CTB Case Study

Frozen Shoulder

Therapist: ​Doug Ringwald

Client:​ 47 yr. Old female
Complaint:​ Very limited left shoulder ROM, frozen shoulder.
Initial Pain Level:​ 8
Post Treatment Pain Level: ​2
Initial Assessments and Observations: ​Client had very limited left shoulder ROM,
frozen shoulder. Painful to move it away from her side. Very limited arm abduction and
internal/external rotation. Forward head posture.
Treatment Design and Rationale: ​Using the CTB shoulder protocol, I had to work
slowly and make incremental increases in ROM while contacting as many muscles as
possible. Developing client trust quickly is crucial​, ​the client is guarding against painful
movement consciously and unconsciously. One must release limiting muscles and
demonstrate that the client can move their arm into territory they thought would be
painful. It is a bit of a detective game to feel which muscles are limiting movement and
slowly unwind all the tension.
Findings During Treatment: ​Pretty much all the shoulder and neck muscles in the
shoulder protocol had TrPs​. ​Subscapularis, infraspinatus were particularly bad and
limiting internal/external rotation. Supraspinatus TrPs and Teres major was locking the
humerus to the scapula limiting arm abduction. Scapular rotation was limited by
mid/low trapezius contraction on the short and serratus anterior TrPs. Glenohumeral
joint was pulled anterior and medially by tight pec major/minor. Neck muscles
(scalenes, levator, upper trapezius) were hard. Scalenes referred prominently into the
shoulder and interscapular area, perpetuating the problems. It was also evident the
client was a chest breather when under stress and had a stressful job (relocating
refugees).
Self Care Recommendations: ​Compression and contract/relax stretch for mid/low trap
and pecs. Compression and contract/relax stretch for subscapularis and infraspinatus.
Outcome: ​Client had a lot more pain free arm motion by the end of the first session.
She had 2 more sessions. She reported that the increased ROM would stay after each
session for a few days but then regress. I attribute this to the dysfunctional breathing
and sympathetic nervous system engagement in her lifestyle.
Commentary: ​This client was somewhat tricky because she was so guarded against
moving her arm. It took awhile to get her arm away from her side enough to be able to
contact the subscap. I also had to always work in muscle pairs, with contact on the
agonist and antagonist, and anything else I could get contact on to stop all the
contraction on the short. But this “wrapping myself around her arm” also worked to help
her relax as well as give feedback to the muscles I was moving.

Teres major was really locking the arm to the scapula, making it hard for the
supraspinatus to abduct the arm. Although in Travel and Simons they write that Teres
major does not usually restrict motion, we have found the opposite to be true in our
clinic in the many frozen shoulder cases we see.

By the end of each session the client had a huge improvement in pain free ROM, but
this only lasted a few days, because of the perpetuating factors of her lifestyle
(dysfunctional breathing, high stress and an ego attachment to that stress). I coached
her repeatedly about her desk ergonomic situation at work, and how it was possible to
work in a high stress environment without taking on that stress, but she wasn’t quite
ready for a yoga lesson in detachment… :)