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.

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