CASE REPORT:

Chiropractic Management of Non-Surgical Rotator Cuff Injury

David D. Leger, D.C.

Shoulder pain can result from several conditions for non-athletes, including adhesive capsulitis. This condition, also called frozen shoulder syndrome (FSS), is a common complaint for older adults, and patients seek relief from various practictioners including chiropractors, osteopaths, medical doctors, and physical therapists. Its causes are generally unknown.1 A case of this variety came to my office in October 2021.

INTRODUCTION
The patient was a 54-year-old female presenting to the practice with acute onset of left shoulder pain and restricted range of motion that started as minor shoulder pain eight months prior. No direct cause was identified for the pain, as no preceding trauma was reported. After an increase in pain intensity and significantly decreased range of motion, the patient sought relief from an orthopedist. After failing to receive much improvement from cortisone injections, she came to me seeking chiropractic relief.

CLINICAL FINDINGS:
The patient’s superficial appearance did not indicate any apparent distress with the shoulder or arm. She was 5 feet 10 inches at 182 lbs., with a body temperature of 97.2°F. Her blood pressure was 138/77 mm Hg, and she had a heart rate of 79 beats per minute. Symptoms included left shoulder pain (10/10); neck pain (7/10); low back pain, bilateral (7/10); hip pain, bilateral (7/10); and left leg pain to the left foot (3/10).
These symptoms affected ADLs including Cleaning: dusting, vacuuming, washing overhead; Dressing: donning/doffing undergarments, lifting overhead, overhead tasks; Grooming: washing and styling hair; Physical activities: exercising, raking, shoveling.

Ranges of Motion:
⦁ Cervical spine ranges of motion: reduced with pain
⦁ Lumbar spine ranges of motion: reduced with pain
⦁ Left shoulder ranges of motion: reduced with pain
Shoulder internal rotation (60°-100°) 79°
Shoulder external rotation (80°-90°) 38°
Shoulder flexion (160°-180°) 129°
Shoulder abduction (170°-180°) 98°
Positive orthopedic tests:
⦁ Maximum cervical compression bilaterally
⦁ Kemps positive bilaterally
⦁ Yeoman’s positive on the left
⦁ Left shoulder supraspinatus tenderness with abduction

In the neurologic exam, upper and lower reflexes, muscle strengths, and sensation tests were normal.

In palpation tests, multiple chiropractic spinal and extremity biomechanical lesions were noted in the lower cervical, thoracic, and lumbar spines and pelvis, as well as the left scapular clavicle first rib, AC joint, and posterior and anterior ribs in addition to right hip.

Exam findings included muscle spasm in cervical, thoracic, and lumbar regions.

IMAGING:
An initial radiographic study of the shoulder was conducted by the orthopedist and spine images were taken in my office.

Radiographic Imaging:
Left Shoulder films revealed three (3) views of the left shoulder and were relatively normal. The glenohumeral joint looked normal. There were some early arthritic changes shown at the AC joint, without any acute fractures or dislocations. It was noted that radiographs of the shoulder are usually negative in cases of adhesive capsulitis (FSS).2

Image 1. Acromioclavicular (AC) joint osteoarthritis

X-rays of the cervical and lumbar spine revealed an acute reversal of the cervical spine apex at C4/5. A forward head position of 1.66 inches. Mild thinning and spurring of the C5/6 disc level.

Lumbar findings were a lateral bending sign at L5 acutely open to the right, indicating disc injury with a compensatory lumbar scoliosis concavity to the right. A retrolisthesis of L3 on L4. Mild degenerative spurring noted throughout the anterior lumbar vertebrae.

Magnetic Resonance Imaging:
MRI study of the left shoulder was reviewed, and those findings included:

⦁ Thickening of the inferior glenohumeral ligament with loss of the subcoracoid fat, suggestive of adhesive capsulitis (frozen shoulder syndrome, or FSS)

 
Image 2. Thickening of the inferior glenohumeral ligament

Buford complex of the glenohumeral anatomy: an absent anterosuperior labrum in combination with a cord-like middle glenohumeral ligament. This represents a normal variant present in approximately 3% of shoulders

Image 3. Buford complex

⦁ Mild tendinosis of the distal subscapularis tendon

 
Image 4. Tendinosis of the distal subscapularis tendon

⦁ Mild to moderate glenohumeral joint effusion

 Image 5. Glenohumeral Joint effusion

⦁ Mild osteoarthritis of the acromioclavicular (AC) joint

 
Image 6. Acromioclavicular joint osteoarthritis

⦁ A mild subcortical cyst within the posterior/superior humeral head, which is likely incidental.


Image 7. Subcortical cyst within the humeral head

From a chiropractic standpoint, I see with rotator cuff injuries a combination of lateral or medial scapular rotation, AC joint pinching, and medial clavicle anterior upper rib chiropractic biomechanical lesions.

This patient’s orthopedic shoulder specialist did not recommend surgery but did recommend physical therapy (PT). She elected to do the rehabilitation at my office where I adjusted her spinal and extremity joints with an instrument technique.

Four months of chiropractic care consisted of external rotation abduction and rhomboid strengthening along with pectoralis and latissimus stretching. The first week, the patient underwent daily therapy; in weeks two through four, I adjusted the patient three times per week. In the final three months, she was treated twice per week. The patient now has only mild pain and full range of motion in the affected shoulder.

References:
1. Studin, M., Schoenfeld, M. (2013). Retrieved from: https://www.uschirodirectory.com/index.php?option=com_k2&view=item&id=721:frozen-shoulder-improve-with-chiropractic-care&Itemid=320&highlight=WyJmcm96ZW4iLCJzaG91bGRlciIsImZyb3plbiBzaG91bGRlciJd, (accessed 25 Apr 2022) 

2. Murphy F.X., Hall, M.W., D'Amico, L., & Jensen, A.M., (2012). Chiropractic management of frozen should syndrome using a novel technique: a retrospective case series of 50 patients. Journal of Chiropractic Medicine 11, 267-272. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3706702/.1016/j.jcm.]
3. Gaillard, F., Weerakkody, Y. Buford complex. Reference article, Radiopaedia.org. (accessed on 25 Apr 2022). [https://doi.org/10.53347/rID-1024]