Case Study: Residual Shoulder Pain From Dislocation

Case Study: Residual Shoulder Pain From Dislocation

SUMMARY

A patient came seeking treatment for pain that has been persistent in her left shoulder for eight months, when she suffered a dislocation and rotator cuff tear. The patient's pain was completely gone after one treatment. The patient continued seeking treatments for other conditions for 9 months. The shoulder pain did not recur over this time.

Patient History

A 36 year old female patient came to the clinic presenting with pain in her left shoulder. The pain started from a shoulder dislocation, with a torn rotator cuff tendon, 8 months previous. The pain presented as dull, burning pain that is aggravated by abduction of the arm. Patient’s AROM was 170 degrees. The area of the pain was located on the posterior aspect of the shoulder on the upper fibres of the trapezius and supraspinatus muscles. The patient rated their pain as a 6/10 on a numerical rating scale.

Objective Findings

The patient’s pain is worse with pressure, exhibiting localized ashi points at the motor points of the upper trapezius (GB21) and the supraspinatus (SI12).

The red dots indicate the ashi (tender points) on palpation of the patients shoulder. The Green triangle indicates the area of the pain as indicated by the patient. The upper red dot is on the upper fibres of the trapezius muscle, while the lower red dot is over the fivers of the supraspinatus muscle.

The patient’s tongue had a pale red body with a thin white coating, a red tip, and a heart crack. Her pulse was 77 BPM and Slippery.

Diagnosis

The shoulder pain is due to Local Qi and Blood Stasis due to the trauma of the dislocation 8 months previous. The red tip of the tongue and heart crack indicate a heart pathology, which is explained by the fact that the patient suffers from anxiety.

Principle of Treatment

Move local Qi and Blood to Stop Pain. Modalities: Orthopaedic Acupuncture

Treatment Plan

Treat once a week for 6 weeks. Modalities: Orthopaedic Acupuncture.

Results of the first treatment

Right after the initial treatment, the patient’s pain on abduction went to 0/10 from a 6/10 with full AROM of 180 degrees. The patient came in for another treatment 6 days after the first. She still had 0/10 pain on abduction of the arm in her supraspinatus and upper trapezius. The patient came back for treatments of other conditions over the next 9 months and the pain in the shoulder did not recur during this time.