SHOULDER CASE STUDY

MEDICAL HISTORY:

A 32-year-old male attends your clinic with a history of a motor vehicle accident 5
months ago, in which he was a pedestrian hit by a truck. At the time he suffered a
fractured left ankle (both tibia and fibula), which was surgically repaired. He was
also complaining of left shoulder pain, which was not resolving. An MRI revealed a
torn supraspinatus tendon and he underwent surgical repair 1 week ago. He was
under a general anesthetic for the surgery and must now wear a shoulder
immobilizer splint. He now has constant aching throughout the left shoulder region.

PAST HISTORY:

This individual has been an active athlete throughout his life in football, triathlon,
mountain biking, rock climbing, and running. He is a Firefighter (for 10 years), but is
on light duty in an office position until his shoulder has healed. He is generally very
healthy, with no complaints prior to his motor vehicle accident, besides multiple
ankle sprains and an Anterior Cruciate ligament rupture, which was subsequently
surgically reconstructed 4 years ago. He drinks moderately and is a non-smoker.

PHYSICAL EXAMINATION:

The shoulder immobilizer splint has been able to be removed during assessment
and treatment. His surgical scar is healing well. He has been instructed to not do any
active movement for 6 weeks to allow the repair to strengthen. His passive shoulder
movement is restricted to 90 of flexion, 70 of abduction, 0 of external rotation and
20 of internal rotation. Active movement may not be tested as per the surgeons
instructions. He is tender to palpation both anterior and posterior Glenohumeral
joint regions and has trigger points in the Infraspinatus and upper fibers of the
Trapezius muscles.


1) What would be your diagnosis (Western and TCM)?

2) List 4 points from the information provided to support your
diagnosis.

3) What is your suggested initial treatment? Please indicate why
you have chosen particular points or techniques.

4) What other advice might you give this patient?