By Dr. Yoon Jeon. MChiro, MB, BSc, Dip.TCM, PGCert.
Case Presentation
A 41-year-old female gardener presented with persistent shoulder pain of more than six months’ duration.
The patient reported gradual onset of pain associated with repetitive overhead and manual work. Symptoms were aggravated by lifting, reaching, and sustained use of the arm, significantly affecting her occupational activities.
Previous management included NHS care with prescribed analgesics and physiotherapy, as well as private chiropractic and physiotherapy treatment. However, these interventions failed to provide meaningful or sustained improvement.
Clinical Examination
Findings were consistent with:
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Painful shoulder movement, particularly during elevation and overhead activity
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Features suggestive of subacromial impingement
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Associated stiffness and dysfunction in the upper thoracic spine
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Myofascial tenderness around peri-scapular and shoulder girdle muscles
Clinical Impression
The presentation was consistent with:
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Shoulder impingement syndrome (subacromial pain syndrome)
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Associated upper thoracic facet joint dysfunction
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Myofascial pain syndrome affecting surrounding musculature
It is well recognised that thoracic spine mobility and scapular mechanics play an important role in shoulder function, and dysfunction in these areas may contribute to persistent impingement symptoms.
Treatment
A multimodal conservative treatment approach was implemented:
Chiropractic Spinal Manipulation
Applied to the upper thoracic spine to improve mobility and reduce mechanical stress on the shoulder.
Glenohumeral Joint (GHJ) Mobilisation & Traction
Used to improve joint mechanics, reduce pain, and increase range of motion.
Electro-Acupuncture (EA)
Electro-acupuncture was applied to local and relevant muscular points.
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High-frequency stimulation (e.g. 1000 Hz) is associated with analgesic effects
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May enhance neuromodulation and reduce pain sensitivity
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Potentially facilitates muscle relaxation and improves local circulation
This modality was not included in the patient’s previous treatments and may have contributed to the observed clinical improvement.
Rehabilitation Programme
A structured home exercise programme including:
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Shoulder and thoracic mobility exercises
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Stretching of involved musculature
Postural & Ergonomic Advice
Targeted advice to reduce repetitive strain and optimise movement patterns during work activities.
Clinical Outcome
After 2 weeks of treatment:
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Noticeable reduction in pain
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Improved shoulder mobility
After 4 weeks:
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Patient reported being nearly symptom-free
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Significant functional improvement in daily and occupational tasks
At 2-month follow-up:
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The patient remained asymptomatic
Ongoing care:
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Periodic maintenance sessions (every 2 months) were advised due to the physically demanding nature of her occupation
Discussion
Shoulder impingement syndrome, also referred to as subacromial pain syndrome, is one of the most common causes of shoulder pain, particularly in individuals performing repetitive overhead or manual work.
Manual therapy, including joint mobilisation and manipulation, has been shown to improve pain and function in shoulder impingement. A systematic review by Jeremy Lewis highlights the importance of addressing movement dysfunction and biomechanical factors in subacromial pain.
Thoracic spine manipulation has also been shown to have beneficial effects on shoulder pain and range of motion, supporting the concept of regional interdependence (Chad E Cook, 2013).
Electro-acupuncture has been investigated for musculoskeletal pain conditions, including shoulder disorders. Studies suggest that electro-acupuncture may:
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Reduce pain through endogenous opioid release
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Modulate central and peripheral pain pathways
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Improve local blood flow and muscle function
High-frequency electro-acupuncture has been associated with activation of different neurochemical pathways compared to low-frequency stimulation (Ji-Sheng Han, 2003).
Systematic reviews also indicate that acupuncture, including electro-acupuncture, may provide benefit in shoulder pain conditions, particularly when combined with other conservative therapies (Caroline A Smith et al.).
Exercise therapy, particularly when combined with manual therapy, is widely recommended for improving outcomes in shoulder impingement (National Institute for Health and Care Excellence MSK guidance).
Conclusion
This case demonstrates that a structured, multimodal conservative approach — including spinal manipulation, shoulder joint mobilisation, rehabilitation, and ergonomic advice — can be highly effective in managing chronic shoulder impingement syndrome, even in patients who have not responded to previous treatments.
The addition of electro-acupuncture, particularly in a patient who had not previously received this modality, may provide additional clinical benefit when combined with manual therapy and rehabilitation.
Addressing both local shoulder mechanics and regional biomechanical factors appears to be key in achieving sustained recovery.
References
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Jeremy Lewis (2016). Rotator cuff related shoulder pain: assessment, management and uncertainties.
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Chad E Cook (2013). Regional interdependence in musculoskeletal rehabilitation.
- Ji-Sheng Han (2003). Acupuncture: neuropeptide release produced by electrical stimulation of different frequencies.
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Caroline A Smith et al. Acupuncture for shoulder pain: systematic reviews and clinical evidence.
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National Institute for Health and Care Excellence. Musculoskeletal conditions: assessment and management guidelines.
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Ann Cools et al. (2014). Rehabilitation of scapular dyskinesis in shoulder disorders.
