Stone-Assist Soft Tissue Mobilization for a Patient with Bilateral Subacromial Impingement as Performed by a Student Physical Therapist: A Case Report

Megan Neitzel

Background and Purpose. There is limited literature regarding the application of instrument-assist soft tissue mobilization (IASTM). IASTM can be performed with materials such as wood, ceramics, plastics, stones, or steel on both acute and chronic soft tissue injuries of muscles, tendons, ligaments, scar tissue, and fascia. The purpose of this case report is to describe the favorable outcomes following integration of stone-assist soft tissue mobilization (S-ASTM) with an exercise program for a patient with bilateral glenohumeral joint capsular restrictions and primary subacromial impingement. Case Description. A 48-year old female with bilateral glenohumeral joint capsular restrictions and primary subacromial impingement completed 7-weeks of physical therapy. Physical therapy interventions focused on S-ASTM in conjunction with therapeutic exercise and neuromuscular re-education. Initial primary findings included sensitivity to touch and pain in the shoulders, posterior neck, and left forearm with upper extremity use. Outcomes. The use of S-ASTM contributed to patient reported satisfaction and significant functional improvements. After completing 14 physical therapy sessions, she reported significantly less pain and 60% increase in function with upper extremity activities such as dressing, reaching overhead, and driving. Significant improvement in shoulder and cervical range of motion, shoulder strength, thoracic spine and glenohumeral joint mobility, neural tension, trigger point sensitivity, and impingement special tests were also seen throughout the course of care. Key Words. Instrument-Assist Soft Tissue Mobilization, Stone-Assist Soft Tissue Mobilization, cervical spine myofascial restrictions

Type of Clinical Analysis Interventions focusing on stone-assist soft tissue mobilization to the upper neck and posterior shoulder girdle region Purpose Statement/Focus The purpose of this case study is to describe and demonstrate the use of stone assist soft tissue mobilization in conjunction with an exercise program for a patient with bilateral glenohumeral joint capsular restrictions and primary impingement due to mechanical compression. Case Description

The patient was a 48-year-old female with bilateral glenohumeral capsular restrictions with musculoskeletal and neuromuscular impairments. She was referred to physical therapy from her physician with a diagnosis of bilateral shoulder adhesive capsulitis. She presented with a 6-month history of bilateral shoulder pain that became constant four months prior to PT referral. Medical management consisted of radiograph and MRI imaging, which were unremarkable; bilateral GH steroid injection, which decreased pain from 8/10 to 1/10; and chiropractic “adjustments” for cervical spine “subluxations.” She complained of sensitivity to touch and pain in bilateral shoulder, posterior neck, and left forearm with upper extremity use. Her primary therapy goal is to improve quality of life by experiencing no pain while performing daily activities. Based on her demographic data, there is and increased likelihood of having adhesive capsulitis. Incidence of adhesive capsulitis increases in females compared to males, middle aged of 40-60 years old, and those with diabetes or thyroid disease.2, 6, 11 Examination

The Disabilities of the Arm, Shoulder and Hand (DASH) was used to quantify functional status. It is designed to evaluate disorders of the upper extremity and assess change and function over time (Smiley rehab measures). DASH scores range from 0 to 100, where the lower the score, the less the disability and the patient’s score was 58.3 and 43.75 on the optional work section of the DASH. The DASH has shown to have excellent test-retest reliability, however minimal detectable change (MDC) and minimally clinically important difference (MCID) have only been established if post-operative or an intercollegiate athlete.17

A detailed upper extremity examination was performed. Postural impairments of forward head, forward rounded shoulders, bilaterally internally rotated glenohumeral (GH) joints, hip and knee flexion in standing, and posterior pelvic tilt causing thoracic kyphosis in sitting were observed. Using standard goniometric technique, 15 shoulder active range of motion (ROM) was performed in sitting and passive ROM in supine to better assess the quality of resistance to motion.2, 6 All active and passive ROM reproduced the patient’s shoulder pain with pain before resistance and muscle guarding during passive ROM. Values did not present in a true capsular pattern on either arm (Table 1), but capsular patterns may not be consistently measured for patients with adhesive capsulitis despite capsular restrictions.6 Less than 30 degrees of passive external rotation is commonly seen with adhesive capsulitis,6 which the patient presented with (Table 1). Using standard strength testing16 for the shoulder musculature, the patient grossly scored 2-/5. Joint play assessment (JPA) was performed to bilateral GH, acromioclavicular (AC), sternoclavicular (SC), and scapulothoracic joints8 (Table 2). Palpation revealed hypersensitivity to touch, pain to bilateral subacromial bursas, and trigger points in bilateral upper trapezius, posterior scalene, levator scapula, and subscapular muscles. Bilateral median, ulnar, and

radial neural tension tests were positive using standard technique9 (Table 3). Impingement tests were performed due to observed postural impairments and pain

to bilateral subacromial area. Neer, Hawkins-Kennedy, painful arc, empty can, and resisted ER tested for subacromial impingement using standard technique.7 With > 3 positive tests, there is 75% sensitivity, 74% specificity, a positive likelihood ratio of 2.93, and a negative likelihood ratio of 0.34.5 See Table 4.

Cervical spine AROM was limited by 25% using standard goniometric technique15 and reproduced posterior and lateral neck pain with overpressure. She reported pain localized to her posterior and lateral neck without peripheralization during the maximum cervical compression test with extension or quadrant test.14 Cervical and thoracic joint play assessment revealed thoracic hypomobility.14 Bilateral elbow, wrist, and hand AROM values were within normal limits15 and strength16 grossly scored 4/5 with neither test reproducing symptoms.

Table 1. Active and Passive Shoulder Range of Motion at Baseline

Left Active Left Passive Right Active Right Passive Flexion 1410 1480 1200 1250 Abduction 1080 1120 880 960 Internal Rotation+ 550 650 550 600 External Rotation+ 320 370 200 280 0 denotes degrees +Measured at 450 shoulder abduction

Table 2. Joint Play Assessment at Baseline

Glenohumeral Acromioclavicular Sternoclavicular Scapulothoracic Hypomobility + bilateral: anterior-

posterior, posterior-anterior, and inferior

- - -

Reproduction of symptoms

+ bilateral + bilateral - -

Table 3. Neural Tension at Baseline

Right Left Median 0% 0% Radial 0% 0% Ulnar 20% 50% Quantified as percent (%) of normal

Table 4. Impingement Testing at Baseline

Neer Resisted ER Hawkins- Kennedy

Empty can Painful Arc Resisted Motion in Neutral

Palpation

Right +: Painful

+: Weak and painful

+: Painful +: Painful

Limited ROM to accurately perform but pain on attempt

-: Supraspinatus and biceps

-: Supraspinatus and biceps tendons +: Subacromial bursa

Left -

+ positive; - negative

Clinical Impression Primary findings identified during the PT examination included the following; 1)

positive impingement syndrome special tests 2) forward head, bilateral forward shoulders, GH internal rotation, and posterior pelvic tilt causing thoracic kyphosis, 3) thoracic hypomobility and bilateral GH hypomobility, 4) decreased GH passive ROM, 5) posterior cervical spine myofascial restrictions with trigger points in the upper trapezius, posterior scalene, levator scapula, and subscapular muscles, 6) decreased shoulder strength bilaterally, 7) bilateral median, radial, and ulnar neural tension, and 8) negative cervical spine quadrant.

Based on these findings, the initial impression was GH primary subacromial impingement. Resisted motion in neutral (RMIN) to the supraspinatus and biceps were negative and there was no pain with palpation to these tendons. Therefore, as a diagnosis of exclusion, subacromial bursitis was ruled in from positive impingement testing and pain with palpation over this structure (Table 4). ROS was negative as her endocrine disorder is managed by medication.

Physical therapy interventions were indicated to address impairments described above. Manual therapy, neuromuscular re-education, and therapeutic exercises were prescribed and the patient was continuously re-assessed to determine her response to these interventions.

Interventions

Instrument assist soft tissue mobilization (IASTM) is used to treat acute and chronic soft tissue injuries of muscles, tendons, ligaments, scar tissue, and fascia.3, 11,13 Theoretically, IASM breaks up tissue adhesions, preventing normal tissue mobility, and initiates healing via an inflammatory response. Friction from the tools aid to increase tissue temperature, increasing blood flow, bringing fibroblasts to the area to promote collagen synthesis and connective tissue remodeling to support and strengthen the tissue.1, 3, 4, 10, 11, 13 IASTM is thought to reset tissue tone, improve the viscosity of tissue, realign collagen, decrease pain, and restore movement between the fascia layers.1, 3, 11

Materials such as wood, ceramics, plastics, stone, and steel are used.13 Instruments allow for magnification of tissue restrictions such as vibrations, grit, ridges, or nodules felt in the clinician’s hands, 3, 13 greater depth of mechanical force are believed to be achieved, and larger fascia areas can be covered as compared to hands alone which decreases stress on the clinician’s hands and arms.1, 3, 13 The patient may experience discomfort and bruise after.3, 13 Parameters are based on stage of tissue healing, reactivity levels, patient tolerance, and post treatment response.3 Suggested parameters1,3, 10, 11, 13 and contraindications and precautions13 are described in Tables 5 and 6 respectively.

Patient education on the PT POC and prescribed interventions was implemented at every treatment session. Interventions focused on stone-assist soft tissue mobilization to address myofascial restrictions and TrP’s. Passive ROM to bilateral GH joints, grade 4 joint mobilizations to the thoracic spine and GH joints, and TrP releasing were included in manual therapy to improve mobility (Table 7).

The patient was treated using stone-assist soft tissue mobilization (stone-assist STM) at the beginning of each treatment session (Image 1). Stone selection was based on clinician preference. The targeted treatment area was divided into sections based on tissue area covered by the stone. Strokes were performed parallel along the muscle belly- three stokes origin to insertion followed by three stokes insertion to origin- repeated three times. This was repeated to the next adjacent fascia structures until the target treatment area was covered. Once the targeted area was initially treated, detailed work was performed to areas with more restrictions as noted based on the presence of grit and nodules which are gravel-

like bumps felt through the stone with strokes. Small, deep pressure, fan-like strokes were used on these areas. See Image 2 for skin reaction of redness indicating increased blood flow and tissue temperature as part of the inflammatory response. Additional manual therapy interventions are described in Table 7.

Neuromuscular re-education and therapeutic exercise were prescribed to address postural impairments, neural tension, diaphragmatic breathing pattern, and core engagement with exercises to increase shoulder active range of motion (Table 7).

Table 5. Suggested Parameters for IASTM

Stage of Healing Stroke Rationale Duration Location Other Acute Injury Light, quick, less

aggressive strokes Open capillaries to increase blood flow

3-5 minutes

Statically or dynamically directly to the painful area plus surrounding tissue

Incorporate with stretching and ROM exercises to increase motion gained

Chronic Injury Aggressive strokes Break adhesions

Table 6. Suggested Contraindications and Precautions of IASTM

Contraindications Precautions Skin infections, open wounds, bone fractures, suture sites, uncontrolled hypertension, kidney dysfunction, and hematomas

Anticoagulant medication, cancer, over varicose veins, and rheumatoid arthritis

Image 1. Stones used for SASTM Image 2. Response to S-ASTM

Table 7. Interventions

Patient Education Patient was educated on initial examination findings, PT POC, and at the reasoning behind each intervention during each treatment session.

Manual Therapy Stone-Assist STM Parameters/Description Patient Position

Upper trap, levator scapula, posterior scalene muscles + fascia

Aggressive, slower strokes parallel and perpendicular to muscle fibers performed statically and dynamically to stretch targeted muscles

Sitting

Myofascial Trigger Point (TrP) Releasing

Parameters/Description Patient Position

Upper trap, levator scapula, posterior scalene, subscapularis

Held until TrP released; Clinician’s elbow placed over TrP (fingers for subscapularis) with maximal patient tolerated pressure until TrP felt to release

Seated except supine for subscapularis

Passive ROM Parameters/ Description Patient Position GH flexion, abduction, internal rotation (IR), external rotation (ER)

Two reps gentle PROM to point of muscle guarding followed by 3 x 5 seconds into maximal patient tolerated overpressure into each motion Three seconds of distraction provided between motions for patient comfort

Supine

Joint Mobilization Parameters/Description Patient Position GH: anterior-posterior, posterior-anterior, and inferior

Grade 4, 2 oscillations/second for 30 seconds each direction, GH in loose pack position

Supine

Thoracic spine: PA Grade 4, 2 oscillations/ second for 10 seconds, spinous process T1-T12

Prone

Neuromuscular Re-education & Therapeutic Exercise Neural Flossing Parameters/Description Patient Position Ulnar, median, radial 5 reps bilateral, 2x/day within pain-free range to avoid

irritating the nerve See Appendix 1-1 to 1-3

Active Assisted ROM Parameters/Description Patient Position GH flexion & abduction at cable cross machine

10 reps bilateral, max resistance without form breaks; address GH flexion and abduction ROM with proper posture and scapular mechanics; focus on slow and controlled eccentric phase while engaging core musculature; therapist performed concentric phase to return to starting position

Standing; arm moves in sagittal and frontal plane

Sitting arm slides on table: flexion, abduction, external rotation (ER)

10 reps bilateral, 2x/day; address GH flexion, abduction, and ER ROM; focus on using trunk to help drive GH movement

See Appendix 1-4

TRX posterior curtsy 10 reps bilateral; address GH flexion ROM and trunk elongation; focuses on engaging core

See Appendix 1-5

Pole assist upper extremity D2 flexion & extension

10 reps bilateral; address GH ROM, thoracic extension, and trunk rotation; focus on breathing pattern

See Appendix 1-6

Hula Forward Bend + Rotation 2 x 30 second hold forward bend + 10 rotations bilateral; address GH flexion ROM and trunk lateral flexion; focus on engaging core

See Appendix 1-7

Active ROM Parameters/Description Patient Position Cable Cross Push-Pull 10 reps bilateral; max resistance without form break; address

GH ROM, trunk rotation, proper posture, and scapular mechanics; focus on engaging core musculature and breathing pattern

See Appendix 1-8

Cable Cross UE D1/D2 patterns

10 reps bilateral; max resistance without form break; address GH ROM; focus on proper posture, engaging core, scapular mechanics, and breathing pattern

See Appendix 1-9

Supine counter rotation arms & knees

10 reps bilateral; address GH ROM and trunk rotation; focus on engaging core and breathing pattern

See Appendix 1-10

Baseball and Golf swings 30 seconds each direction each swing; address GH ROM and trunk rotation; focus on moving arms through available ROM versus exact form of swings.

Standing, knees slightly bent

Corner High Low Reaching 10 reps bilateral each direction; address GH ROM, trunk rotation and side-bending, and weight shifting; focus on engaging core and breathing pattern

See Appendix 1-11

Side-lying counter rotation 10 reps each side; address GH ROM and trunk rotation; focus on breathing pattern

See Appendix 1-12

Core Engagement Parameters/Description Patient Position 4-point hand slides on table 3 reps each angle (straight in front, straight to the side, 45

degree angle between) bilateral; address GH ROM, GH proximal stability, core engagement; focus on keeping a neutral back and breathing pattern

See Appendix 1-13

Chair Plank + knee to elbow Hold 2 x 20 seconds, progress as tolerated without form breaks; address core engagement and bilateral GH proximal stability; focus on maintaining a neutral back and breathing

See Appendix 1-14

4-point cat/camel 10 reps; address GH proximal stability and trunk movement; focus on breathing pattern

See Appendix 1-15

4-point anterior pelvic tilts 10 reps; address proper pelvic positioning to assist with appropriate upright posture and GH proximal stability; focus on breathing pattern

Hands and knees

Posture Parameters/Description Patient Position Scapular retraction to squeeze corner of wall

10 reps with 3 second holds; address proper shoulder girdle positioning; focus on upright posture

Standing at corner, arms at side, elbows in 900 flexion; try to pinch corner with shoulder blades

Bosu thoracic extension with trunk rotation

10 reps; address thoracic mobility into extension, trunk rotation, and GH ROM; focus on breathing

See Appendix 1-16

Bosu thoracic extension with GH horizontal abduction

10 reps; address thoracic mobility into extension, GH ROM, and scapular positioning; focus on breathing

See Appendix 1-17

Bosu thoracic extension with diaphragmatic breathing

1 minute; address proper breathing pattern while promoting thoracic extension

Supine with Bosu ball under thoracic spine; use hand to cue diaphragmatic breathing

Hula standing twist 1 minute; address trunk rotation and GH ROM; focus on letting momentum of hula-hoop drive the motion

See Appendix 1-18

Stretching Parameters/Description Patient Position Pectoralis major/minor stretch Hold 3x30 seconds; address pectoralis tightness contributing

to posture impairments; focus on upright posture and scapular retraction and depression

See Appendix 1-19

Levator scapula stretch Hold 3 x 30 seconds bilateral; address short levator scapula contributing to postural and scapular movement impairments; focus on upright posture

See Appendix 1-20

Scalene stretch Hold 3 x 30 seconds bilateral; address short scalene contributing to postural impairments; focus on upright posture

See Appendix 1-21

Childs pose + lateral flexion Hold 30 seconds bilateral; address trunk lateral flexion mobility

See Appendix 1-22

Outcome

Outcome measurements were recorded at baseline, 4 weeks, and 7 weeks with two treatment sessions per week. After 7 weeks, reported functional improvements included ease with upper extremity dressing, reaching overhead, putting on a seat belt, and turn the wheel while driving. The patient stated she was satisfied with physical therapy and requested to continue to address remaining impairments, primarily her left shoulder. She will continue physical therapy with the clinical instructor to address posture and positioning, range of motion, shoulder strength, GH and thoracic spine joint mobility, and neural tension.

After 7 weeks of physical therapy, DASH scores improved from 58.3 to 12.5 on the right and from 58.3 to 22.5 on the left. The work section improved from 43.73 to 25.0. Postural impairments were 75% improved as she had decreased hip and knee flexion contributing to a neutral pelvic position in standing and an anterior pelvic tilt in sitting; both contributing to decreased thoracic kyphosis and forward rounded shoulders. Thoracic spine joint play assessment improved from hypomobile initially to minimally restricted, nearing normal mobility. Bilateral shoulder AROM was pain free in all directions with the exception of left shoulder abduction causing minimal pain towards end range. Shoulder PROM with overpressure reproduced minimal pain on the right and moderate pain on the left in all directions limited by short musculature stretching on the right and muscle guarding on the left (Table 8). Gross shoulder strength improved from 2-/5 to 4/5 on right and from 2-/5 to 3+/5 on the left. Cervical spine AROM initially was limited by 25% and painful with overpressure, improved to full and pain free range of motion with overpressure. Additional objective measures include decreased trigger points and pain with palpation (Table 9), increased mobility bilaterally during GH joint play assessment (Table 10), decreased bilateral neural tension (Table 11), and improved impingement testing results (Table 12). Table 8. Active and Passive Shoulder Range of Motion Outcomes

Pre Mid Post Left Active/

Passive Right Active/ Passive

Left Active/ Passive

Right Active/ Passive

Left Active/ Passive

Right Active/ Passive

Flexion 1410/1480 1200/1250 1480/1520 1500/1580 1520/1700 1700/1750 Abduction 1080/1120 880/960 1150/1250 950/1120 1240/1500 1670/1750 Internal Rotation+

550/650 550/600 610/680 600/640 650/680 680/750

External Rotation+

320/370 200/280 350/410 380/420 400/510 700/770

0 denotes degrees +Measured at 450 shoulder abduction

Table 9. Palpation Outcomes

Findings Pre Hypersensitivity to touch, pain to bilateral subacromial bursas, and trigger points

in bilateral upper trapezius, posterior scalene, levator scapula, and subscapular muscles

Mid No hypersensitivity to touch, minimal pain to bilateral subacromial bursas, and trigger points in bilateral upper trapezius, posterior scalene, levator scapula, and subscapular muscles

Post No hypersensitivity to touch, no pain to right subacromail bursa, minimal pain to left subacromial bursa, trigger points in left upper trapezius, and bilateral subscapular muscles

Table 10. Joint Play Assessment Outcomes

GH AC SC ST

Hypomobility Pre + bilateral: anterior-posterior,

posterior-anterior, and inferior - - -

Mid + bilateral, improved 25%: anterior-posterior, posterior-anterior, and inferior

- - -

Post + bilateral, left improved 50%, right 75%: anterior-posterior, posterior-anterior, and inferior

- - -

Reproduction of symptoms

Pre + bilateral + bilateral - - Mid + bilateral; minimal + bilateral;

minimal - -

Post + left; minimal and – right - bilateral - - Table 11. Neural Tension at Outcomes

Pre Mid Post Right/Left Right/Left Right/Left Median 0%/0% 40%/40% 75%/50% Radial 0%/0% 50%/40% 75%/75% Ulnar 20%/50% 40%/60% 75%/65% Quantified as percent (%) of normal

Table 12. Impingement Testing Outcomes

Pre Mid Post Right Left Right Left Right Left Neer +: Painful

+: Minimal Pain - + Minimal pain

Resisted ER +: Weak and painful +: Weak and minimal painful - +: Weak and minimal pain

Hawkins- Kennedy

+: Painful

- -

-

Empty can +: Painful

+: Minimal pain - +: Minimal pain

Painful Arc Limited ROM to accurately perform but pain on attempt

Limited ROM to accurately perform but no pain on attempt

-

Resisted Motion in Neutral

-: Supraspinatus and biceps

-: Supraspinatus and biceps -: Supraspinatus and biceps

Palpation -: Supraspinatus and biceps tendons +: Subacromial bursa

-: Supraspinatus and biceps tendons +: Subacromial bursa; minimal pain

-: Supraspinatus, biceps tendons, and subacromial bursa

-: Supraspinatus and biceps tendons +: minimal pain to subacromial bursa

+ positive; - negative Reflection

I believe this case was managed appropriately and accurately overall. The initial examination was done well and provided a starting point to identify her impairments and contributing factors to identify appropriate intervention prescription. This case was very involved as she had a variety of impairments and contributing factors to be addressed. I believe I did a good job at identifying these and understanding the relationship between them to educate the patient. Intervention prescription was done well because they had several different intents targeting multiple impairments such as range of motion, core engagement, and breathing pattern. I also explained why each intervention was important, how it addressed the impairments and contributing factors, and how it linked to functional goals. I especially think I did a good job with the stone-assist STM intervention. Even though there is limited research on this technique, the theorized scientific rationale behind it appeared appropriate for this patient. She also did not demonstrate any adverse reactions to suggest the application be contraindicated.

Improvements could have been made with the duration of each therapy session. Based on her insurance and clinic policy, she was only allowed 30 minutes per visit. Since she required a fair amount of manual work and had a variety of impairments to address, it may have been more beneficial to have 45-60 minutes per visit. Despite the limited visit time, outcome measures still improve. I believe a major contribution to this was her compliance. Over the course of 7 weeks, she did not miss any therapy sessions and reported doing her HEP regularly.

I also believe improvements could have been made to reinforce relaxation techniques and allow the patient time to express her feelings. I know she had a young child who was sick, which I believe was contributing to added stress. She never openly talked about this, but I was able to piece it together by her comments over the course of several treatment sessions. However, there was never a good time or enough time for her to open up and talk about her stressors. I think it would have been beneficial to have time for her to express her psychosocial struggles to better establish rapport and apply relaxation strategies. One alternative strategy not used was dynamic neural mobilization to address neural tension. This was not done because she was prescribed neural flossing exercises to perform at home and there was limited time in the clinic. More focused relaxation and deep breathing strategies may have been beneficial however were not done due to time constraints and incorporation into other interventions. I believe EBP was appropriately applied for the management of this case. EBP contributed to standardized examination techniques to ensure accurate impairments and contributing factors were identified. EBP especially contributed to intervention prescription of stone-assist STM. I have found EBP to be very helpful and effective in the management of this case. Through the course of my physical therapy education at Carroll University, I have definitely found and appreciate the value of EBP in physical therapy practice. Since I have limited clinical experience to draw from, EBP provides me with valuable information and

suggestions in evaluating and treating patients and thus I plan to continue using and applying it throughout my career as a physical therapist. Writing this case report has been helpful to me for several reasons. It helped me directly apply EBP and allowed me to see favorable results from using it. The case report assisted me in reflecting on how I managed this patient’s care from the examination process to intervention prescription. The process of writing this case report will assist me in the future to write another one if I can fill a research gap. It was extremely beneficial to receive feedback on the content, quality, and style of my writing. It was extremely difficult at times, but I was able to practicing writing concise without compromising and losing valuable information. I probably required more assistance/feedback than others to reach a final draft of each section due to my wordy writing tendencies. Despite this, I was a great learning experience to write concise and scientifically and I feel that I truly understand what this means now.

The work/course for this case study turned out to be close to what expected. The hardest part for me was getting used to the writing style versus the research and information presented. I was able to apply and successfully use EBP fairly easily which is encouraging me to keep doing this once I am a licensed PT. Overall, I feel this case report has helped me reflect on my clinical decision-making, taught me to write concise and scientifically, and was beneficial to my learning.

References

1. Baker R, Nasypany A, Seegmiller J, Baker J. Instrument-assisted soft tissue

mobilization treatment for tissue extensibility dysfunction. International Journal Of Athletic Therapy & Training. 2013;18(5):16-21.

2. Clewley D, Flynn T, Koppenhaver S. Trigger point dry needling as an adjunct treatment for a patient with adhesive capsulitis of the shoulder. Journal of Orthopaedic & Sports Physical Therapy. 2014; 44(2): 92-101.

3. DeLuccio, J. Instrument assisted soft tissue mobilization utilizing Graston technique:

A physical therapist’s perspective. Orthopedic Practice. 2006;18(3): 32-34.

4. Hammer W. The benefits of instrument-assisted soft-tissue mobilization. American Chiropractor. 2005;27(9): 40-41.

5. Hegedus EJ. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. British Journal Of Sports Medicine. 2012; 46(14): 964-978.

6. Kelley M, McClure P, Leggin B. Frozen shoulder: evidence and a proposed model guiding rehabilitation. Journal Of Orthopaedic & Sports Physical Therapy. 2009;39(2):135-148.

7. Kelly S, Brittle N, Allen G. The value of physical tests for subacromial impingement

syndrome: a study of diagnostic accuracy. Clinical Rehabilitation. 2010;24(2):149-158.

8. Kisner C, Colby L. Therapeutic Exercise Foundations and Techniques. F.A. Davis

Company, Philadelphia. 2012; 6th edition.

9. Kleinrensink G, Stoeckart R, Mulder P, Hoek G, Broek T, Vleeming A, Snijders C. Upper limb tension tests as tools in the diagnosis of nerve and plexus lesions, anatomical and biomechanical aspects. Clinical Biomechanics (Bristol, Avon). 2000;15(1): 9-14.

10. Kline C. Instrument-assisted soft-tissue mobilization: when to start and what's on

the horizon. Journal Of The American Chiropractic Association. 2010;47(7): 2-7.

11. Kline C. Soft-tissue healing, part II: what does instrument-assisted soft-tissue mobilization bring to the table. Journal Of The American Chiropractic Association. 2010;47(6): 2-7.

12. Levangie P, Norkin C. Joint structure and function – A comprehensive analysis. F.A.

Davis Company, Philadelphia. 2011; 5th edition.

13. Lukacs C. Instrument-assisted soft-tissue mobilization explained. American Chiropractic Association. 2013;9(8): 20-21.

14. Magee D. Orthopedic physical assessment. Elsevier Saunders. 2014; 6th edition

15. Norkin C, White, J. Measurement of joint motion: A guide to goniometry. F.A. Davis Company, Philadelphia. 2009; 4th edition.

16. Reese N. Muscle and sensory testing. Philadelphia, PA: Elsevier, Inc. 2012; 3rd edition.

17. Smiley J, Todd A, Calabrese F, Fagan A, Galvin P. Disabilities of the arm, shoulder,

and hand questionnaire. Rehab Measures 2013.

18. Wolf E, Cox W. The external rotation test in the diagnosis of adhesive capsulitis.

Orthopedics. 2010;33(5):303-308.

1. Ulnar Nerve Glide

Begin with elbow, wrist, and fingers flexed and bring arm in front to shoulder height. Slowly straighten elbow, wrist, and fingers.

2. Median Nerve Glide

Begin with elbow, wrist and fingers flexed, place hand at neck height with palm facing upward. Flip fingers and wrist. Straighten elbow. Swing arm out to the side. Return to start position.

3. Radial Nerve Glide

Stand with arms at your side with palm facing your thigh. Lower your shoulder keeping the elbow straight. Bend wrist and rotate arm inward and behind you.

4. Sitting Arm Slides on Table

Abduction: Sit in a chair so the table is to your side. Place arm palm up on table and use your trunk to assist with your arm sliding away from you body. Repeat on the other side. Flexion: Sit in a chair so the table is in front of you. Place you hands on the table with palms down. Use your trunk to assist with your arms sliding forward. External Rotation: Sit in a chair so the table is at your side. Place your forearm on the table with the palm facing down. Lean forward with your trunk to help drive the external rotation of your shoulder. Repeat on the other side.

5. TRX Posterior Curtsy

Stand upright holding the TRX bands taught. Step behind one leg and bend the knee of the leg that did not move. Elongate your trunk on the stepping side. This motion will help drive shoulder flexion. Return to the starting position and repeat on the other side.

6. Pole assist D2 Flexion & Extension

Use a long pole or broom, placing one hand at each end of the pole, make sure both thumbs are pointing toward the ceiling. Start with your feet hip width apart. Inhale and with the hand at the top of the pole, reach upward toward the ceiling, backward, and rotate through your trunk. Shift your weight onto the leg you are turning toward. Then exhale, bringing the pole down across your body rotating and bending your hips and knees towards the other leg shifting your weight on the leg you are rotating towards.

7. Hula Forward Bend + Rotation

Stand with hands on top of hula-hoop. Engage your core as you bend forward hinging at the hips, keeping your knees slightly bent. Side-bend to the right and then the left; keep your head neutral between your arms.

8. Cable Cross Push-Pull

Start with one hand grasping the handle in front and the other grasping the handle in back. The front arm pulls into GH extension with the motion initiated from scapular retraction. Simultaneously, the back arm pushes into GH flexion while rotating the trunk. Return to the starting position slow and controlled. Focus on engaging the core musculature and breathing to exhale into the motion (concentric) and inhale back to the start position (eccentric).

9. Cable Cross UE D1/D2 patterns

D1: Initiate movement with scapular depression and retraction and move the arm into GH extension, abduction, and external rotation while exhaling. Return to the starting position of GH flexion, adduction, and internal rotation slow and controlled while inhaling. Engage the core musculature throughout the exercise. D2: Move the arm into GH extension, adduction, and internal rotation while exhaling. Return to the starting position of GH flexion, abduction, and external rotation while inhaling. Engage the core musculature throughout the exercise.

10 Supine Counter-Rotation Arms & Knees

Lie on your back with your knees bend so your feet are flat on the mat. Raise your arms overhead into flexion (can progress into greater flexion), clasping hands. Alternate rotating your arms and knees opposite directions to promote trunk rotation inhaling as you rotate to one side and exhale as you return to the starting position.

11. Corner High Low Reaching

Stand with your back in a corner take a step forward so your shoulders and hips are not touching the wall. Stand with one foot in front of the other. High: Inhaling, reach with both hands up high, shifting your weight and rotating toward the wall to the side of the front leg. Low: From the high reach, exhale and bring both your hands across and down toward the opposite side reaching down and rotating as far as possible. Bend your knees and hips, shifting your weight to the back foot.

12. Side-Lying Counter Rotation

Lie on your side and exhale while you reach forward with your top arm while simultaneously extending your top leg to produce trunk rotation. Inhale and reach backward with top arm while simultaneously flexing your top leg. Repeat on other side.

13. 4-Point Hand Slides on Table

Start on hands and knees with pillowcase or towel under hands to decrease friction between hands and surface of table. Keep one arm stationary, inhale, and move the other arm straight out in front of you so that your hips and trunk drive the motion. Exhale while tightening your core as you bring your arm back to the starting position. Repeat to other angles of moving arm straight out to the side and then 45 degrees between and repeat on the other side. Repeat on other side.

14. Chair Plank + Knee to Elbow

Place hands on edge of chair ensuring shoulders are over the elbows, which are over the wrists. Keep your back neutral, engage your core, and hold for 20 seconds. Increase difficulty level by moving feet further away from chair or bringing one knee to the same elbow. 15. 4-Point Cat/Camel

Start on hands and knees and while inhaling, arch back down (‘cat’ position) to feel a stretch in the abdominals. While exhaling, arch back up (‘camel’ position) to feel a stretch in the back musculature.

16. Bosu Thoracic Extension With Trunk Rotation

Place Bosu ball under thoracic spine, bend knees so feet are flat on the table, clasp hands overhead. While inhaling, rotate arms to one side. Exhale and return to starting position. Repeat to the other side. 17. Bosu Thoracic Extension With GH Horizontal Abduction

Place Bosu ball under thoracic spine, bend knees so feet are flat on the table, raise arms up overhead. While inhaling, squeeze shoulder blades together and slowly lower both arms to the table bending at the elbows. Exhale and return to the starting position. 18. Hula Standing Twist

Begin by holding hula-hoop with arms fully extended. Use the momentum of the hula-hoop to rotate your trunk side to side while keeping your head focused straight ahead.

19. Pectoralis Major/Minor Stretch

Stand in a doorway with arms positioned as indicated in pictures A-C. Focus on retracting scapula and keeping your trunk upright.

20. Levator Scapula Stretch

Look towards your armpit and use the same side hand to provide slight overpressure. Depress the other shoulder to feel a stretch in the depressed side levator scapula muscle. Repeat to other side.

21. Scalene Stretch

Place both hand crossed under the clavicles and pull downward toward your feet. Keep your jaw closed look up toward the ceiling leading with your chin. Then turn your head slightly to one side and drop your ear to your shoulder leading with your chin. Repeat on the other side.

22. Childs Pose + Lateral flexion

Sit back on your heels and move your hands to one side keeping your hips straight. Repeat on the opposite side.