Barral Institute Case Studies

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.


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."

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