Abstracted by: Christopher Viehmann PT, DPT – Anchorage, Alaska
Abstract:
A 75-year-old male with a three-month history of right shoulder pain accompanied by numbness and tingling was referred to physical therapy for management of symptoms. With all patients that have diagnosed shoulder pathologies, approximately 54% of them report peripheral paresthesia.1 Following the initial examination for this case report, the physical therapist clinically diagnosed the patient with subacromial impingement syndrome with associated peripheral paresthesia. Glenohumeral joint specific mobilizations as well as specific neuromotor and somatosensory re-education to the right shoulder has improved pain, mobility, and paresthesia intensity for this patient. Clinicians should consider utilizing specific glenohumeral joint mobilizations as a treatment option for patients who report peripheral paresthesia symptoms.
Introduction:
Shoulder Impingement, often identified by the location of the impingement, is one of the most common causes of shoulder pain, accounting for 44-65% of all shoulder related complaints.2 It commonly causes pain around the anterior shoulder complex and can refer pain distally towards the elbow, with occurrences referring pain towards the hand. Individuals reporting of numbness and tingling symptoms associated with their impingement syndromes is less common with minimal current literature due to nerve involvement not typically linked with subacromial impingement syndrome; however, with all patients who report having shoulder pain, approximately 54% of them report having peripheral paresthesia symptoms.1 Furthermore, It has been documented that peripheral paresthesia symptoms may manifest in cases with severe pain symptoms and increased age.1,3,4 A possibility for these additional symptoms is considered to be due to the additional impingement of the Coraco-thoraco-pectoral space, or subcoracoid space, as the distal portion of the brachial plexus travels through this region.5
Impingement Syndrome is condition characterized by inflammation, irritation, compression, and degradation of anatomical structures surrounding the glenohumeral joint, specifically around the subacromial space. These characterizations can be caused by structural changes, such as narrowing and compression on surrounding tissues in the subacromial space, often due to anterior and superior placement of the humeral head within the glenoid cavity. It can also be caused by functional or dynamic disturbances, such as muscular imbalance from rotator cuff musculature or biomechanical changes in the glenohumeral joint, thoracic, spine or scapula.6,7,8,9 The purpose of this case report was to examine the effects of glenohumeral and soft tissue mobilizations on a patient with subacromial impingement and associated peripheral paresthesia.
Case Description:
The patient, a 75-year-old male, presents with a 3-month history of right shoulder pain accompanied with right peripheral paresthesia. He describes his shoulder pain to be in the anterior shoulder region with the peripheral paresthesia following the median nerve distribution in the ipsilateral hand. His pain was gradual with onset, with no known mechanism of injury, but suspects it is due to a significant increase in activity from undergoing a complete remodeling of his kitchen, which initially began about four months ago. His symptoms are currently exacerbated with repetitive overhead activities, horizontally adducting his right shoulder with at least 90 degrees or greater of shoulder flexion, and sleeping or leaning for a prolonged period on the impacted side. While he can tolerate his symptoms enough to complete his daily tasks, he experiences difficulty with all overhead activities, lifting heavier objects, using handheld tools, has limited range of motion (ROM), and has disrupted sleep. At worst his shoulder pain symptoms are rated a 7/10, at best a 3/10, with his current symptoms being a 3/10 on a visual analog scale (VAS). His peripheral paresthesia symptom intensity are rated a 9/10 at worst, a 4/10 at best, with his current symptoms being a 4/10 on a VAS.
He does report a previous history of right shoulder pain which has been infrequent over the past five years, with his symptoms typically improving on their own. During this time frame he recalls receiving a steroid injection to an unspecified region to the right shoulder which yielded no significant improvement. He states his symptoms of peripheral paresthesia are new to his current condition and he has not experienced this sensation before. Approximately two years ago he underwent a consultation with a Medical Doctor (MD) which suggested a total shoulder arthroplasty as the next likely course of action. The patient was not favorable towards this option and has not had further medical professions involved since. Due to his symptoms not improving over the past three months and with the peripheral paresthesia continuing to worsen, he requested a referral to physical therapy (PT). Other previous medical history consists of coronary artery disease with CABG, hypertension, pre-diabetes, and GERD, which is all being managed appropriately with medications. Lastly, he is currently being seen in physical therapy for ongoing chronic low back pain and sacroiliac joint dysfunction.
Clinical Examination:
Significant findings from the basic clinical examination indicated limitations in passive and active ranges of motion in a non-capsular pattern presentation, and limited cervical range of motion. The most provocative special test was Hawkins-Kennedy subacromial impingement test followed by other impingement related tests. He scored a Quick DASH score of 28.0 out of 100, where 0 indicates no disability or likely limitations and 100 indicates total disability. The basic clinical examination is presented with (Table 1) with the special tests performed on (Table 2).
Table 1: Findings from basic clinical examination; (+) = mild pain, (++) = moderate pain, and (+++) = severe pain.
| Test performed | Outcomes |
| Cervical Screen (AROM) | |
| Flexion | Full ROM |
| Extension | Full ROM |
| Side bend | Mild limitation bilaterally |
| Rotation | Mild limitation bilaterally |
| Shoulder Girdle Screen | |
| Elevation | WNL |
| Depression | (+) pain on R |
| Retraction | (+) pain on R |
| Protraction | WNL |
| Shoulder PROM | |
| Flexion | L 125 R 100* with (+) pain |
| Abduction | L 120* R 100* with (+) pain |
| External Rotation | L 45* R 60* |
| Internal Rotation | L to T12 R to PSIS with (+) pain |
| UE Resisted Tests | |
| Abduction | L 5/5 R 4-/5 with (++) pain |
| Adduction | 5/5 bilaterally |
| External Rotation | L 5/5 R 4/5 with (+) pain |
| Internal Rotation | L 5/5 R 4/5 with (+) pain |
| Elbow Flexion | 5/5 bilaterally with (+) pain on R |
| Elbow Extension | 5/5 bilaterally |
Table 2: Findings from the performed special tests with the associated specificity and sensitivity.10,11; (+) = mild pain, (++) = moderate pain, and (+++) = severe pain. An (*) indicates peripheral parathesis symptoms provocation.
| Test performed | Specificity; Sensitivity | Outcomes |
| Shoulder Special Tests | ||
| Painful Arc | 80.5; 32.5 | (+) Pain on R |
| Neer Impingement | 30.5; 88.7 | (++) Pain on R |
| Hawkin-Kennedy Impingement | 25; 92.1 | (+++) Pain on R* |
| Subcoracoid Impingement | 87; 96 | (++) pain on R* |
| Roos test for TOS | 30; 84 | Negative Findings |
| Empty Can Test | 62; 69 | (++) Pain on R |
| O’Brian Test | 91; 71 | (+/-) Pain on R |
| Resisted Pull Test: | 81; 54 | Negative Findings |
| Phalen’s Test | 73; 68 | Negative Findings |
| Carpal Tunnel Compression | 95; 87 | Negative Findings |
Differential Diagnosis:
Following the initial clinical evaluation, the patient presented with reproduceable musculoskeletal signs and symptoms consistent with subacromial shoulder impingement of the right shoulder, indicating he would be appropriate to be treated by physical therapy. Differential diagnosis includes adhesive capsulitis, labrum lesions, cervical radiculopathy and referred pain, and thoracic outlet syndrome.
From the basic clinical examination, his findings indicated limited shoulder mobility in a non-capsular pattern, with weak and painful right shoulder resisted testing in multiple muscle groups. Due to his shoulder presenting with a non-capsular pattern, adhesive capsulitis, osteoarthritis, and activated arthritis/synovitis related conditions can be ruled out.12 His cervical spine was screened with no symptoms provocation, though with mild mobility deficits and mild pain during the shoulder girdle screening; likely ruling out but not completely excluding the possibility of cervical referred pain.13 With the findings from the basic clinical exam not being suffice to formulate a clinical diagnosis, special testing was required. From all the testing performed, the most provocative special test was the Hawkin-Kennedy Impingement test, with a specificity of 25% and a sensitivity of 92.1%.10,11
The following most provocative tests were the Neer Impingement test, Subcoracoid Impingement test, and the Empty Can test, all reproducing the patient’s shoulder pain symptoms in the anterior shoulder. The patient’s peripheral paresthesia symptoms were mildly provoked with Neer Impingement and Subcoracoid Impingement tests, hypothesized to be due to impingement of the Coraco-thoraco-pectoral space or subcoracoid space. Roos Test for Thoracic Outlet syndrome was negative for symptom reproduction, as well as resisted pull tests which likely rules out bursa involvement. Given the presentation of this patient, a labral lesion is statistically likely due to their age, as individuals over the age of 65 have a greater than 80% likelihood of having an asymptomatic labrum lesion, but testing indicates it his not his primary pain generator.14
It is evident from the full clinical examination that the patient’s primary clinical diagnosis would be right subacromial impingement syndrome, as multiple tests with significant sensitivity and specificity towards shoulder impingement pathologies were positive for symptom reproduction. Secondary pain generators include possible labral and rotator cuff pathologies, which both have been found to contribute towards impingement syndromes.
Interventions:
The patient was already being seen for low back and sacroiliac joint pain and not interested in increasing session frequency, so Physical Therapy for his shoulder was recommended once a week for 12-15 weeks to focus on improving glenohumeral and thoracic joint mobility as well as improving upper extremity sensorimotor control to improve his functional abilities with overhead activities. The patient was treated with one-to-one care for 45-minute treatment sessions, with no other Physical Therapist partaking in his case for shoulder rehabilitation. At the time of this Case study the patient’s treatment was ongoing.
At the start of each session, soft tissue massage was performed using the press and stretch technique, and was focused on thoracic and cervical paraspinals, upper, middle, and lower trapezius, latissimus dorsi, and pectoralis minor muscles. Then, a variety of specific glenohumeral joint mobilization techniques were utilized to restore mobility, which included an emphasis on improving forward flexion, rotational mobility, abduction, and horizontal adduction. All joint specific techniques utilized were performed in the supine position. Forward flexion was achieved by stabilizing the ipsilateral scapula with an emphasis on a inferior glide to the humeral head with the mobilizing hand. Internal rotation and horizontal adduction was performed with prepositioning the shoulder in forward flexion, horizontal adduction, and internal rotation up to 90 degrees, with an emphasis on a posterior-inferior glide of the humeral head with the mobilizing hand; Internal rotation mobilizations were progressed by prepositioning the shoulder in approximately 30 degrees of abduction followed by maximal tolerated internal rotation, with an emphasis on a posterior lateral glide of the humeral head. Abduction mobilizations were performed with an emphasis on inferior glides of the humeral head. Grade III-V mobilizations were performed, dependent on the patient’s sensitivity to each positioning. Following manual mobilizations, neuro-muscular re-education activities were performed, including contract relax techniques and isometric holds at available end ranges for each position, to reduce a rebound effect from occurring and to help maintain motion gained during mobilizations. Following the International Academy of Orthopedic Medicine (IAOM) methodology, each mobilization was performed until there was a change in end feel, which was repeated up to three times.
In addition to the manual and neuromuscular interventions mentioned, further shoulder stability and motor control exercise progression were assigned as his home exercise program (HEP). Initially his HEP started with isometric ER/IR doorway presses, banded rows and shoulder extensions, and scapular squeezes which were performed twice daily for three weeks prior to being progressed. Progression through his HEP was determined by his ability to perform the exercises with minimal to no symptom reproduction, while also demonstrating a minimum of 75% effort with the isometric doorway presses. Next, the second phase included banded isometric ER/IR walkouts and an anti-rotation press with an emphasis on scapular retraction, which were performed in addition to his banded rows and extensions. This second phase was maintained for six consecutive weeks, increasing resistance when appropriate without provoking symptoms. The next and current progression of his HEP incorporated banded anti-rotation overhead pressing as well as the previous HEP exercises, and has continued for two additional weeks thus far.
Outcomes:
Given that the patient continues to be seen by physical therapy during the time of this case report, outcomes will be described based from the most recent re-evaluation performed. Following the previously mentioned interventions, there has been 11 sessions over the course of 11 weeks. During this time his Quick Dash outcome measure score improved from 28% to 23% disability, and his overall shoulder pain symptoms have improved by a reported 70%, rating his pain at worst to be a 3/10 and his pain at best to be a 0/10 on the VAS. As for his peripheral paresthesia symptoms, he reported an approximate 50% improvement, rating the intensity of his symptoms at worst a 6/10 and at best a 1/10 on a VAS. His passive range of motion improved from 100 degrees to 135 degrees for both abduction and forward flexion, from 60 degrees to 65 degrees for external rotation, and from being able to reach to his PSIS to approximately L2-3 for internal rotation. By the time of this report he continues to have discomfort with maximal internal rotation and managing heavy loads overhead, but otherwise reports such improvement in his symptoms that he would rather his remaining time in physical therapy mainly be focused on his LBP, even though there is still objective improvement to be made.
Discussion:
Throughout the course of treatment, the patient demonstrated significant improvement in mobility, pain symptoms, and peripheral paresthesia symptoms, although all of the above would still be considered ongoing limitations based on his condition at the time of this Case Report. It is possible that part of his peripheral paresthesia symptoms is contributed to his cervical spine, but due to improvements made with the current interventions, further cervical examinations have not been initiated. Progress made with Physical Therapy has been slow, but gradual due to the patients preference to only be seen once a week. The preference of the author would have been to be seen 2-3 times for 6 weeks, followed by reducing the visits to once a week for 3-4 weeks to monitor independence. Furthermore, this patient’s recovery was also likely delayed due to being seen for multiple regions, requiring management of his LBP symptoms as well as progressing his shoulder rehabilitation.
Conclusion:
This report demonstrates the ongoing, but successful treatment for a 75 year-old male with clinically diagnosed subacromial and subcoracoid impingement syndrome. Manual interventions were heavily utilized to decrease soft tissue restrictions, improve joint mobility, and decrease pain symptoms, while neuromuscular and therapeutic exercise interventions were given to help maintain gained progress during sessions. This report exhibits the benefit of utilizing glenohumeral joint specific mobilizations in addition to select neuromuscular and therapeutic exercises to treat subacromial impingement syndrome with peripheral paresthesia symptoms.
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