Archive for December 2010

Anterior Shoulder Pain!

The following is an interesting sequence of events of a new granddad who had recently been carrying around his 20+ pound grandson.

Case Presentation

A young grandfather was in my office the other day and his main complaint was left anterior (front) shoulder joint pain.  He denied any neck symptoms and no complaint of radiating symptoms.

Observation

He sat with his left shoulder lower than right.  His trunk was side bent to the left.  His shoulder elevation was limited by 15 degrees but not painful.  Resisted flexion and rotation of his shoulder reproduced his anterior shoulder symptoms and were weakened (probably inhibited/interfered with by pain and malposition?).  Also his left shoulder was protracted and slightly subluxed anteriorly.

His neck was blocked in left side bending and rotation of the lower neck segments.  He was not aware of this difference until formal testing.  Passive range was also blocked in the lower cervical spine in this left direction.

Also when I tried to side bend him to his left from caudal (head to tail) pressure on top of his shoulder he was easily moved.  Side bending to the right was markedly restricted in the mid thoracic (rib) spine.

Immediate investigation

I started with the hypothesis that there was a strain to the shoulder, possible due to poor stabilization of the shoulder complex–that was brought out in a more pronounced way due to having to carry around his grandson for long periods.  He could have over recruited his neck and set up very poor neurmuscular motor and sensory flow to the upper quadrant area.   Since he had such a pronounced movement dysfunction in thoracic side bending, I thought it would be interesting to see what if anything this lack of side bending may have to contribute.  (Both to mal-position of the shoulder on the opposite side and poor transference of stabilizing forces through the trunk).

  1. Tried to initiate active assisted trunk side bending to his right (remember he was already in a left side bent position).   This did not occur readily so looked lower.
  2. His right hip was carried in external rotation in sitting, his right hip internal rotation was limited.
  3. In sitting:  immediately had him place his right hip in internal rotation (foot out to the right side)–until we could cause him to shift his weight onto his left IT (sit bone) and gently start encouraging his trunk to side bend to the right–slowly as this side bending became easier we facilitated left side bending also of his lower neck segments.
  4. Had him sit straight again and noticed:  His shoulder less protracted and less subluxed.  He gained 10 degrees in shoulder elevation.  His resisted movements were much less provocative but still weak in external rotation.
  5. Finished with some activating/strengthening/stabilizing exercises for the scapula and shoulder complex.  Included cervical and thoracic active mobility also.
  6. Upon completion of the exercises, there were no reported symptoms with the previous provocative movements.

Summary

OK, not everything that walks into my office has such an easy resolution.  I just thought this case at least demonstrates some of the interesting connections that I find in working with people.  Also it has been my experience over many years that once could have started in different places and shown success.  I think success does not necessarily always mean such a quick resolution to a person’s problem.

One of the most important points I find is to see the relationships that exist.  Possibly an isolated approach of the shoulder or neck may have proved helpful.  If the whole pattern that is involved is not understood/recognized, then in more protracted cases, important elements may be ignored.

Now

Let me know what you think.  If there is any way I can be of service, please contact me here, for a consultation.  Thank you.

Holiday Wishes

Holiday Wishes for Us All


The

Cab Ride


I arrived at the address and honked the horn.
after waiting a few minutes
I walked to the
door and knocked.. ‘Just a minute’, answered a
frail, elderly voice. I could hear something
being dragged across the floor.

After
a long pause, the door opened. A small woman in
her 90’s stood before me. She was wearing a
print dress and a pillbox hat with a veil pinned
on it, like somebody out of a 1940’s
movie.

By her side was a small nylon
suitcase. The apartment looked as if no one had
lived in it for years. All the furniture was
covered with sheets.

There were no
clocks on the walls, no knickknacks or utensils
on the counters. In the corner was a cardboard
box filled with photos and
glassware.

‘Would you carry my bag
out to the car?’ she said. I took the suitcase
to the cab, then returned to assist the
woman.

She took my arm and we walked
slowly toward the curb.

She kept
thanking me for my kindness. ‘It’s nothing’, I
told her.. ‘I just try to treat my passengers
the way I would want my mother to be
treated.’

‘Oh, you’re such a good
boy, she said. When we got in the cab, she gave
me an address and then asked, ‘Could you drive
through downtown?’

‘It’s not the
shortest way,’ I answered
quickly..

‘Oh, I don’t mind,’ she
said. ‘I’m in no hurry. I’m on my way to a
hospice.

I looked in the rear-view
mirror. Her eyes were glistening. ‘I don’t have
any family left,’ she continued in a soft
voice.. ‘The doctor says I don’t have very
long.’ I quietly reached over and shut off the
meter.

‘What route would you like me
to take?’ I asked.

For the next two
hours, we drove through the city. She showed me
the building where she had once worked as an
elevator operator.

We drove through the
neighborhood where she and her husband had lived
when they were newlyweds She had me pull up in
front of a furniture warehouse that had once
been a ballroom where she had gone dancing as a
girl.

Sometimes she’d ask me to slow
in front of a particular building or corner and
would sit staring into the darkness, saying
nothing.

As the first hint of sun was
creasing the horizon, she suddenly said, ‘I’m
tired. Let’s go now’.

We drove in
silence to the address she had given me. It was
a low building, like a small convalescent home,
with a driveway that passed under a
portico.

Two orderlies came out to
the cab as soon as we pulled up. They were
Solicitous and intent, watching her every move.
They must have been expecting her.

I
opened the trunk and took the small suitcase to
the door. The woman was already seated in a
wheelchair.

‘How much do I owe you?’
She asked, reaching into her
purse.

‘Nothing,’ I
said

‘You have to make a living,’ she
answered.

‘There are other
passengers,’ I responded.

Almost
without thinking, I bent and gave her a hug. She
held onto me tightly.

‘You gave an
old woman a little moment of joy,’ she
said.
‘Thank you.’

I squeezed her
hand, and then walked into the dim morning
light.. Behind me, a door shut. It was the sound
of the closing of a life..

I didn’t
pick up any more passengers that shift. I drove
aimlessly lost in thought. For the rest of that
day, I could hardly talk. What if that woman had
gotten an angry driver, or one who was impatient
to end his shift?
What
if I had refused to take the run, or had honked
once, then driven away?

On a quick
review, I don’t think that I have done anything
more important in my life.

We’re
conditioned to think that our lives revolve
around great moments.

But great
moments often catch us unaware-beautifully
wrapped in what others may consider a small
one.

PEOPLE MAY NOT REMEMBER EXACTLY
WHAT YOU DID, OR WHAT YOU SAID ~BUT~THEY WILL
ALWAYS REMEMBER HOW YOU MADE THEM
FEEL.

is the random acts of
kindness that most benefit all of
us.

Anonymous:  From the Expanse of WWW