A 65-year-old male patient with a history of ischemic cardiomyopathy developed 
ventricular tachycardia resulting in presyncope. An ICD was indicated for 
secondary prophylaxis of ventricular tachyarrhythmias. A dual chamber ICD was 
implanted from the right side because insertion of the device from the left side 
was unfeasible after surgery of a left subscapularis tendon lesion. ICD 
implantation and testing of defibrillation threshold were uneventful. During 
early follow-up a progressive increase of the stimulation threshold was 
detected. On chest X-ray coiling of both atrial and ventricular leads was noted 
and caused inadvertently by active shoulder-arm physiotherapy. Complete revision 
of the ICD system was necessary for restoration of the pacemaker function of the 
ICD. This unique case highlights important steps for early recognition and 
prevention of Twiddler's syndrome that may occur due to physiotherapy treatment 
even without abnormal manipulations by the patient.