Case Of Torn-loose Shoulder

PATIENT PROFILE:

Age and gender: 31years / male

Occupation: social worker (predominantly desk-based job)

Complaint: Left shoulder pain

HISTORY:

The patient presented with long-term pain in the left shoulder, associated with a history of recurrent shoulder dislocations.

In 2012, while playing handball, the patient sustained a traumatic anterior shoulder dislocation following a collision with three players. The shoulder was relocated on-field by the coach, and the patient was advised to wear a sling. However, no structured rehabilitation was undertaken. Following this incident, the patient avoided weightlifting and activities involving overhead movements.

After six years, in 2018, the patient experienced a recurrence of shoulder dislocation while lifting a heavy rice bag. He sought physiotherapy care, where the shoulder was relocated, and modalities such as IFT and ultrasound were administered for seven days, with minimal pain relief.

Subsequently, a physiotherapist friend assessed him and suggested a diagnosis of periarthritis of the shoulder. Exercise-based treatment was initiated, but symptoms worsened, and he became unable to perform basic activities such as riding a bike.

The patient later consulted an orthopaedic surgeon and underwent a PRP injection in April 2023. Although he regained the ability to ride a bike, pain persisted. He was prescribed steroids for approximately 1.5 years, yet his symptoms failed to resolve.

The patient reports progressive fear, apprehension, and functional avoidance of the left shoulder.

Relevant Background Information

Past Medical/Surgical History: He has a history of recurrent shoulder dislocation
Physical Activity Level: Sedentary
Sleep: 5–6 hours; disturbed sleep due to pain when lying on the affected side
Stress Levels: High, related to persistent pain
Previous Treatments: Multiple consultations, physiotherapy modalities (IFT, US), PRP injection, long-term steroid use
Patient’s Goal: To be pain-free and regain normal shoulder function

PAIN ANALYSIS:

Intensity – 7/10
Aggravating factor – Lifting heavy objects (water cans, rice bags), Overhead movements (>90° flexion, abduction, external rotation), Driving with jerky movements
Relieving factor – rest
Location: Diffuse pain in the Left Shoulder

Duration – Chronic, the problem has been persistent for 13 years, but it has been severe for the past 2 years.
Type of pain – nociceptive pain
Character – intermittent pain, mechanical
Irritability – low (pain started gradually after lifting above 90 degrees in flexion, abduction, and external rotation)
Sensitivity – low (if he stopped doing overhead movement, then pain would subside)
Lifestyle impact: Moderate level of impact. He can’t use his left shoulder during any functional activity.
Fear of movement analysis – fear induced during external rotation, abduction, flexion above 90 and also lifting heavy weights.

Our understanding from the history and pain analysis:

The patient likely developed chronic shoulder instability following the initial traumatic dislocation due to a lack of rehabilitation, leading to recurrent dislocations, weakness, fear avoidance, and functional decline.

PHYSICAL EXAMINATION:

Observational findings:

Slight muscle atrophy on the left deltoid (reduced muscle bulk). No other visible changes like swelling, redness, or bruising.

ROM analysis:

AROM – restricted, painful in all directions on the left shoulder

	Right	Left
Shoulder flexion	180 degree	>170 degree (Painful)
Shoulder abduction	180 degree	>170 degree (Painful)
External rotation	100 degree	>80 degree (Painful)
Internal rotation	90 degree	90 degree

Mobility screening

Shoulder overhead flexion mobility: left side reduced
Thoracic rotation: slightly reduced on the left side.

Stability screening

Strength Test	RIGHT	LEFT	LSI%
Side lying Shoulder External Rotation (ER) – 1kg	20	7 (Painful)	35%
Shoulder press – 3kg	17	4 (Painful)	24%
Bench press – 3kg	20	6 (Painful)	30%
Lateral raise – 2kg	19	7 (Painful)	36%
Biceps curl – 3kg	20	7	35%

[Weights selected based on patient capacity]

Palpation – No pain on palpation

Special tests

The break test was positive on the left shoulder compared to the right shoulder [shoulder flexion, shoulder abduction, shoulder external rotation]
SPRULING TEST – Negative
UPPER LIMB TENSION TEST – Negative

INVESTIGATION:

MRI – Cervical Disc Bulge

DIFFERENTIAL DIAGNOSIS:

Stiff Shoulder - Ruled Out

Mostly occurring in old age, above 45 years
More common in women.
Pain stimulates the affected side while the patient sleeps on the unaffected side.
A stiff-shoulder patient will be unable to lift the full range actively
The patient’s affected side may have a reduction of at least 30 degrees in elevation and 50 degrees in external rotation.
Both AROM and PROM will be restricted in stiff shoulders.

Cervical radiculopathy - Rule out

No radiating pain in the left side
No numbness
Spurling test negative
ULTT was negative

DIAGNOSIS:

1) What is the patient’s perception of pain? He had a poor understanding, and he had apprehension.

2) Psycho-social factor analysis

Cognitive	Highly affected (poor pain understanding)
Affective	Moderate affected
Social	Minimal Impact

3) Belief and expectation from the patient

Patient Belief: he attributes pain primarily to cervical disc bulge
Expectation: Pain-free movement and functional recovery

4) Diagnosis With Clear Explanation

Unstable Shoulder (Torn–Loose Shoulder)

The patient has recurrent shoulder dislocations and multidirectional instability, resulting in pain, weakness, fear of re-dislocation, and significant functional limitation—especially during overhead activities. Long-term avoidance and sedentary behaviour have contributed to muscle weakness, apprehension, and poor motor control, leading to a painful and unstable shoulder.

Key Clinical Features Supporting Diagnosis:

History of recurrent shoulder dislocations
Painful and restricted AROM in all directions
Significant strength deficit (LSI <40%)
Positive break test
High fear avoidance and poor pain understanding

TREATMENT PLANNING:

1) How long will it take to cure? Approximately 3 months.

2) How many sessions – 12weeks – 3 sessions per week

3) Things need to be focused on Treatment:

Mobility restoration
Shoulder and scapular stability
Progressive strengthening (isometric → isotonic → eccentric → dynamic stability)
Fear reduction and confidence building

4) Treatment planning strategy

TIME FRAME	TARGET	SAMPLE EXERCISES
First week	Mobility with isometric exercises	Thoracic rotation mobility, thoracic extension, isometric exercises for external rotation and internal rotation.
2^nd week and 3^rd week	Isometric progression, isotonic exercises with manual and scapular mobility.	Mobility exercises progression, side-lying external rotation activation with manual, lateral raise, shoulder press, prone V, T, W, and scapular push-up.
4^th week and 5^th week	Progressive developing load and core muscle activation.	Banded external rotation, banded lateral raise, half-kneeling shoulder press, and banded rotation.
6^th week and 7^th week	Start eccentric exercises	Crook-lying external rotation activation with the assisted opposite hand.
8^th week to 9^th week	Start stability exercises	Shoulder tap, push-up, downward dog, toe touch.
10^th week to 12^th week	Stability exercises progression with kettlebell	Windmill exercises, Turkish get-up, lunge kettlebell, press kettlebell, and single-leg standing kettlebell.