Presentation Due to Anterior Pain in the Right Shoulder
Case Background
The patient, a man in his 50s, reported right shoulder pain that began three weeks ago, with a sudden inability to lift his shoulder starting about one week ago.
He initially visited a hospital when the pain began, where the doctor diagnosed it as frozen shoulder (adhesive capsulitis) and casually remarked, “It’s just frozen shoulder,” while prescribing only painkillers and a topical patch. Feeling that no actual treatment would be provided at the hospital, the patient decided to look for alternatives.
While searching online for clinics near Kannai, he came across my website by google Map and was impressed by the detailed explanations regarding symptoms similar to his own. This prompted him to schedule a visit.
The patient had never experienced chiropractic care before and was initially apprehensive about what it would involve. However, after reading through the information on our website, he felt confident that proper treatment could be provided and decided to proceed with the visit.
Examination Details
History Taking:
The patient reported beginning weight training a few years ago, maintaining a routine of 1–2 sessions per week. Although he had not experienced any issues previously, he noted mild discomfort in his right shoulder three weeks ago after performing a bench press.
Initially, he could move his shoulder freely, and pain was limited to specific movements, such as pulling his shoulders horizontally backward (as in a bench press). However, about a week ago, he woke up with generalized pain in the shoulder and an inability to lift it.
After the initial onset of pain, he visited a hospital, but as previously mentioned, the response was limited to prescribing painkillers and patches. Dissatisfied with the lack of treatment, he sought out our clinic.
Visual Inspection:
During the consultation, the patient’s seated posture was observed. The right shoulder appeared to be positioned forward compared to the left.
Static Palpation (Passive Examination):
- Tension in the anterior fibers of the deltoid: Positive (+)
- Pain in the biceps tendon: Positive (+)
- Tenderness in the subclavius muscle: Positive (+)
- Tension and tenderness in the pectoralis minor muscle: Positive (+)
Motion Palpation (Active Movement Testing):
- Shoulder elevation in external rotation (thumb up): Limited to 80° due to pain.
- Shoulder elevation in internal rotation (thumb down): Less pain, with movement reaching 120°.
- Shoulder elevation in neutral position (palm down): Limited to 90° due to pain.
- Horizontal position (elbow bent at 90°): Significant pain during internal rotation.
Orthopedic Tests:
- Painful Arc Test: Positive (+)
- Dawbarn’s Test: Positive (+)
- Codman’s Drop Arm Test: Negative (-)
- Yergason’s Test: Positive (+)
- Speed’s Test: Positive (+)
Muscle Strength Testing:
- Deltoid: Unable to maintain position due to pain.
- Biceps brachii: Strength rated at 4/5.
- Other tests were not performed due to pain limitations.
[Initial Treatment Plan]
Given the strong suspicion of biceps long head tendinitis, the first session focused on reducing inflammation and alleviating muscle tension around the affected area
- Therapeutic Ultrasound and Cryotherapy:
- Used to mitigate inflammation and provide pain relief.
- Reduction of Surrounding Muscle Tension:
- Addressed the heightened tension in the surrounding muscle groups caused by the three-week subacute phase of pain.
- Joint Range of Motion (ROM):
- While a decrease in ROM was noted, it was unclear during the initial visit whether this was due to adhesions from inflammation (as suspected) or purely excessive tension in the surrounding muscles.
Given this uncertainty, the approach prioritized:
- Calming the inflammation.
- Improving soft tissue flexibility and elasticity.
Further assessments and treatments will be conducted in subsequent sessions to clarify the root cause of the ROM limitation and adjust the treatment plan accordingly.
[Prognosis]
Second Visit (One Week Later):
The patient reported that the pain persisted and that there was no noticeable change in the range of motion when lifting the shoulder. However, he mentioned that the pain seemed slightly reduced. Treatment during this session was similar to the first visit.
Notably, passive movement (performed by the practitioner while the patient relaxed their shoulder) showed a slight improvement in range of motion. As a result, treatment included techniques aimed at gradually restoring mobility in the joints surrounding the shoulder, particularly the clavicular joint.
Third Visit (One Week Later):
The patient reported a slight increase in both pain relief and range of motion following the previous session. Based on this progress, it was determined that flexibility in the muscles was improving, and the strain on the tendons and ligaments was lessening.
This session introduced techniques to actively expand the shoulder’s range of motion. A key focus was correcting the anterior displacement of the right shoulder joint (rounded shoulder posture).
At the end of the session, I advised to the patient that…
This session involved actively mobilizing the joint, which may cause tendon or ligament irritation and discomfort. If pain arises, please apply ice to reduce inflammation.
Fourth Visit (One Week Later):
The patient reported experiencing some pain when moving the shoulder on the evening of the previous session. As advised, he used ice packs to cool the area. He noted that the pain persisted for two days but subsided by the third day. By then, his shoulder felt lighter and moved more freely than before.
Treatment during this session continued to focus on expanding the joint’s range of motion, with similar advice provided. It was determined that longer intervals between sessions could now be implemented, and the treatment schedule was adjusted to once every two weeks.
Fifth Visit (Two Weeks Later):
The patient reported no recurrence of shoulder pain after the previous session. Additionally, despite the extended interval, his shoulder had not reverted to its pre-treatment state. This allowed for continued and more active treatments to further increase the joint’s range of motion.
Based on these observations, it was concluded that biweekly sessions would be sufficient, and the patient’s progress is being closely monitored.
Current Status:
Treatment is ongoing, but the patient reports a 70% reduction in pain compared to the initial visit.
The patient has been advised to continue avoiding high-stress activities, such as bench presses. However, lightweight chest press exercises performed while seated are permitted, primarily to assess movement and facilitate gradual adaptation.
[Practitioner’s Opinion]
This patient’s condition can be classified as a sports injury. It is a common issue with exercises like the bench press. During the movement of lowering the barbell to the chest, not only are the pectoral muscles stretched, but the biceps tendon also experiences significant stretching. When lifting the barbell back up, stress is placed on the tendon, which can result in injury—particularly if the individual’s form is suboptimal.
A significant contributing factor to this patient’s biceps tendon injury during bench pressing was the anterior displacement of the right shoulder joint (rounded shoulders). With this condition, combined with poor form, the tendon was overstretched in a convex direction, likely initiating inflammation.
Diagnosis and Chiropractic Approach
Although chiropractors are not granted diagnostic authority under Japanese law, and this is merely a personal opinion, I determined the condition to be biceps tendinitis rather than the “frozen shoulder” diagnosis provided by the patient’s physician.
Maintaining flexibility in the soft tissues surrounding the shoulder joint while correcting the anterior displacement (a common issue for those engaged in desk work) was explained as key to symptom improvement and reducing the likelihood of future issues. While the patient is still under observation, they have expressed a desire to transition to preventative maintenance care in the future.
Philosophy of Care at Spine Chiropractic
At Spine Chiropractic, I believe in not only addressing the root cause of musculoskeletal symptoms but also preventing future recurrences. This proactive approach reflects the ideal role of alternative medicine.
I aim to serve as a guide for health, ensuring that individuals can continue exercises meant to promote health without compromising their well-being. My goal is to empower patients to maintain a healthy and active lifestyle.
If you or someone you know is experiencing similar symptoms, please visit my clinic, Spine Chiropractic, located just one minute from Bashamichi Station, eight minutes from Nihon Odori Station, seven minutes from Kannai Station, and twelve minutes from Sakuragicho Station. I will provide dedicated and sincere care.