# Ultrasound-Guided Rotator Cuff Re-education for Residual Dysfunction After Shoulder Manipulation Under Ultrasound-Guided Cervical Nerve Root Block: A Case Report

## TL;DR

This case report shows how ultrasound-guided training and therapy helped a patient regain shoulder function after a procedure to improve range of motion.

## Contribution

A novel rehabilitation approach using ultrasound-guided real-time feedback and targeted interventions for post-MUC residual dysfunction is presented.

## Key findings

- Ultrasound-guided contraction training significantly improved rotator cuff strength and reduced pain in one month.
- Targeted manual therapy on the axillary nerve reduced movement apprehension and improved functional motion.
- The patient fully returned to recreational golf within 12 weeks with minimal disability scores.

## Abstract

Shoulder manipulation under ultrasound-guided cervical nerve root block (MUC) can effectively restore the range of motion (ROM) in frozen shoulders; however, some patients experience persistent functional limitations. This case report describes a post-MUC rehabilitation program using ultrasound-guided real-time visual feedback to re-educate patients on rotator cuff contractions, complemented by targeted neural and muscle interventions. A recreational golfer in her 50s presented with frozen shoulder; ROM was limited to flexion 100°, abduction 80°, external rotation (ER) 20°, and internal rotation (IR) to L5, and she underwent MUC. At one month after the first MUC, the Disabilities of the Arm, Shoulder and Hand (DASH) decreased from 65 to 48 and ROM improved (flexion 165°, abduction 150°, ER 50°, IR to T12); at three months the DASH was 32, yet movement-evoked pain and motion apprehension persisted. A second MUC was performed; one month later the DASH was 15, but pain remained at 8/10 on the Numerical Rating Scale (NRS), dressing was infeasible, and golf practice/swing were not possible. She was referred to our clinic for physiotherapy. During the first session, ultrasound-guided contraction training immediately increased ER/IR strength from 2/10 to 7-8/10 on a patient-reported 0-10 scale, and movement-evoked pain decreased to 3-4/10 on the NRS. Ultrasound-guided manual therapy targeting the axillary nerve reduced apprehension in provocative positions and improved hand-behind-back motion. Subsequent training enhanced subscapularis strength in elevated position (bear-hug test: 3/10 → 7/10 on a patient-reported 0-10 scale). At 12 weeks, she returned fully to recreational golf, with a DASH score of 2 (sports module: 0). Ultrasound-guided real-time feedback with targeted neural and muscle interventions may facilitate neuromuscular re-education of the rotator cuff and bridge the gap between restored passive motion and functional performance after MUC.