Adhesive Capsulitis treated with Pro Muscle Release 1000

Flores, M DC CCSP

22362 Gilberto Suite 250 Rancho Santa Margarita, Ca 92660

HISTORY

Patient is 51-year old female presented with severe pain and minimal range of motion to right shoulder for over 2 months. Patient has no history of prior injuries or pathologies to neck, shoulder, scapulo-thoracic joint or any other associated extremities. No history of cancer, associated family health, hypertension. Note: patient has already been through menopause. No other pertinent history to report.

Patient reports 8 weeks of physical therapy with little to no relief of symptoms with no corticosteroid injections administered


PHYSICAL EXAMINATION

Age 51

Weight 142

BP: 104/70

HR: 64

VAS: 7/10 in right should joint (patients points at the entire joint) 9/10 when patient actively or passively attempts movement with associated popping.

DTR B/L C5 WNL, C6 WNL, C7 WNL

MMT RIGHT ARM C5-T1 too painful LEFT C5-T1 WNL

DERMATOMES B/L C5-T1 WNL

DIFFERENTIAL DIAGNOSIS

Adhesive Capsulitis

Degenerative Joint Disease

Rheumatoid Arthritis

Menopausal joint pain

SLAP Tear

Rotator cuff pathology

TEST AND RESULTS

Very minimal PROM and AROM associated pain

+3 TTP on anterior, superior, lateral and posterior aspects of the affected  shoulder joint.

X-ray Results: Negative for degenerative signals or traumatic pathology.

Hormone exam: normal

Blood panel: normal

FINAL/WORKING DIAGNOSIS

Adhesive Capsulitis

TREATMENT

1st appt for exam 10/15 referred patient Corticosteroid injection to reduce pain to administer treatment

10/19 corticosteroid injection

10/22 treatment began

Pro Muscle Release to Upper, Mid, Lo traps, levator scapula, rhomboids, supraspinatus, infraspinatus, teres minor, teres major, subscapularis, serratus anterior, lats, deltoid(all heads), pec major and minor, posterior capsule.

Myofascial Release to same structures

Mobilize and Adjust shoulder and Scapulo-thoracic Jt

In office and at home exercise protocol:

Daily exercise program (approx 40 minutes) exercise increased as necessary

1.       Door stretch for 30 seconds (did at start and end of daily program)

2.       Moved my arms like riding a bike – forward 50 times and back 50 times

3.       Bent over and held a water bottle for 30 seconds; moved to 3 pound weight and them 5 pound weight as I improved

4.       Used pole to stretch arms up (10 times, holding for 5 seconds) and did the same thing behind my back

5.       Side lateral arm roll forward and back for 25 times each

6.       Arm roll holding shoulder – rolling forward and back for 25 times each

7.       Sit on hand and stretch the next – 90 and 45 degrees for 30 seconds each

8.       Sleeper stretch - 90 and 45 degrees for 30 seconds each

9.       Bottle life for strength – laying on side lifted water bottle half way  up and then did an inside lift – 15 reps, 3x each

10.   IYT’s – did 12 reps of each

11.   Face end of a wall and lean shoulder with arm down (awkward position), turn to stretch for 30 seconds, 3x

12.   Held and stretched arm behind back for 30 seconds, 3x

Daily supplement program

Before you:

Centrum silver multivitamin (for women over 50 L)

Fish oil (1200 mg 2 x daily)

Calcium/Vit D (1000 mgs 2x a day)

Added

Shaklee Joint Health Complex (2x daily)

Hyaluronic Acid (2x daily)

B-12 1000 mcg (1x daily)

Other

20 minutes in the Jacuzzi every other day, doing basic shoulder stretches and movements

Last appointment and discharge was 12/19 with Full Range of Motion with no pain

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