Complex Case Awareness: Bad Medicine and a 14 YO female athlete with adhesive capsulitis

Yes, this title is correct. A 14 YO with adhesive capsulitis! What better picture to use in a case example of bad medicine!

In my cash based practice, we not only see patients who just see the value of physical therapy and get superior outcomes with our approach, but we also see very complex cases that have failed multiple treatments. This is why I recommend other PTs, when starting a cash based practice to make sure you have advanced training and expert clinical decision making, because if you are good, you will see a whole caseload of complex cases.

Here is the story:
Pt is a 14 YO female student athlete (softball pitcher) who is L handed. In Dec 2014, she initially injured her shoulder playing softball. She consulted a orthopedic physician group for her L shoulder pain and was Dx with L shoulder tendinitis. She rested for 1 month and attempted softball again with no change in s/s. Consulted physician again and received MRI with contract. MRI was unremarkable as per mother. Pt was referred to outpatient ortho sports med PT clinic for physical therapy for 3 x a week for 4-8 weeks. After 2 weeks no major change in s/s and pt received a cortisone shot March 2015 (into bursa as per mother????) and then she returned to physical therapy. She progressed much better after injection and eventually returned to a throwing program. In May 2015 she attempted a throw and heard a “pop” sound with increased L shoulder pain. She continued with PT with no change in L shoulder pain symptoms and mother states PT was very aggressive and pt would leave therapy crying due to pain. Hmmmm?

In June 2015 she was scheduled for surgery and nothing was found during a scope into L shoulder. After s/p L shoulder scope with no remarkable findings, he was referred back to physical therapy from June until August with no progress being made at all. A second MRI was also performed to rule in and rule out brachial plexus pathology. MRI was unremarkable as per mother. July 2015 was last orthopedic physician visit, when physician did not understand why pt was having pain and he could not help her. Physician stated: she has a “low pain tolerance” or she was “making it up” WOW!

At this time, pt and mother consulted another PCP physician after this (a DO) with sports medicine experience with no change in symptoms after multiple treatments. In August 2015, pt and mother consulted my services after getting no answers with other treatments, worse symptoms, and not knowing what to do. Pt presented with a severe case of L glenohumeral hypertonicity and joint immobility secondary to pain and L shoulder trauma from prior PT. pts shoulder presented just like adhesive capsulitis but I have never seen a young patient with adhesive capsulitis. Possible CRPS and hypersensitive response to pain that is centrally mediated with h/o anxiety, mechanical allyodynia, sensitivity to hot and cold, and adverse pain response. I felt she present with L shoulder adhesive capsulitis also with distal ulnar nerve paresthesias from TOS vs ULTT - ulnar nerve bias. We began treatment: pain education, desensitization of L UE, decreasing radicular symptoms, and light manual therapy on L shoulder. pt initially was responding good with decreased pain, decreased sentization to pain, increased PROM, etc but L GH PROM began to plateau. "If it sounds like a duck, looks like a duck, and walks like a duck, maybe it is a duck." Everything pointed towards adhesive capsulitis. But I have never seen a case of adhesive capsulitis in a 14 YO before.

In October 2015 the patient's mother was still willing to do anything to get answers so the pt was seen by a chiropractor who manipulated cervical spine, thoracic spine, and L shoulder that flare up L shoulder pain and resulted in increased ulnar nerve symptoms, increased shoulder pain, decrease L shoulder PROM in all planes. So I had to deal with this now and most of her symptoms and responses to pain returned. Pt consulted with another physician in October 2015,who did not agree with my diagnosis, and decreased all pain medications, told pt to continue PT, gave pt lidocaine patches to use to help with pain, and wanted to order EMG to rule in rule out brachial plexus pathology. From my understanding, a compressive injury to a nerve or nerve root with > 80% damage would show a positive EMG results, but an inflammed nerve or irritation to a nerve would come back negative???? Not sure what the brachial neuritis Dx from and EMG would do or to help dictate a new treatment, but I warned them not to get upset if it came back negative. Again I still thought she presented with adhesive capsulitis and she was definitely "frozen" by now. I have already ruled out cervical pathology and a nerve EMG was performed in Dec 2015 and it returned unremarkable. Pt has been under my care for roughly 20 visit now and still showing slow progress with ROM. Still no other physician nor health care provider was agreeing with my findings of adhesive capsulitis. But, I was not going to give up on this patient!

Finally in Jan 2016, a new pediatric physician at a local hospital, actually read my note and reviewed clinical findings and finally agreed with my theory after all other unremarkable testing and ordered a intra-articular inejction in her L GH joint. I have found, and the research does support, that an intra-articular injection in true adhesive capsulitis has been shown to help regain PROM and expedite results. So the patient received the inejction and responded great to it. Now the pt is still getting intermittent L UE radicular symptoms but she is is starting to get L sided headaches and pain at her L 1st rib. 1st rib dysfunction is noted and scalenes have active TrP that reproduce headaches. Symptoms correlate with 1st rib and scalene TOS, but she is not responding to my treatments. Wonder what came first the chicken or the egg? L adhesive capsulitis then TOS, or her TOS, that was covered up by L adhesive capsulitis and L shoulder pain????

Current status:

She is responding great now and her L GH AROM, PROM, and strength is returning well. L GH intra-articular injection helped us get past our plateau. I have exhausted her conservative treatment for her TOS with no change in pain, headaches, and L UE radicular paresthesias. (I would love to try dry needling to the scalenes but I still cannot perform this in Florida). She is currently under a TOS physician specialist care for her TOS and we are continuing her L shoulder pain treatment. We are working together on this and we are exhausting all conservative treatments but may opt for surgery if she does not respond to treatments for her TOS. The mother actually found a closed facebook group for TOS and found many other cases of young throwing athletes with similar cases that have failed standard orthopedic physician and PT care! Some even had a case adhesive capsultitis along with there TOS symptomatic side. I thought this was amazing because I had never heard of this. She would show me her questions and posts, and she would get 15 responses in a matter of hours of similar cases and treatments. Some of these cases even opted for TOS surgery and eventually returned to sport.

My clinical findings to be aware of:

PMH and subjective:
throwing athlete with high workload and overuse
h/o anxiety
fear avoidance of pain
h/o of trauma and s/p surgery
poor sleep secondary to pain (decrease in pain threshold)

TOS
intrascalene - first rib pathology
scapular retraction and depression increases L UE distal radicular paresthesias
manual therapy to L 1st rib increases symptoms with no change in mobility
active TrP referral of pain and headache from L scalene mm
no change in symptoms with L pec minor release
unable to perform other tests due to GH hypomobility
inconclusive ULTT due to GH hypomobility. ULTT in available range did not reproduce radicular symptoms

L Adhesive capsulitis
text book capsular pattern
textbook endfeels with increased resistence with increased joint mobilization grade

Overall this has been a great learning experience for me and I personally have never seen a case of adhesive capsulitis with TOS at such a young age. The goal of this blog was just to share this case with other physical therapists to be aware of a case like this. I will give an update as she progresses.

Regards,

Ron Miller, DPT, OCS

Owner of Pursuit Physical Therapy
email: pursuittherapy@gmail.com

Owner of CashBasedPhysicalTherapy.org

Adjunct Faculty of University of Central Florida

Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

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