An amiable 56 year-old woman described a 10-year history of debilitating pain in her right shoulder. She underwent shoulder replacement surgery. One year later she still felt sharp, knife-like pain that travelled from the front of her shoulder to the middle of her upper arm. Ten months of physical therapy and multiple cortisone shots had not been able to solve this pain riddle.
Evaluation, clinical reasoning and treatment strategizing
Postural assessment showed a low right shoulder and a ‘tipped scapula’ (the inferior scapula angle had lifted off the ribcage indicating a tight pectoralis minor muscle). Shoulder range of motion was limited for flexion and abduction. She was unable to reach behind her back, carry anything heavy or work at her computer for any extended amount of time. Our approach was to methodically scan for trigger points in any and all muscles related to the shoulder, neck or torso that could reproduce her symptoms.
Bi-weekly NMT sessions over six months released trigger points in her shoulder muscles. Those found in infraspinatus and subscapularis re-created her familiar pain. The muscles that form functional muscle units of the shoulder were of particular interest: lower trapezius, serratus anterior, and latissimus dorsi. Many sessions were focused on releasing the pectoralis minor and major. All sessions concluded with a decompression stretch to reinforce joint space.
Outcomes and follow-up
This case shows the importance of addressing the myofascial contributions of post-operative pain. After six months, she achieved an acceptable and comfortable range of motion given the history of the shoulder replacement surgery. She could abduct her arm to 90˚ (twice what she could prior to therapy) without pain, fasten her bra easily, and carry small things comfortably. Most importantly, she could get through the day without thinking about her pain anymore.