I love a good challenge.
I did a pro bono examination on a patient’s adult college age son the other day who has been to three different physical therapy offices for chronic shoulder pain. He has been having problems for 5 years with no real significant improvement. His mom was telling me how concerned she was about his shoulder not getting better and was picking my brain while I was treating her problem. I offered to a take a look at it, mainly to satisfy my own curiosity about why he is not getting well. I’m an idealist sucker like that.
According to the son, he has had several injuries including a front impact car accident, a collar bone fracture, and some weight lifting injuries. He has some neck injuries that do bother him but these have been previously ruled out by MRI on the cervical spine. MRI on the shoulder a few years ago showed bursitis (inflammation at the joint) and some degenerated tendons, but no obvious tearing.
One of the reasons why I agreed to see the client is that after 5 years of pain, bursitis should have been healed by now. In addition, it seems the primary intervention from all his previous physical therapy visits was dry needling, a treatment that consisted of placing acupuncture needles in muscle trigger points. His shoulder would be a little “looser” for a few days, but would eventually hurt again and become stiff. He is currently seeing a physical therapist at another office and his range of motion (ROM) has improved slightly with dry needling. He was extremely frustrated with having pain for 5 years and he was unable to return to working out or weight lifting.
From the clinical exam, there was three findings that appears to have been missed, or at least not addressed through previous plan of care:
- Anterior glenohumeral joint instability.
- Acromioclavicular joint (ACJ) hypomobility.
- Possible injury and scarring to the Corococlavicular.
- Long head of the biceps tendinopathy.
Dry needling is not going to address any of the above listed problems. In my humble opinion, the primary interventions should have been:
- Glenohumeral joint stability program.
- Manipulation of the acromioclavicular joint and associated ligaments.
- Proven treatments to address tendon pain and irritation.
I felt the limited mobility at the ACJ was due to ligament damaged that had scarred down and stiffened up. To test my theory, I spent 5 minutes of joint manipulation to the ACJ. After treatment, he had full, pain free shoulder ROM in all directions for the first time in 5 years
The key to success in managing orthopedic problems is a good clinical exam and being open to a variety of possibilities and conditions. Anchoring biases in one particular approach, or in this case, the most popular new modality in physical therapy, can lead to ineffective treatments and poor outcomes.
Although I do think dry needling does have a place in the physical therapy profession, but it is not a one size fits all approach and is not the magic wand that is marketed to health care consumers. There are no magic wands in physical therapy!
With the current changes in health care, the odds are you are going to pay more out of pocket for your physical therapy services. At Metropolitan Physical Therapy, we believe you should get your money’s worth.