In our last post, we met Bill and his wonky shoulder (if you haven’t read this case yet, go read that first, before continuing on! You can find it here)
We’d gotten Bill sorted with a home exercise plan to improve scapular mechanics, and we also did a bunch of soft tissue work and acupuncture to reduce tension in the anterior deltopectoral region. Bill was feeling great…a little bit too great.
Now what happens if things don’t go according to plan?
Bill was feeling SO good, that he took it upon himself to go back to doing pushups before we gave him to go ahead….and disaster strikes! His shoulder gets super flared up, he can barely lift his arm. The pain is located at the front of the shoulder, and the worst movement is reaching out in front. Now what do we do??😖
Well, upon reflection, we really should have been more careful to keep a short leash on Bill. We know he’s a go-getter at work, and pushes his body hard (anyone who hikes up mountains for fun has a little too much appreciation for suffering, in our opinion). So now we are back to doing some easy pendulums and shoulder isometrics, as we do some systemic regulatory and axial needling to settle things down. Hopefully this is just a flare up of his biceps tenosynovitis (did we mention that Bill’s family doctor ordered an ultrasound a couple weeks ago? We probably forgot to mention it because it was pretty ho-hum. A bit of supraspinatus tendonitis, a bit of inflammation around the long head of biceps - to be expected!)
Pro tip: this is often the expected natural history of anterior deltopectoral myofascial tension - makes it harder for the scapula to do its job and for the rotator cuff to centrate the head of the humerus, which often irritates the supraspinatus and inhibits the rotator cuff, and then the last man standing is the poor biceps - which then of course starts to get inflamed because he’s trying to do so much work on his own!)
So we send Bill off for a few days with his super easy exercises, with the intention of settling down the inflammation. Easy peasy, right? Wait, there’s a twist!
Bill reports back at his next session that after a couple days he developed shooting pain and tingling down his arm. 👀 What!!
So when Bill’s family doctor ordered the ultrasound of his shoulder, she also ordered an x ray of the neck and shoulder, which showed that he had arthritic changes at C5-6. Makes sense - the main nerves that affect the shoulder are being irritated at their source. What we didn’t know was just how irritable that spinal segment and its peripheral nerves were - the traction motion of the pendulum exercises created neural tension, and now we’ve got a neural sensitization on our hands too! 😭
So where to go from here? Well, Bill is leaving on vacation next week and wants to be able to enjoy himself, so we’ve got to buckle down. In addition to doing lots of segmental and systemic regulatory needling, we also referred him to our physician colleague - he’s a pain specialist who can do injection therapy. He did an ultrasound examination in his office and found tons of inflammation around the long head of biceps, so he did a cortisone injection there and a few nerve blocks and our patient has settled right down and can enjoy his trip. Phew! Crisis averted.
We sent him off with strict instructions to stick to his prescribed physio exercises only, and we’ll rebuild his tolerance for loading when he comes back. We know now that we have to go super slow with this patient - he really needs to make sure to stay within his tolerances and progress incrementally. We’re also going to have to really focus on treating his neck. This is where our acupuncture skills come in super handy - it's the most effective way to communicate with a pissed-off peripheral nervous system!
So here we have a case that started out simple, where we can apply our framework and get good results relatively easily - and for most cases, that’s all you need to do! But then sometimes things don’t go according to plan, and that’s when it's important to know how to adjust. Our most important teachers are our patients - everything we needed to know to treat Bill was right there the whole time, it's just a matter of knowing where to look and what to pay attention to. The longer you are in practice, the more of a database of cases like this you will have to form your pool of experience to draw from. Want to speed this process along? Discuss your tricky cases with a mentor! Jump on a free call with us by clicking the booking link below.
¹ Want to learn more specific functional assessment measures? Check out Dr Mike Prebeg’s excellent Foundations in Neurofunctional Assessment course https://skillsinhand.com/
² We think Dr Alejandro Elorriaga’s Neurofunctional Soft Tissue Microconditioning is the best (www.mcmasteracupuncture.com), but Jim Bilotta’s Soft Tissue Release course is a fantastic intro (https://softtissuerelease.ca/)
³ ACE Massage Cupping (https://massagecupping.com/?gclid=Cj0KCQiA6vaqBhCbARIsACF9M6lyBNqqvPKczPPqpou4bgnvGhPSerxKpL6qdjXOw1nq_QOA26XOoHUaAjA3EALw_wcB) does a fantastic intro course, but this is a tool that is very appropriate to get a quick lesson from a mentor on and practice on yourself - it's not hard to learn the technique!
⁴ The Heskiers tool (www.heskiers.com) is by far the most ergonomic, but a low-budget version works just fine too - you can find Gua Sha tools for under 10$ at Chinese medicine retailers or Amazon
⁵ Want to learn how to effectively change your patients’ movement patterns? Check out Sally Belanger’s courses at Link Advanced Movement Mechanics https://linkamm.ca/link-education/
Comments