Shoulder Pain

[c.falco]

Ok, I've been trying to figure this out for a while now. I think I have it nailed down, but want an outside professional opinion on it.

One of my clients has been complaining of shoulder pain. He is an avid golfer and has recently started going to the driving range and doing some preliminary rounds on the courses around here. His shoulder doesn't bother him when he's swinging the club though. It hurts with shoulder abduction and shoulder horizontal flexion mostly, with minor pain with shoulder flexion. Is this indicative of an injury to the Supraspinatus?

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[neurospast]

Well not necessary Supraspinatus. Impinchment likely. You need to do some testing here. Like empty can, scarf test. Supraspinatus most active early abduction, stretched on adduction. With abduction and flexion there is a lot of pressure on AC Joint. and so on. So you need to look into the biomechanics of the shoulder(girdle) and possible neuro irritation before you can answer this question. Work to do!

[tonywoodall]

The shoulder can be the most difficult to treat. Multiple diagnoses can be made, depending on the Physios experience.
If there was no direct trauma and assuming no condition like Rheumatoid arthritis, Gout etc, then it is likely that the problem is refered pain from the spine. In general, Anterior shoulder pain is from the upper Cervical spine, lateral pain is from the C6,7, T1 area and posterior pain from the C6 to T3 area. Often there is a upper Thoracic spine Kyphosis and a resultant Cervical Lordosis. Calcification of ligaments at the shoulder can result from a chronic condition and this may require surgery.

So the Physio may choose to mobilise and or manipulate the upper spine + or - the other Physio teatment modalities.

[neurospast]

The shoulder can be the most difficult to treat. Multiple diagnoses can be made, depending on the Physios experience.
If there was no direct trauma and assuming no condition like Rheumatoid arthritis, Gout etc, then it is likely that the problem is refered pain from the spine. In general, Anterior shoulder pain is from the upper Cervical spine, lateral pain is from the C6,7, T1 area and posterior pain from the C6 to T3 area. Often there is a upper Thoracic spine Kyphosis and a resultant Cervical Lordosis. Calcification of ligaments at the shoulder can result from a chronic condition and this may require surgery.

So the Physio may choose to mobilise and or manipulate the upper spine + or - the other Physio teatment modalities.

Dear Tonywoodall; could you please explain why you come to the conclusion that anterior shoulder upper C-spine thus C1-4 ( do you mean C3-C5?), lateral shoulder C6-T1 and Dorsal C6-T3? Is this based on innervation of the shoulder? What are your findings based on?

[tonywoodall]

Hi Neurospast, My comments are based on the learning process of 26 years as a Physiotherapist in Private Practice. From which I have now retired. I originally followed the path of convention in making a diagnosis based on symptoms and the related book anatomy for about 1 1/2 years. I then remembered a Tutor who talked about the T4 Syndrome, which was never covered in depth. But the information given indicated that formal anatomy based treatment from time to time did not give good quick results.

To cut a very long story short I followed this alternative path and gradually created a new map of symptoms and how they were connected to alternative anatomical locations. So my treatments concentrated on these locations with excellent and predictable results. This is nothing like the "maps" produced by the Acupuncturists.

If you choose to follow the conventional way, you cannot be faulted. But if you are interested in further detail I'll be happy to oblige. It is not easy to break away from convention in the medical arena but now I have retired I can talk about it with impunity. There are not many Physios I know of who follow this T4 Syndrome approach, mostly because if they spoke up they would be shouted down.
Cheers,Tony Woodall.

[Dr Damien]

Dear tonywoodall and neuroplast

Thank you for the insight, i think you guys both have valid points as to the differentials to the problem however c.falco has not given enough information about this clients problem (unless he has done this on a previous thread) for any real input or speculations. I agree with Tonywoodall that shoulder pain definitely can be from a cervicothoracic origin however shoulder movements specifically causing pain indicate that the problem is from the shoulder not the spine. If the pain was constant and not influenced by shoulder movements then I would consider other possible origins. neuroplast is right in suggesting an inpingement syndrome and infact the movements that c.falco have described, some correlate to a scarf test...which opens a whole possibility of other structures being involved.

If c.falco would like our opinion, then there is a need for more information before we can clinically reason the problem...

[alophysio]

Hi guys,

@tonywoodall...i can certainly appreciate your experience and insight but i wouldn't rush to be so definitive of where referred shoulder pain comes from. I have helped many a T4 syndrome patient by fixing their hips...hip dysfunction leading to all sorts of issues ending up with overactive external obliques which lock down the ribs from 5 - 8 and so the T4 moves over a basically immobile T5 causing T4 syndrome. But i would certainly encourage physios to go look further afield than the classic innervation/dermatonal maps

As for the original poster (c.falco), your patient is a golfer who doesn't get symptoms with his golf swing but during classic shoulder testing of ABD and FF and HzF? HzF is usually an AC problem for me, esp if ABD is involved. Test his ABD or HzF with different glides of his AC joint to see what is happening. If there is no structural issue with the AC joint (no laxity etc) then start looking to see why his shoulder motor control is off...support his ribs - the ones which are moving during shoulder motion (none of them should move if he is below 90deg), test his C/S segments - again none of them should move below 90deg. The movement in the joints failing load transfer could be moving during the movement initiation so make sure you are monitoring before the patient even BEGINS to think about moving!!

Cheers!