Physical Therapy Case Study: Shoulder And Neck Pain

by Nick Kossor, PT, DPT

PT For Shoulder & Neck Pain Case Study

History

A 72 year old male entered the clinic with right scapular pain and radiating “throbbing” pain down the right arm. The patient reported first noticing symptoms after performing overhead presses with his personal trainer 6 weeks prior. Symptoms have progressively worsened since the initial onset. The patient reported symptoms are aggravated mostly while driving.

Evaluation

During the first visit, various objective measures were taken to determine if the true source of the symptoms was in the periphery/extremities, or if they were associated with the cervical spine. Objective measures included screening dermatomes, myotomes, manual muscle tests, and range of motions to outline an individualized plan of care.

Treatment

Visit 1: Education of the etiology of symptoms included an overview of anatomy and proper joint movement of the neck and shoulder region. After determining symptoms were stemming from a compressed nerve root in the neck, we utilized manual traction to centralize radicular symptoms in the right arm. Once symptoms were centralized to the neck, manual therapy to the cervical spine helped restore normal range of motion. Soft tissue work to various scapular muscles further reduced symptoms and discomfort in the shoulder region. At the conclusion of the first visit, home exercises were prescribed with the intent of improving posture and reducing future compression of the cervical nerve root that aggravated symptoms in the first place.

Visit 2: The patient returned with no reports of tingling down the R arm. Postural recognition was improved, but the patient still presented with a forward head and rounded shoulders. This session was focused on stretching the pectoral region and strengthening scapular muscles responsible for upward rotation.

Visits 3-9: These sessions maintained cervical range of motion, progressed scapular strengthening, and ensured radicular symptoms were completely alleviated. Various modalities and manual techniques were used to maintain comfort and alleviate muscle soreness. Extensive neuromuscular re-education was a focal point in these sessions to reduce the activation of muscles that would contribute to regression of symptoms in the future.

Results & Follow Up

The patient reported complete alleviation of all shoulder and neck pain and also stated that he was able to drive for prolonged periods of time pain free. The patient also expressed excitement in being able to return to his normal workout routine. Significant improvements were made in objective measurements compared to the first visit.

Read More Physical Therapy Case Studies  from Capital Area Physical Therapy.

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