Shoulder Pain: Differential Diagnosis with Mechanical Diagnosis and Therapy Extremity Assessment E a Case Report

Manual Therapy 18 (2013) 354e357

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Manual Therapy

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Case report Shoulder pain: Differential diagnosis with mechanical diagnosis and therapy extremity assessment e A case report

A. Menon a,S.Mayb,* a Shri Giridhari Physical Therapy Center, Mumbai, India b Faculty of Health and Wellbeing, 38 Collegiate Crescent Campus, Shefﬁeld Hallam University, Shefﬁeld S10 2BP, UK article info abstract

Article history: Mechanical Diagnosis and Therapy (MDT) is now probably the only non-specific classification system Received 29 May 2012 that can be used with both spinal and non-spinal patients. Derangement syndrome, which presents with Received in revised form rapid changes in symptoms or mechanical response with the use of repeated movements, appears to be 20 June 2012 common in both spinal and extremity cases. Shoulder problems can be attributed to specific shoulder Accepted 26 June 2012 problems, but may also be referred from the neck. The case report describes a patient presenting with shoulder pain and limitations to shoulder function, and who tested positive to functional shoulder tests. Keywords: However, repeated neck movements demonstrated the ability to worsen and improve the shoulder pain McKenzie ‘ ’ Mechanical diagnosis and therapy and limitations. MDT was an effective tool at making the differential diagnosis between genuine and Shoulder referred shoulder pain. Classification Ó 2012 Elsevier Ltd. All rights reserved.

1. Introduction prognosis and facilitates research (Long et al., 2004; Cook et al., 2005). Shoulder pain is reported to be the most common musculo- The McKenzie Method of Mechanical Diagnosis and Therapy skeletal disorder after spinal pain (Eltayeb et al., 2007). There is (MDT) (McKenzie and May, 2000, 2003, 2006) uses posture and end evidence that shoulder pain is often recurrent and persistent (Croft range repeated movements whilst monitoring symptom and et al., 1996; Van der Windt et al., 1996; Van der Windt and Croft, mechanical responses to classify patients into one of three 1999; Winters et al., 1999; Kuijpers et al., 2006, 2007). Accurate mechanical syndromes: derangement, dysfunction or postural differentiation between shoulder and cervical disorders causing syndrome, or ‘other’ if it does not fit the operational definitions of shoulder pain is important not only for epidemiological studies, but one of the mechanical syndromes. In extremity problems, also to improve targeted treatment and prognosis (Mannifold and dysfunction is further sub-classified as either contractile or artic- McCann, 1999). ular dysfunction based on responses to resisted tests and end-range The pathoanatomic model in shoulder pain is of questionable repeated testing. Treatments directed at these homogenously value given that the clinical tests for making a diagnosis do not have exclusive subgroups are specific to each subgroup (McKenzie and good levels of reliability (May et al., 2010) or validity (Dinnes et al., May, 2000, 2003, 2006). Reliability between therapists trained in 2003; Mircovic et al., 2005; Dessaur and Magarey, 2008; Hegedus the McKenzie system has been shown to be moderate to good for et al., 2008; Hughes et al., 2008). Furthermore the value of spinal problems (Razmjou et al., 2000; Kilpikoski et al., 2002; Clare imaging is questionable as rotator cuff tears are seen commonly in et al., 2004, 2005; Dionne et al., 2006), and prognostic validity has asymptomatic subjects (Tempelhehof et al., 1999; Schibany et al., been previously demonstrated in spinal disorders (Long, 1995; 2004; Yamaguchi et al., 2006). Therefore, it has been recom- Werneke and Hart, 1999; Werneke and Hart, 2001). There is mended that these diagnostic labels be abandoned, and instead evidence for high levels of reliability between trained MDT thera- patients are classified based on treatment response and common pists evaluating completed assessment forms, with kappa values of clinical characteristics (Schellingerhout et al., 2008). There is 0.7 (Kelly et al., 2008), and 0.83 (May and Ross, 2009). evidence that sub-grouping of patients with spinal problems and The purpose of this case report was to demonstrate how directing treatments in this way aids better outcomes, predicts a patient presenting with an apparent shoulder problem, when assessed using an MDT examination, ultimately responded to repeated movements at the cervical spine. The patient gave * Corresponding author. Tel.: þ44 0114 225 2370. permission for the case report to be presented if this was done E-mail address: [email protected] (S. May). anonymously.

2. History He slept on his sides and his sleep was not disturbed. Initially he had taken non-steroidal anti-inflammatory drugs, but as these had A 47-year old male patient was referred by his family physician not helped he had discontinued them. His general health was good with shoulder pain. The patient worked as an air-conditioning and he had had no previous shoulder or spinal history or any technician, which involved working with arms overhead and neck concurrent symptoms. extended for prolonged periods, and occasionally lifting heavy A recent MRI reported a complete tear of the subscapularis weights. His only leisure activity was watching television, which he tendon, a type 2 SLAP tear, hypertrophy and cystic changes in the watched for at least 4 h every night ‘relaxed’ on a sofa. His only lesser tuberosity, soft tissue thickening with synovitis in the rotator functional limitation was lifting moderate to heavy weights due to cuff interval, tendinosis in the infraspinatus and supraspinatus with shoulder pain. At this point he was on annual leave back in India fatty atrophic changes in the infraspinatus. from working abroad, but not on sick leave (Fig. 1). The following outcome measures were obtained at baseline: the 3. Physical examination Shoulder Disability Score (Croft et al., 1994) e 4/22; the Oxford Shoulder function score (Dawson et al., 1996) e 45/60; numeric As factors from the history were suggestive of a shoulder pain score e 5/10 (Sim and Waterfield, 1997). disorder, a McKenzie extremity assessment was undertaken. The He had a 4 month history of intermittent left shoulder pain patient had a poor posture in sitting and standing with a flexed which was improving, but there was consistent pain on elevation of lumbarspine,protrudedheadpostureandprotractedshoulders. the shoulder more than 90 , with abduction worse than flexion. Single movements were first examined for a baseline under- This was the first episode and the symptoms started for no standing of pain, range and the functional activity. He had full apparent reason. He was never off work, but he had avoided lifting active and passive range of shoulder flexion, abduction and heavy weights. His symptoms were absent in the morning, not medial and lateral rotation. Abduction and flexion had pain worse as the day progressed, but were worse in the evening. during movement beyond 90 and medial and lateral rotation Consistently lifting weights made him worse, which would stop had minimal end-range pain. Active abduction was the most with rest, analgesic spray and hot packs. Continuous use of his left symptomatic movement. Resisted abduction and flexion arm did not affect his symptoms as long as he did not lift weights or provoked concordant shoulder pain, but there was good raise his shoulder above 90. strength on both.

Fig. 1. Body chart illustrating area of symptoms. 356 A. Menon, S. May / Manual Therapy 18 (2013) 354e357

Repeated movements in upright standing were tested to ascer- produce any symptoms at the shoulder nor cause any mechanical tain the possibility of a reductive or consistent pattern to the responses to the shoulder or cervical spine. Maintaining a static symptoms. Active abduction being most symptomatic was tested protruded neck, active shoulder movements were asymptomatic. first. Two sets of 10 repetitions produced pain which remained Maintaining static protrusion, resisted abduction produced pain worse after testing. Repeated flexion increased the symptoms during movement beyond 150, with a pain score 0.5 which was further, and remained worse. No movement was found to decrease not worse afterwards. With a retracted neck resisted abduction the symptoms, neither was there any change in pain pattern. It was produced no pain during movement. The cause and effect of the now clear that symptoms were being affected with loading the arm, shoulder pain was demonstrated to the patient. but no clear pattern was emerging and the pain pattern could not be The patient was advised to carry on with repeated retraction, classified to any mechanical syndrome of the extremity at this stage. extension and end-range extension, which involves a slight rotation The cervical spine was tested next in sitting. To enable the best of the head at end-range in both directions to obtain full end-range. range of movement the patient was shown how to restore the Since resisted abduction in static neck protrusion had still produced lumbar lordosis and retract the head. This position abolished the some pain during movement at the shoulder, it was reasoned that symptoms made worse by the repeated movement testing during this over-pressure would be useful to fully abolish symptoms. the shoulder assessment. The initial single baseline movement The next follow up was done by telephone after one month as testing showed a moderate loss of retraction and extension, but no the patient had returned to his job overseas. The patient was loss to any other cervical movements. In the MDT system move- asymptomatic at that point in time. A further long-term follow-up ment loss is defined as nil, minor, moderate, or major, which was done at one year. The patient remained asymptomatic, but had although suffering from imprecision is meaningful to MDT clini- continued to use the exercises if ever he felt stiffness or discomfort. cians and relevant to individual cases. The telephone follow-ups were done by another therapist blinded There were no baseline symptoms at rest prior to repeated to the treatment and outcomes. movement testing. There was still pain during movement beyond 50 of abduction at the shoulder. Repeated protraction produced 5. Discussion the shoulder pain at rest, which remained worse afterwards. There were no mechanical changes at either the cervical spine or the This patient’s symptom being intermittent, improving, worse in shoulder. Repeated retraction abolished the baseline shoulder pain; the evening, and affected by loading, pointed to its mechanical and further repetitions abolished the baseline pain during nature. Factors from the history and from the physical examination abduction. suggested a shoulder disorder. However, posture in the evening, To further re-confirm the directional preference and differen- when he was worse, while watching the television could point to tiate the cervical spine as the symptom creator at the shoulder, the the cervical spine. Interestingly the MRI findings were not relevant patient was asked to carry out the movements of the shoulder in to the patient’s symptom. static protrusion. The pain during movement in abduction was Cervical disorders can often cause symptoms at the shoulder produced, but this was abolished when the movement was carried (Wells, 1982; Schneider, 1989; Van der Windt et al., 1996; out with the neck in retraction. Thus sustained and repeated Mannifold and McCann, 1999; McKenzie and May, 2000; Bogduk, movement testing of the cervical spine affected the symptoms of 2002). Despite all the factors that suggested the symptoms origi- the shoulder, demonstrating a directional preference at the cervical nated from the shoulder when reductive mechanical forces were spine. Hence no further examination was deemed necessary. applied to the cervical spine, these abolished the symptoms. The provisional classification was cervical derangement. The Opposite movement produced the symptoms, providing further patient was educated on maintenance of posture, use of a lumbar evidence of the source of symptoms, giving a classification of roll, and was asked to perform 10e12 repetitions of retractions derangement of the cervical spine, and providing a directional every hour with the avoidance of provocative postures. preference in exercise to guide the treatment (Donelson et al., 1991; McKenzie and May, 2000, 2003; Long et al., 2004; McKenzie and 4. Reviews May, 2006; Kolber and Hanney, 2009; Scannell and McGill, 2009). The exact source of pathology is less clear. The cervical discs are Twenty-four hours later the patient reported compliance with largely fibrocartilagenous and without a mobile nucleus make any carrying out the exercises. He reported that he had not felt the pain explanation of this within a conceptual mechanical model rather with shoulder movement beyond 90, but still felt it with move- challenging (Taylor et al., 2000). However, the source of pathology ment beyond 120, with a pain score of five, but this was no worse is academic and ultimately it is best to use clinical reasoning afterwards. After repeated retraction with patient overpressure the principles based on symptomatic and mechanical responses to pain on abduction beyond 120 was two. The classification of assessment and treatment. cervical derangement was confirmed. Limitations of this case report are that both long-term follow-ups Forty-eight hours later at baseline examination there was were done by telephone, and the patient was improving when he minimal end-range pain on abduction. In order to achieve further first sought treatment. But it could be argued that the outcome could symptomatic responses at the shoulder and reach an end range at be distinguished from the natural history as it was clinically induced. the cervical spine, retraction and cervical extension was introduced. 6. Conclusion At 10 days outcomes were assessed by another therapist who had not been involved in treatment: Shoulder Disability The case report highlights the importance of differentiating score e 0/22; Shoulder Function assessment score e 55/60; shoulder pain that is from the shoulder from cervical referred pain, numeric pain score was 0/10. The patient self-reported excellent despite many factors suggesting the opposite. It also supports the satisfaction. During the last 10 days the patient had lifted heavy clinical utility of the McKenzie assessment as one approach in weights without pain. There were no symptoms at rest, nor pain making this differential diagnosis. The McKenzie assessment is during movement. The intermittent pain with lifting weights or a low technology, effective mechanical assessment that helps in the moving the shoulder beyond 90 remained abolished. Repeated differential diagnosis between shoulder and cervical sources of movements of the cervical spine in protrusion or flexion did not symptoms. A. Menon, S. May / Manual Therapy 18 (2013) 354e357 357

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