntary ability to lift arm off of thigh in sitting. 

Passive ROM was significantly limited with only ~ 15 degrees of elevation and ER was limited to negative 30 degrees (yes, negative).  I get very concerned with the lack of ER in particular as I find this is a huge indicator of freezing shoulder starting to arise (not uncommon for a female, middle-age who was recently immobilized).  Read a past post here.  Nevertheless, any type of movement was painful to her; including scapular active range of motion.  Attempts of passive ROM via therapist was poorly tolerated with again pain in mid-brachium and not in the “joint” (harder to treat in her main complaint location!).  Not too much of a response either from a retrograde myofascial release of the lateral deltoid and biceps brachii or 1st rib and lower cervical spine mobilizations. 

With a doctoral intern accompanying me, the first thought of treatment was to provide distraction.  This is usual right as it is pain-relieving?  Not in this case and we decided to go the opposite direction.  Compression.  

With a squeeze grasp approach at the upper end of the humerus and a graded axial load superiorly, I was able to “sit” the humeral head more comfortably in the glenoid fossa.  She had an immediate response with ability to tolerate passive ROM supine and even scapula active range of motion seated.  Pain instantly decreased to a 1-2/10 scale and she was prescribed seated scapula retraction with neck extension and shoulder shrug with self axial compression via contralateral arm.  Also, codmans was modified to a “baby cradle” hold (which was much more comfortable for her).

It appeared that her humeral head was basically resting on the axillary pouch of the inferior glenohumeral ligament due to lack of any type of dynamic stability (she was very weak!).  Painful ER was possibly due to amount of stress that this ligament was already enduring and the anterior band could not help assist with keeping humeral head seated in glenoid as it rolled anteriorly. Providing the heel of my hand over the anterior aspect of humeral head during ER helped some, but not significant unless I provided compression.  

I thought this was interesting and not a typical manual approach for post-op RTC repair.  Hope you enjoyed!  

 

Adhesive Capsulitis Screen

See video below for 3 clinical tools to screen for true frozen shoulder.

To sum up:
1.  Pain at end range ER passively by side. No active motion here, only passive.

2. #1 can lead us to many disorders so I like to further narrow it down. 30 degrees of ER by side passively is my cutoff.  Anything more usually is not frozen shoulder (give yourself a little wiggle room though).

3.  No pain to provocation to anterior or lateral subacromial space.  If this creates pain, more than likely rotator cuff.

Now there is usually a derangement of the shoulder that will put undue stress on the RTC and have pain arising from this dysfunction too.  However, I do find these 3 clinical tools give me bang for my buck for true frozen shoulder.

Of course you need to consider the whole picture and not just these clinical tools but this is usually what I see (age, comorbidities, MOI, etc.) What do you think?  

C7-T1 Extension Mobilization/Manipulation

There has been a vast influx of evidence lately showing benefits of thoracic mobilization/manipulation, particularly the upper thoracic spine, cervical spine, lumbar spine, shoulder pain, elbow pain; well just about every type of pain!  It has been shown to be beneficial in all levels of evidence, including type 1 here.  A few pictures below:

Cross et al. JOSPT. September 2011.

Gonzales-Iglesias et al. JOSPT. 2009.

Here is a video of myself performing a version below.  To capture the hybrid component, I was saying in the video to look up (facilitate neck extension) and squeeze shoulders (facilitation retraction). Pending the type of patient that comes in the door, you can modify the technique for most appropriate action. Feel free to add comments.  

 

Positive: I like this technique as shown above for several reasons.

1.  This technique facilitates the opposite posture, or as Mike Reinold has coined (at least where I first read it): reverse posturing.  

 

2.  I am a huge fan of addressing the cervicothoracic junction.  There are many techniques for this area but many others put the patient in awkward positions and are simply not appropriate in many cases.  This technique can be used on majority of patients.

 

3.  You can provide as much force and perform what grade you feel is appropriate for the patient.  Meaning, you can perform high thrust or if not indicated, can perform more of a distraction pull, or even oscillate in a cephalad/posterior direction.  

 

Negative: reasons I don’t like this technique.

1.  Do ‘yourself’ no harm. For obvious reasons, don’t hurt yourself when working on large patients.  Ouch, my back!

2.  You can’t ‘feel’ the joints(s) to determine end feel as you can with other techniques.  There are not as many levers involved (you could technically put other levels into play) so this tends to lead to more force.  Some clinicians just yank the patients!  I don’t like this approach.

3. For individuals with quite a bit of pain and restrictions in GHJ, this position can be awkward for them.  

4. This technique is quite non-specific.  You can claim to work anywhere from lower cervical spine to upper thoracic spine.  Not a bad thing though and may should be filed under positive as studies have shown we are not as specific with our techniques as we think.