Hello triplanar thinkers!
For those wondering, the picture is relevant because it shows a technique not often considered for the condition treated: keeping a severed hand alive by grafting it to the patient’s ankle, then later replanting the hand back on his arm.
The conclusion of my story about Don didn’t involve any external fixators, but the treatment that he needed might surprise some of you. To review, Don was the patient with left shoulder bicipital tendinosis whom I treated in part I (link) with the “gold standard” conservative orthopedic approach and part II (link) with the according postoperative approach as a good therapist has been trained to. As mentioned, I outline this case to review the path that is so very accepted and yet, in my experience since I began training with PRI, not the most effective. Don’s story concludes below:
Don returned to clinic 8 months after discharge with a new diagnosis of left shoulder pain with the remarks on the script “MRI negative” and “eval and treat.” This is generally understood as physician lingo for “I have no idea what to do now…good luck with all that.”
Upon evaluation, Don reported that these left shoulder symptoms started about 2-3 months after we discharged him from PT intervention in spite of his persistence with his HEP and “it was all back to the starting point three months later.” He still tested as a bilateral brachial chain patient with a PEC pattern, again was positive with impingement tests—Hawkins-kennedy, empty can, Neer sign. He was frustrated, unable to work in his wood shop or play his accordion for more than 10 minutes without severe pain. At this point, the patient and I discussed that fact that I had let him down to a degree because I wanted to take a different approach before surgery, but didn’t want to irritate Don or his referral source. He understood, accepted my apology and we moved forward.
During the first 3 visits, we established that his bilateral brachial chain pattern and according left shoulder dysfunction was not the root of his dysfunction, but rather the manifestation of a “bottom up” pelvis patient whose primary difficulty was in maintaining frontal plane position of his pelvis.
The key to Don’s left shoulder function? Right posterior inlet inhibition of his pelvis. During the seven visits we treated Don using a PRI approach after the gold standard of orthopedic medicine and orthopedic physical therapy had failed to maintain his shoulder function for more than 3 months, his symptoms resolved. He left the clinic a reciprocal, alternating, smiling woodshop athlete with bilateral HADLT tests of 4/5 at 72 years of age, “tickled” that he could play his accordion as long as he wanted without pain for the first time since before he first went to see the doctor more than two years prior. Don is in occasional contact for the past 6 months with no return of symptoms, lots of activity and happy thoughts.
Six-month follow-up with no return of symptoms after the rest of my conservative clinical skills, an appropriate surgery and present day gold-standard postoperative care was unsuccessful. These are the types of outcomes that keep my passion for this science alive and accelerating. Moreover, these are the types of patient successes that remind me to be gentle but bold about intervention that I know clinically to be the most effective tool I have in the entire tool chest.
Clearly, each patient is different, and no, I have not seen a consistent correlation over time between the diagnosis of left shoulder bicipital tendinosis and the need for right posterior inlet inhibition. The objective tests guided me to find the appropriate treatment, not my innate ability to hear the pelvis or shoulder speak to me.
The point here is not to create a case study for anyone to memorize to use in the future for that one seemingly random patient. Rather, I hope that the take home is that there is a chance that this gentleman didn’t need as much intervention as he ended up having. And, even in the face of the “old school” telling you exactly what they want from PT intervention, the risk is worth the reward if one can just take the first three or four visits to break down barriers to a different way of approaching an age-old mechanical dysfunction of a “shoulder.”
Thank you for reading, perhaps you can save a few visits for a few of your patients by way of my experience with Don. My best to you!
Jess
