Gathering place for osteopaths
Patient with scapular winging & inability to elevate arm
41 year old man, AV technician, presented with right shoulder pain of 1 week o/s, localised to the bicipital groove/deltoid insertion area. He didn't report any Csp or neurological symptoms and is medically well. 1 month ago he was hit by a bicycle (as a pedestrian) into the left hand ribs (according to the pt).
Upon examination, the patient was unable to elevate the right upper limb beyond about 90deg (in both abduction & flexion) and there was significant scapular winging on the right, which was shown again when testing the serratus anterior. Myotomes on right were slightly weaker C4-C5 with a generalised "dull ache" throughout all the muscle testing. (I will admit that I need to actively test each of the muscles better next time). Active spinal movements were very reduced, sway back posture, and general poor muscle tone, ESP in the shoulder girdles.
So...I'm a little bit baffled. DDx's of Parsonage Turner Syndrome or Fasiculo-glenohumeral muscular dystrophy have popped into the back of my mind, but what could be some of the more simpler explanations for this presentation?
Also, how would you treat this patient/scapular winging in general?
I look forward to hearing your views..!
Replies to This Discussion
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Permalink Reply by indikate on -
Hi Monica
Thank you for sharing the information about your patient, sounds like one of those "tricky shoulder problems" so beloved by us all
It may be worth checking the AC joint, see if the shoulder is slightly anterior and if the clavicles and first ribs are dancing together, some pathologies of which you are aware may or may not be involved but first see how the anatomy is moving then maybe spend a little time listening to the tissues periperherally and centrally as they may reveal the state of health in the local tissues and the patient himself.
It is always worth a look at the deep cervical fascia in these cases, does he have axilla discomfort, congestion?
I would start at the feet and work up in a case like this.(sacrum, diapragm etc, head if its your thing) to make a diagnosis
Hope it helps
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Permalink Reply by Small Fry on -
It's hard to analyse a case that isn't in front of you, it's easier with a phone call. It takes a discourse rather than a simple answer. Hence for times like this it is worth having an experienced mentor available.
It's easy to find yourself lost in the specific diagnosis, sometimes zooming out and looking at the broader picture really helps. Some of the most surprising successes come when you realise there isn't time to work it all out in fine detail, so you just go for the most obvious big-picture features, not forgetting the role of general health. You might not even touch the injured part directly, not least because you're only going on a working diagnosis. The rest is confidence, because you won't always know what you have done to help, until next time you see them, when they tell you about the improvement!
I guess what ik is driving at is if you're not sure why tiles are falling off the roof, at least check the foundations, in which case I would agree.
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Permalink Reply by indikate on
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Exactly, and in this process of analysis a diagnosis usually pops up. I must say for me this seems to take a bit of time these days (list time one hour up from 30 mins when I started) but it is a fascinating way to work and is often very appreciated by the patients.
It is maybe the case at the moment that you are concerned about the winging, wheras he will be concerned about the shoulder symptoms, which is why this may be a particularly good case for being "zoomed out" holistic to find the common ground.
pls let us know your thoughts Monica
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Permalink Reply by Man Dibble on -
In addition to all that has been said, sway backs are prone to shoulder problems. Look at his arch mechanics and how this will effect the shoulder and scapula, lateral curves will often produce winging, the trauma could cause all sorts of problems or could have just have been the final straw on the camels back, often the specifics will not make much sense so look at reducing the strain in general.
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Permalink Reply by Roger Kingston on -
It sounds like the central stability processing has been compromised.
The only effective way I have ever found is using Prof Pavel Kolar's DNS approach of reflex stimulation and rehabilitation exercises. www.rehabps.com
As now taught at post grad at the ESO in Maidstone.
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Permalink Reply by Small Fry on
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It works even better if you change the old dilithium crystals for new ones at the same time.
Roger Kingston said:It sounds like the central stability processing has been compromised.
The only effective way Ihave ever found is using Prof Pavel Kolar's DNS approach of reflex stimulation and rehabilitation exercises. www.rehabps.com
As now taught at post grad at the ESO in Maidstone.
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Permalink Reply by Francine Tseng on -
is his scapular-winging pivoting around the acromio-clavicular joint... and is the winging more pronounced, when he actively moves his neck into certain directions? if so, then one of the possible causes of his problem, could be a somatic dysfunction at T2...
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Permalink Reply by Wes on -
Hi all, nice challenging case and nice input from everyone so far.
I agree with Small fry about the difficulty in speculating when you can't sense the person/problem... however, as a very general rule, my thoughts on shoulder issues that do not have a sudden traumatic onset like falling/throwing/forceful use of upper extremity... is that some structures are failing (very frequently at the site you mention - anteriorly generally and close to the bicipital groove) because the upper extremity has poor connection to the thorax, particularly the posterior myofascial routes as well as serratus anterior
And by connection i mean on many levels... weak, poor condition of muscles and fascia intergrating the arm with ribcage and pelvis, poor control, lack of awareness of movement and the very connection i'm speaking of.
I do believe that all things can and do have an effect regarding the totality of an individual on all levels not just the physical...but i also strongly believe that deviations from the usual shape/form regarding spinal curves it not as important as our studies would have us believe when it comes to functional ability. I say this as i experience this in myself, i have altered curves etc but function physically at a high level... i believe because the control and awareness of my movements/myself are very good. Im sure there are many examples in the sporting world...Usain Bolt is a good one, he has a proper lateral curve and lege length descrepency but is the fastest sprinter.
Anyway, my point is i bet he has poor awareness and control of how his arm attaches /intergrates with the rest of him. All somatic dysfunctions will be a result of poor usuage, excluding of course traumatic causes and assuming a fairly normal nutrition, genetic and emotional history.
If you get him to explore these connections both actively and passively so that he can intergrate his arm more fully, it'll improve fast. Here is where i believe all the schools fail us in our training, clever academics and not enough encouragement in experiencing movement ourselves and hightening our self awareness.
I'm very interested to hear what you all think and if you understand where i'm coming from.
http://www.ted.com/talks/daniel_wolpert_the_real_reason_for_brains....
TED Air (http://goo.gl/2Aftm) this is an interesting video and emphasises both my points... importance of awareness and control, and too much cleverness not enough sense.
Wes
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Permalink Reply by Small Fry on
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In health, a shoulder serves the hand. Whatever the hand needs to do, the shoulder dutifully and silently orients itself to provide a platform, usually below the level of awareness. In injury, it switches. The function of the hand changes to protect the shoulder from movements that may harm it. One recognised obstacle to recovery is that the patterning of movement in the brain becomes disrupted, and attention is drawn continually to the shoulder, when really in health we want to forget all about the shoulder.
In physical training, or in rehabilitiation there may be a case for turning detailed mental attention to our bodies, but in health the body is an agent for greater expression, and operates for the most part below awareness. The objective of recovery is to reach a point where it is not necessary to think about every position and every motion all the time.
Hence it is a mistake to think that the cause of the problem is a lack of motion training or of body awareness. At root there is an injury, perhaps direct or perhaps caused by the body's postural response - through contraction or contracture - to some acute stress or strain. Hence whilst I believe the osteopathic remit may be broad, it's falling short to overlook huge importance of the bodywork, which presumably is what this patient is expecting.
By all means look into the rocket science if that interests you, but please please do not overlook the basics. When I see cases that have failed to respond, that's usually the mistake that's been made.
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Permalink Reply by Wes on
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Nice point Small Fry, but i do not see the hand as separate from the shoulder or the shoulder as subservient to the hand.
I see the hand as an extension of the shoulder, of the mind in fact... a tool with which we can manipulate our surroundings with. To even consider them as separate misses the truth i believe, of how truly integrated we really are.
You say that in health the body is an agent for greater expression, but there is no way that we can express ourselves without moving some part of ourselves. Also, we all know moder man suffers from many dis-eases that brew below the surface of our conscious awareness and this is the same for the musculoskeletal system, acute stresses and strains are no excepction. How we move is paramount to our health, in every sense.
Say someone has strained or injured as you say, the tendon of the long head of the biceps, i believe the tissue is under too much strain because of poor connection of the arm to the body in the first place. By this I mean that the long head of biceps is transmitting more force to the scapula than it should be (also true of the rotator cuff) because the latissimus dorsi, lower tapezius, rhomboids, serratus anterior, triceps etc are in a poor state and under-used. Unable to dissipate force themselves sufficiently and transmit forces globally than just through the rotator cuff or biceps. Poor shoulder girdle posture, thoracic lack of compliance etc are all the same thing.... the patient not being in their body as much as they could be, should be... lack of BASIC awareness and control. Tissues break down over time because they are used poorly, asked too much of, whilst others never truly reach their potential, never really enter into consciousness.
no acute stress or injury happens without cause, and how parts are used or misused over time must not be overlooked. This is i believe very difficult, to look at and feel someone, and understand how they have become what is in front of you, over time, through they way they have conducted themselves and lives.
The point is truly fundamental to health, rehabilitation is not what i am speaking of, embodied awareness is getting closer with words.
The beauty of osteopathy is that it recognizes the importance of the musculoskeletal system to our health. You understood me wrong if you took it that i just get people to exercise, far from it.
I treat usually for an hour, because i find that the vast majority of people are not very aware of themselves, or the problem. I treat to address all the things mentioned and have found to be relevant to the individual case. I bring life to underused tissues, warmth, bloodflow, sensation, AWARENESS through touch so that the patient can understand more fully what state they are in. I try to influence postural balance, but always making the patient aware somehow of why and how!
then i get them to experience themselves via movement and sensation, so that they can push the changes necessary themselves, ongoing.
i hope that is a little more clear :-)
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Permalink Reply by HVTand Artic on -
Dear Monica Have you considered injury to the Long Thoracic nerve?
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Permalink Reply by Adrienn Fulop on
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I know this kind of Differential Diagnostic thinking is what makes us osteopathic but I find this very far out there. Sorry Monica but your DD's are sooooo far out there!
It is just probably a local injury, overuse. What it really needs is some rest from aggrevating activities, daily rythmical soft tissue-articulatory type treatment (taught to the patient so they can do it every day not just when they come for treatment).
I don't believe that we can change anybody's posture not unless we loosen their tight muscles daily and they exsercise the weak ones daily, they change their jobs and get counceling to change their body image. And if this regime stops their posture will revert back to what it used to be within weeks. Just remember how quickly muscle looses tone when you stop excercising regularly.
There is a lot of research out there that just couldn't find connections between postural misalignments and back ache. There is a great paper about this on Eyal Lederman's website.
Off course we should advise the client about excercises they could do to improve muscle balance but I think what we can truly achieve in our 30min-1hour time once a week is some help with local tissue healing which will reduce symptoms.
Sorry if this is not very osteopathic but I think it's a lot more realistic then treating someone's foot because they have shoulder pain. That kind of DD is very impressive to the clients...they think we are amaizing for making this kind of connection, but I'm afread you will not change anyone's posture by articulaing their foot for half an hour and showing them excercises that they will stop doing after a week.
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