Case Study: Shoulder Pain and Restricted ROM in Young Male

Our Patient

Our patient is a young adult male in his 20s complaining of right anterior shoulder pain, and unable to lift his right arm above 90 degrees. He reported a snapping sensation in his shoulder with certain movements. He has had shoulder pain since he sustained repeated dislocations at age 18. 

The Challenge

The patient brought with him an MRI report from earlier in the year of his right shoulder . 

The MRI report indicated:

• Glenohumeral joint osteoarthropathy with patchy chondromalacia and a diffusely attenuated labrum with suture anchors in the glenoid 
• Subacromial subdeltoid bursal fluid
• Mild supraspinatus tendinosis 
• A split long head biceps tendon that was not fully residing in its groove 

The surgeon with whom the patient consulted concluded that the MRI reading was incorrect, and he insisted that there was a large biceps tendon partial thickness tear, which he wanted to surgically reattach to the proximal humerus. The patient came to NYDNRehab for a second opinion.

Our Diagnostic Process

Clinical Exam

Our clinical exam revealed multiple issues:

• His pelvis was leveled with transverse plane rotation to the left, with the trunk rotated to the right. 
• He was unable to depress his ribcage and control his core. 
• He had a tight and hyperactive iliacus – a fan-shaped muscle in the pelvis that forms the iliopsoas muscle, a hip flexor. 
• Visual examination revealed atrophy of the right infraspinatus and supraspinatus, along with loss of tone in all right periscapular muscles. 
• His right shoulder an anterior glide, with excessive inferior play. 
• There was multidirectional glenohumeral instability. 
• There was loss of tension of the paraspinal muscles. 
• The  serratus-external oblique chain was weakened, involving the lower scapular angle through the rhomboid major, and the latissimus dorsi aponeurosis. 
• He had multiple fascial densifications  in retrolateral and retro lines. 

Ultrasound Exam – Right Shoulder

• Examination with high-resolution ultrasonography revealed a hyperechoic fibrous band  extending anteriorly beyond the tendon footprint, representing supraspinatus expansion – a normal anatomical variant that functions as a lever for distributing force across the rotator cuff. 
• We were able to differentiate the bifid biceps from a partial thickness tear, and found no pathological entity.

Our findings reassured us that the recommended surgery was unnecessary, and that strengthening of the posterior rotator cuff muscles was needed. 

Ultrasound Exam – Right Scapula

• We identified a tear in the serrati-rhomboid fascia at the level of the mid scapula.
• We found a dehiscence (separation) in the posterior deltoid-infraspinatus fascia, and in the conjoint tendon of the latissimus dorsi, serratus anterior and rhomboid major. 

Shoulder Kinematic Analysis 

Our kinematic analysis revealed multiple biomechanical issues:

• A marked tilt of the scapula, with hysteresis – a difference in force production between the concentric and eccentric phases – during scapular depression, and during protraction-retraction. 
• Excessive activity in levator scapula and upper trapezius muscles.
• Loss of force coupling of the serratus anterior with the lower trapezius.

We analyzed and interpreted 3D graphs of the patient’s humero-scapular mechanics, which classified the patient’s condition as secondary dyskinesis, with multidirectional humeral instability. This provided pertinent information for rehabilitation and prolotherapy.  

Our Treatment Protocol

We created a customized rehab protocol based on our kinematic analysis of the patient’s scapulo-humeral motion, which correlated with the results of our scapular ultrasonography. 

Our treatment protocol involved:

• Dynamic neuromuscular stabilization, to restore innate motor patterns.
• Training with the Neuralign Shoulder Pacemaker – a shoulder rehabilitation device with a kinematic sensor activated by patient movement. 
• Stecco Fascial Manipulation, to restore gliding in the parascapular fascial planes.
• Targeted physical therapy, to strengthen and rebalance muscles.
• Fascial Prolotherapy, once gliding was restored and the glenohumeral stabilizers were adequately reconditioned. 
• Platelet-rich plasma (PRP), to accelerate tissue healing.

Two months after beginning physical therapy, we conducted two sessions of D5W Prolotherapy to repair fascial lesions. After an additional month of physical therapy, the patient received one injection of PRP, which was sufficient, as opposed to the three injections typically given. 

After five months of rehabilitation, the patient was able to return to the gym with zero discomfort when lifting weights.

Discussion

When it comes to musculoskeletal dysfunction, MRI imaging at the locus of pain is almost always inadequate to arrive at an accurate and complete diagnosis. At NYDNRehab, our diagnostic process is comprehensive and multifaceted. Our integrative approach is based on the knowledge that biomechanical issues affect – and are affected by – multiple tissues and structures.

In this case, we used:

• High resolution diagnostic ultrasonography.
• Dynamic scapular ultrasonography – an approach unique to our clinic.
• Shoulder kinematic analysis.

Dynamic high-resolution ultrasonography is superior to MRI for visualizing the body in motion, in real time. Our findings negated the surgeon’s assertion of a tendon partial thickness tear and the need for surgical intervention. We identified and corrected multiple biomechanical factors that were contributing to the patient’s shoulder pain using targeted physical therapy, fascial manipulation, and regenerative therapy.

The takeaway message is that comprehensive diagnosis is foundational to rehabilitation and, in many cases, targeted physical therapy can only be successful when supported by regenerative interventions like Prolotherapy and PRP.