Case Stories

L shoulder impingement syndrome, Mike Burggraaf, PT, DPT, LAT

Patient Age / Gender: 65 y/o male

Patient Symptoms:
Referring diagnosis of L shoulder impingement syndrome. History: Pain in both shoulders with L being worse than R. Sitting with arms on the arm rest of a chair for any extended period will increase the pain in both arms. Holding the reigns and driving the horse bothers the shoulders more than any other activity. Over the last 5 years the patient reports significant upper back and neck stiffness and soreness.

Evaluation / Treatment:
Initial Findings: Active left shoulder flex and abduction at initial visit were 10 degrees less than the right. Passive external rotation R=90 and L=72. Empty Can and Speed’s Bicipital Tendonitis tests were both positive on the left. Thoracic rotation was limited at 25% of normal bilaterally and thoracic extension was limited at 25% of normal.

Before attending VM1 I saw the patient for four visits focusing on improving passive ER in the L shoulder and working to gain extension in the mid to upper thoracic spine to facilitate shoulder mechanics. After four visits the patient had full PROM and full AROM with decreases in pain when he wasn’t riding horses, but he still had pain with riding horses and sitting at work for extended periods of time.

Outcome:
This patient was the first patient I saw after returning from VM1. I did general listening and got pulled to the L lower thoracic spine. I was thinking stomach, but it was maybe a bit too far posterior for stomach. I started asking more questions he started giving me some history that he previously hadn’t told me. He had his L kidney removed in his 30s due to a tumor. He has a hernia in his anterior midline along his stem to stern incision and has recently had to go on daily meds for reflux. I performed the stomach mobility and motility techniques from VM1 and worked through the hepatoduodenal ligament. I also tried some work through the area of the kidney that had been removed (as I’ve only taken VM1 I improvised on working the kidney area). Thoracic rotation improved by 25 degrees immediately after the treatment. At the next visit the patient reported: “I’m feeling pretty good, with less shoulder pain. I rode a couple of days this week and I’m feeling more comfortable on the horse as I’m not getting jarred like I was before the last treatment. I have also felt like I have more stability on the horse.”

Patient Age / Gender: 22/Female

Patient Symptoms:
From the patient: I am sixteen weeks pregnant, and have been throwing up multiple times every day. I was only able to drink Ensure. I had one VM/CST session with Dee Ahern 8 days ago and have not been sick once since then, and have been able to eat!

I have more energy. For example, since I’ve been pregnant I have been taking the elevator to get up to the 3rd floor because I can barely make it up the stairs…but since the session, I’ve been taking the stairs every day and breathing better.

Evaluation / Treatment:
One VM/CST treatment session

Outcome:
More energy, can breathe better and can eat!

Patient Age / Gender: 61/Male

Patient Symptoms:
My client is a 61 year old man, who after fracturing C1,2 (titanium plate in after) in 2003 ruptured his esophagus in 2004, and had a stomach and esophagus repair consequently. Since 2007 he was in near unbearable pain in his right rib cage area. He visited every doctor and was put on oxycontin, prednisone (which caused osteoporosis) and valium. He is a tall man, was skin and bones when he came, permanently flexed forward around the T7-9 area, his right chest cage looked like someone had put his boot in from the lateral side and pressed the all area medially . The all torso showed how the body had rearranged itself around the visceral restrictions. His left shoulder was about 20 cm than the right, with his head stuck in an extreme sidetiled position. His spine had solidified around several compression fractures and his neck felt like it had never moved since 2003. His voice was very husky. He was booked in two weeks later to have surgery for pain relief/severing nerves. I could see he was totally at the end, He was hardly able to stand up, did not say a word.

Evaluation / Treatment:
I managed to get a listening in standing, very clear to the right, LL then took me to the liver. I was very aware of the osteoporosis when treating him. All I did in this first session was a liver lift in supine, which basically was in a near sitting position on my table, motility to the liver and Gallbladder (which took a long time) .I felt the listening extended to the gallbladder also. I released his first ribs and did a very long sternal lift. I released the occipital area as well. He slept through it all, got up very unimpressed by it all, feeling no different. 2 days later I find a 10 min( !!) message on my machine, that he has hope again, that he is better for the first and only time since 2007…emotional message. I gave it at least 2-3 weeks between sessions, I felt specially he needed integration time .2nd session was still him needing to sit up during the treatment, and I worked (according to the listening) on his pylorus / then all sphincters. I did an induction on his stomach, which then lead me to the liver again, I repeated the liver lift and motility, and linked the motility with the stomach. By then he had cancelled the upcoming (pain relief) surgery.

Outcome:
When he came back to his third visit, he walked nearly straight, he had taken up his work as a journalist again after not writing for years, his pain was maybe 20/25% of his original pain. This time I treated him lying nearly flat!! Known as an opinionated man, he followed every advice I gave him. I actually felt his system being dehydrated from my listening, and indeed he hated water, drank only milk! He immediately started on 2 liters of water daily, stopped the 30 cups of coffee a day to 2 max!, stopped smoking and reduced his medication by 3/4. Even his voice had changed to less husky!! I am still in disbelieve that such gentle techniques can result in such a change of the skeletal system. And also that it would not cause pain for a spine to straighten up that much after so long..?? His physical change is so obvious, that people ask him constantly what had happened to him by just seeing him in the street. I got now countless clients that booked in for that reason, hardly anyone with any musculoskeletal pain, just unwell for various reasons. Basically I am having a really rewarding time at work.

Patient Age / Gender: Female 72 yr old

Patient Symptoms:
History: 72 yr old female presents with B knee pain. Coming for preop therapy for Right TKR in early April. Pt had 3 yr Hx of L knee pain and had been through synvysc injections which helped at time.Xrays showed moderate to severe degenerative changes on L knee. Had planned to have L knee replaced but in last few months R knee had become very sore and more of a problem than Left knee since November 08, no Hx of injury, xray showed mild degenerative changes, but as R knee more problematic and painful than L had opted to have R knee done 1st then later would have L knee done . O/E L knee 108deg flex -5 deg ext Pain EOR. Decreased quad strength and some VMO wasting. Pain worse after prolonged weight bearing/walking, sitting in one position too long and stiff feeling. Going up and down stairs was difficult. R knee 125deg flex 0deg ext. Pain in R knee worse when sitting and standing for too long, but sore most of the time whatever she was doing.

Evaluation / Treatment:
GL: forward with R side bend R Ki. LL: R Ki motility stuck in expiration and internal rotation // 3rd degree ptosis Treatment; R kidney pt treated supine worked Ki on psoas with patients R leg over therapist shoulder, contract relax of hip flexors then mobilize R Ki on relaxation of contraction, also used expiration. Following this balanced L and R kidneys and did some motility work. Rest of treatment was traditional exercise for B knees to finish session.

Outcome:
After 1st treatment R knee about 50% less pain, the following week did one more treatment for R kidney in sitting position and worked cecum with long levers of legs, finished with motility of ki and cecum, Lv and stomach. In following week R knee pain pesolved and pt continued with preop therapy for L knee. Pt called her surgeon up North to cancel R knee TKR and have L knee replaced instead. Pt had L TKR done April 09.Had not had return of R knee pain when last spoke to her.

Patient Age / Gender: 40 yr old female

Patient Symptoms:
History: 3 yr Hx of coccyx pain, following an MVA x 2, 1st in 8/08 then another 3/10.Pt is c/o pain in coccyx area 10/10 when sits, standing 3/10 to 9/10, can’t walk at all due to coccyx and B foot pain also gets HA’s and L sided neck and shoulder pain and some upper back pain near L scapula. Pt unable to do any housework or cook etc. She has tried internal coccyx manipulation, this did not help, has had epidural and steroid shots to spine and locally to coccyx, has tried PT, but nothing has helped and since 2nd accident has got a lot worse. Pt has 10 yr old son. PMH graves disease DH pain meds. O/E: posture scoliosis long standing, bony convex to L and some R trunk rotation. AROM L/sp flex fingers to mid shin pulls coccyx, ext 10deg . Sitting root test L knee -60deg ext // pain. R full ext. Very sore to touch sacrum and coccyx, hypomobility of spine esp lumbar and thoracic. In sitting coccyx does not move away from L and is hard for her to weight bear through L ishial tuberosity. GL: L fwd bend and L side bend. LL L Ki stuck in expiration and lateral.

Evaluation / Treatment:
Treatment treated coccyx in sitting used L leg to aide in releases. After able to get -15 knee ext with sitting root test. L Ki mobility worked on with pt sitting. positional release of coccyx. All diaphragm releases.Ki motility balancing. Tx 2. GL still L Ki area, LL: L ureter. Checked coccyx moving better, still tethered a little to L released again, coccyx, dural tube release pt sitting. Ki L ureter release and also ureter at bladder released. Sigmoid colon released. Anterior neck starting with coracoclavicular ligamnents, coracoacromial ligamnets and AC then subclavius and MCF releases.Tx 3 obturator internus releases, sacral compressions, more coccyx work linking to rectum and creating a listening then release. Venous decongestion of lumbar area via Ki in side lying. Dural tube 3 position release from VM3 in prone.Tx4: Descending colon from fascia of Toldt, L ovarian vein, L ki in sitting this has pull into coccyx and neck and after decreased coccyx pain and full knee ext on L when sitting. Ischial tuberosity spread pt sitting. Vertebral artery stretch and some more anterior neck releases.Tx 5: symptoms have eased able to sit 20 mins can walk 30 mins, not having the intense pain nearly as often.Listening still L Ki area. Motility balancing of Ki. Liver releases, working associated structures of kidneys , CST ,Tx 6, plexi releases hypogastric,inferior hypogastric, sacral splanchnic and pelvic splanchnic linked to sacrum and organs also linked to frontal lobe.CST, motility of bladder, Ki’s rectum.Tx 7 can sit for 20 mins consistently now, standing to prepare food and able to resume some light housework, walking every day 30 mins has sometimes done more than this without pain above 4/10.Neck pain is about resolved.Checked some of exs for core stabs and spinal ROM progressed them. Added in warrior poses from yoga. GE junction releases and Lv triangular ligaments released. Ovary balancing and releases and uterine sacral releases.Checked all uterine ligaments B .Tx 8 Coccyx pain has been a little more sore had to sit on hard chair at dr office. Positional release of coccyx, L ki release in sitting, MFR linking foot to sacrum then Ki area, listening to root of mesentery this released. All diaphragm releases.

Outcome:
OUTCOME did a total of 10 treatments pt got to 20 mins sitting , walking up to an hour return of being able to do light housework, neck and shoulder pain resolved, coccyx pain still could be 10/10 on occaisions if sits too long. Less bad days more better days pain less intense but not progressing patient further so referred back to physician, gave pt Dee’s number and suggested she call and make an appointment as I felt I was missing something as often got listening to L Ki area. In addition to the mainly visceral work also did MET of pelvis and sacrum and spine.

Patient Age / Gender: 54 yr old male

Patient Symptoms:
HISTORY 54yr old male T boned by car into drivers side door 1 week ago. Pt had Xrays NBI, L ribs severely bruised and still sore can�t take deep breath or cough with out pain. Some neck pain and low back pain also, but ribs are most severe. Painful area above L iliac crest where door collapsed and hit pt�s side. Very hard to perform all transitional movts esp sitting to supine and rolling and getting from lying to sitting. PMH asthma but not on any meds for this currently.Lisinipril for BP and skelaxin and oxycodone post accident. O/E L/sp Flex fingers to toes, Ext 5 deg pain in ribs. C/sp Ext 50deg stiff, Flex 3 finger breadths to sternum, L rot 60deg R rot 65 deg. L shoulder flex and abd full range but very sore in ribs.Moderate decrease in L lower lobe lung expansion. Rib pain 8/10 on movt and coughing.

Evaluation / Treatment:
Treatment 1, Showed assisted coughing with towel support around chest wall //able to cough stronger and with less pain. GL to L lateral axillary line. LL 6th rib area laterally. Also listening to L Sterno clavicular area. VM to ant neck including B coracoclavicular ligaments, coracoacromial ligaments, coracohumeral ligaments, subclavius muscles B did in supine with support under shoulder girdle to bring anterior to access subclavius muscles. Pec releases B then MCF release. SC jt release B. finished with diaphragm releases and some MFR through L rib area where sore. Encouraged full intake of breath esp into L lower lobe with manual proprioceptive cueing. Treatment 2 states ribs much better coughing with towel very helpful. GL left anterior clavicular area. LL to sternum and ribs some L pleural listening also. Tx VM to , costotransverse ligaments ,and costovertebral ligaments, levators costoram brevis and longus, then transversus thoracic muscle released , pleural release from mediastinum, then did diaphragmatic recess of pleura release B in supine. Opened anterior neck again and MCF .finished diaphragm releases. Treatment 3 rib pain about resolved now able to palpate area with no discomfort. Some neck and low back pain. GL L gastrooesophageal area. LL gastrooesophageal junction some listening to Left triangular ligament of Lv. Tx sitting L triangular lig release,and L lobe of Lv, then created stretch at oesophageal/gastric junction, then balance tension in diaphragm and cardiac sphincter. Worked ribs again as per last session, R triangular ligament release, released oesophagus pt supine as per VM 4. Motility of Lv and stomach and balancing the 2 together. Treatment 4symptoms settling able to move much better no trouble getting up and down. GL L lung, LL L anterolateral mid rib area.Tx VM to L oblique fissue of lung also did R lobes of lung, L and R bronchus and pleural releases ,ligament of lung L and R.Checked anterior neck , did vertebral artery release B, pleural dome and stellate ganglion. Worked on all plexi cardiac, celiac and phrenic nerve, balance plexi to each other. Lung motilitychecked and balanced.

Outcome:
Treatment 5 and 6 pt doing much better finished last 2 sessions with Lv lift, dural tube releases, further freeing up ribs, balancing pelvis and sacrum, CST, rechecking things that had been previously treated to make sure had correct mobility and motility. Taught core stabs and postural re ed. Pt responded well to treatment and regained full C/sp ROML/sp ROM WNL�s and pain free no rib pain and no lung expansion restrictions pt returned to prior functional level.

Patient Age / Gender: 42 yr old female

Patient Symptoms:
Hx; 42 yr old female w/ increased frequency of urination and mild stress incontinence when sneezing/coughing. Also has some R inguinal pain when gets up from lying and sometimes sitting, this can be very sharp and deep and stop her from moving for a moment then once up eases and is gone.Gets up 4x night to urinate and in am until after lunch has to urinate every hour.Rest of day can go every 3 to 4 hours. PMH 3 children vaginal deliveries, in early 20�s had ovarian cyst had laparoscopy but unable to remove cyst so had laparotomy.As far as is aware ovary was not removed just cyst. O/E spinal ROM WNL�s some restriction segmentally L4/5 and L5/S1, R SI some restriction to standing flex tests. GL to mid line fwd bend. LL umbilical area inhibition was to root of mesentery. Inferior leaf more restricted. Tx;restriction in root of mesentery found then pt L side lying and treated.in Supine some restictions on loops of SI these gently worked then worked with root of mesentery. Created listening between root and bladder, followed listening to get release.

Evaluation / Treatment:
Motility of jejunem, ileum balanced, then bladder motility and balanced bladder motility with Small intestine motility.Pt taught Kegels exs and bladder handout given to her with list of possible irritants for bladder. 1 week later pt returned stated better last 4 days had not had to get up at night to go to bathroom. Still goes every hour to 90 mins in am. Lessening of R inguinal pain on sit to stand but still there ly to sitting. GL pt fwd bend to mid line then some rot to R inguinal area.LL to R inferior parietocecal ligament. Tx released R inferior cecal ligament supine w/ long levers of legs then had listening to R ovary, worked to unpleat and unfold ovary, then listening to R ovarian ligament,treated this in R side lying balancing ovary to uterus. Other uteral ligaments checked , R uterosacral ligament released , then sacrum and uterus created listening and treated and bladder uteral relationship balanced.Better movt of lumbosacral junction and R SI moving on standing flex tests. Tx 3 10 days later, all symptoms significantly improved. GL forward to mid line LL bladder. Went through bladder protocol from VM 3 , mobility tested bladder, pubovesical ligament tight on L side so treated, median umbilical and urachus tested, treated urachus as restricted, treated B obturator membranes then combination technique for inferior and superior suspensory ligaments. Bladder was not frozen, but did have decreased inspir, corrected this. Finished with linking bladder to nervous system, Bl to S2,3, Bl to T11,12 L1,2 then Bl to pons. Finished with all diaphragm releases up to OA.

Outcome:
Pt had a total of 3 treatments called her 3 weeks after last treatment stated was very happy with outcome, hasn�t had to get up at all at night to go to bathroom, no stress incontinence at all, no R inguinal pain on any transitional movts,still has to urinate about every 2 hours from 6am when gets up to about 10am,but then OK for rest of day and if couldn�t make it to bathroom exactly at 2 hours it would not worry her as she knows she could hold urine.

Patient Age / Gender: Michael D., last date of treatment 5/1/09, age 57

Patient Symptoms:
Left hip pain localized for 1 year to anterior aspect of Left hip with worsening of symptoms 1 month prior to initiating treatment with new functional limitation of standing after sitting for any length of time. Referring M.D. ruled out inguinal hernia and past treatment of stretching exercises given 1 year earlier by physician did not result in any change in symptoms. PMHx: Significant for acute LBP and “severe” upper back pain and sciatica 20 years ago, L shoulder surgery 2001.

Evaluation / Treatment:
Postural alignment symmetrical in crest, shoulder heights with symmetry of ileal positioning. Lumbar spine and sacrum positioned in Left rotation with increase in this with flexion of lumbar spine. Trunk AROM: restricted in Lumbar and L-S flexion to 80% normal ROM, Left sidebending and Left rotation to ~70% of normal ROM Hip PROM: Limited on left to 125′ (10″ less than uninvolved R) with increase pain Hip external rotation PROM 45′ bilaterally with more restriction noted in FABER than with hip flexion combined with ext rotation. Internal rotation painfree & WNL Left hip abduction and extension limited to 1/2 normal range with increase pain. Strength: 5/5 throughout all major mm groups of L.E.’s except FHL 4/5 Reflexes: +2 bilat at knee and ankle Flexibility: Poor in HS, piriformis bilaterally, gastrocs on Right only. Pain increased with testing piriformis Palpation: Tenderness in Gtrynfelt’s space, Visceral fascial restrictions primarily in Mesenteric root, Sigmoid colon leg 2 Neural restrictions: Right tentorium, Left and Right sciatic nerve, Left Femoral nerve, spinal dura G. L. at time of Initail eval: FB/SB to left LQ with + IBT at sigmoid. # treatments; 5 Treatment consisted of Visceral fasical release to sigmoid colon. PPP, mesenteric root, descening colon Neuro-meningeal manipulaton to Tentorium R, both sciatic nerves, Left Femoral Nerve.

Outcome:
Patient discontinued PT after last visit May 1, 2009 due to significant improvement, no functional restrictions with sitting or standing after sitting and able to return to long car rides. He had discontinued all anti-inflammatory meds that had been taken for 4 weeks prior without relief. Objective gains: Normal alignment of Lumbar spine and sacrum positioning with gain in painfree mobility in Lumbar Lex, Extension and SB/Rot to at least 90% normal throughout.

Patient Age / Gender: Kate D., age 16. Last date of treatment 12-15-08

Patient Symptoms:
Self referred for mid-back and neck pain, headaches of gradual onset 2-3 weeks following MVA Sept 08 when she lost control of her car as she was driving around a corner and ran her right front bumper into a ditch flipping the car onto its side. Functional restrictions: must change postions frequently due to pain. C-T junction pain radiates to shoulders bilaterally. Unable to run for exercise as done usually. PMHx: orthodonics age 13-15, Concussion age 14 with loss of consciousness for less than 1 min., closed head injury at age 2 when hit in forehead by swing.

Evaluation / Treatment:
Significant postural asymetry in shoulder heights (R lower by 1″), head slightly SB to R. Left shoulder positioned forward, marked Forward head posture. Trunk AROM: Normal and painfree in flexion and Right Rotation, restricted in extension to 1/2 normal ROM in Thoracic spine and she deviates to left. Sidebending normal to Left, 75% to right with increase pain lower parathoracic area. Left Rot is 2/3 normal with c/o Left SI pain. Neck AROM: normal and painfree in extension, flexion 75% normal and rotation R 65, Left 50′ with c/o midline C-T junction pain. Left SB 30′, R SB 40′ with c/o mid c-spine pain. Strength – Normal throughout U.E.s without pain. Joint mobility: restricted right SB at C6/7 – T2/3, restricted R 1st rib depression, restricted A/A rotation to right 45′, Left 55′ Palpation: Dural restrictions right lower C spine, significant cranio-fascial restrictions on Left affecting sphenobasilar junction. Cranial restrictions in coronal suture, post falx cerebri, osseous restriction left post parietal area. General List: left post cranium. 3 visits including Initial evaluation 12-1-08 Treatment consisted of cranial techniques to address intracranial pressure, craniofascial sutural membrane restrictions, osseous restrictions L post parietal,sutural release Left temporal/parietal, Right tentorium, spinal dura manipulaton, Visceral fascial release of VSON, Pharyngeal basilar fascia, Right pleural dome.

Outcome:
Gain in left SB to 40′ and Rotation right 70′, Left Rotation 70′ without pain. No headaches, no midback or C-T junction pain and able to return to running. Discontinued all meds after first visit.

Patient Age / Gender: Female

Patient Symptoms:
Infertility for 7 years.

Evaluation / Treatment:
Four treatments over four months; uterus rotated, side bent to left; Listening to right fallopian tube, listening to inferior hypogastric nerve plexus.

Outcome:
Baby! Along with reduced period pain and regulation of menstrual cycle.

Patient Age / Gender: N/A

Patient Symptoms:
Heartburn and reflux symptoms.

Evaluation / Treatment:
Gastroesophogeal junction restrictions at lesser curve, greater curve of stomach, cardiac sphincter, pyloric valve. Poor motility at esophagus and stomach. Gall bladder, common bile duct, Sp. Oddi all involved, as well as hepato-duodenal ligament. Treatment focused on restoring mobility to GE junction, esophagus, stomach, making valves functional and releasing gall bladder, common bile duct, H-D-Lig with Sp. Oddi and restored motilities. Discussed with patient to stop coffee consumption and alcohol and drink green tea.

Outcome:
Affter one treatment patient reported complete reduction in symptoms. Stopped drinking coffee (after three days) – was a chronic coffee drinker and switched to green tea. Now walking daily and stretching and has no more symptoms.

Patient Age / Gender: N/A

Patient Symptoms:
Headaches, neck pain, nausea, head neck SB R 20d., LBP. First gastric bypass did not go well. Seven years after second revision of bypass, gallbladder removed.

Evaluation / Treatment:
Two months of treatments. Liver was stuck superior; cardiac sphincter area immobile. Tightness in dura and fascia from posterior diaphragm and liver to top of head R>L. Visceral Manipulation to liver, stomach, sphincters, dural glides, and myofascial release cervical areas. CST and SER work around the area of first “botched” surgery.

Outcome:
Headaches 90% better; head straight; neck pain decreased 70%; no nausea; normal bowels; starting to work again.