AUTHOR: Jeff Funnell
The ClientIs a 44 year old male and retired veteran. He presented with right shoulder pain which increased during loaded activities in the gym.
Previously the client had lost 25kg on a structured 12 month exercise program under guidance from an experienced personal trainer. But ceased all training to go on a holiday for 3 months where he regained 10kg.
The only previous injury to note was a grade 1 Achilles tendon strain, fully rehabilitated in 2008.Subjective Examination:
- Pain 7-9/10 depending on activity
- Localised to the shoulder and non-specific
- Onset of pain 3wks after returning from holiday
- Insidious onset with no report of injury or trauma
- Specific aggravating activities include loaded shoulder press and bench press.
- Imaging: nothing abnormal detected (tears, calcification, degenerative change etc.)
- Local examination: acute pain present in majority of movements.
1. Reduce pain & Client EducationThe conclusion of the examination was that inappropriate load management was the most significant contributing factor to the onset of symptoms.
Initial management consisted of education about appropriate load management and exercise progression, the importance of ‘relative’ rest, addressing threat perception in relation to activity and symptoms, and manual therapy for pain modulation (reduction).
Using the model of tissue homeostasis and ‘envelope of function’ (Table 1.1) we were able to educate the client in regards to the tissues in the shoulder being overloaded beyond their biological capacity to adapt and repair.
During the 3 month holiday period, the client had not maintained the same volume of exercise and failed to engage in any dedicated physical activity. In doing so, the tissue tolerance (envelope of function) had reduced (Table 1.2). Having returned from holiday the client immediately returned to his pre-holiday exercise loads (Table 1.3). This pushed the tissues into the ‘zone of overload’ with no time for recovery.
2. Exercises:After 2 weeks of relative rest and manual therapy some loaded shoulder exercises were re-introduced with reduced load. Load was determined using a Visual Analogue Scale (0-10) for pain. Appropriate load would not exceed a reported 2-3/10. Also the client needed to report no adverse symptoms the next day.
3. ProgressionAfter determining an appropriate start point, load was increased by 5-10% each week as long pain remained at 2-3/10 or lower, with no adverse symptoms post training.
The ResultsWithin 2-3 months the client reported pain free movement and strength had returned to 95% of pre-holiday capacity.
DiscussionThe versions of the envelope of function as presented in this case study (Table 1.1) are simplified versions representing the four responses of musculoskeletal tissues to differential loading homeostasis, loss of homeostasis caused by disuse or overuse, and structural failure. The interfaces between the four zones are represented as lines and therefore if interpreted literally imply clear, definable indicators of zone change. Although this may be true for sudden, high-loading events that result in overt structural failure, it probably is not true for the interfaces between the other regions. It is likely that the actual loading events that would define the interfaces between the other regions are not exact but are gradual and are better represented by shaded overlapping. The zones likely blend from one to another rather than change abruptly.
The tissue homeostasis theory provides a framework for Myotherapists to help educate their patients in the principles of musculoskeletal tissue overuse and healing.
It has led to therapeutic principles that are rational and safe.