My treatment philosophy is guided by 2 core principles: 1. I optimize my patients' recovery time frame as much as possible. 2. I empower my patients to be as independent in their rehab as much as pos...
In this article, I will tell the story of Ms. V., who has had pain in her right shoulder for over a decade. Although chronic shoulder pain is a very common clinical presentation, what distinguished her case and made me want to tell her story, is that it was referred from the spine. As always, identifying details and descriptions were modified to respect patient anonymity.
Her pain being referred from the spine means that the source of her pain was not in her shoulder but in her neck. As explained in my article on referred pain, referred pain is when the pain you feel in one part of your body is actually caused by irritation at another part of your body.
Ms. V. had had pain in the superior part of her right shoulder in her late 50s. The pain came on gradually without being caused by any trauma or activity. Over the years, it worsened to the point that just lifting her arm to grab things or showering was painful. Now in her 70s, this pain was preventing her from enjoying her much-deserved retirement.
Ms. V. had been proactively looking for a solution for her pain. In 2016, she had an MRI which showed a partially torn right rotator cuff, which is a group of muscles covering your shoulderblade and accomplishes functions such as helping you lift your arm and providing stability during movements. After working hard with other physical therapy, where she performed many rotator cuff mobility and strengthening exercises, she felt more robust and more mobile than before, but her pain did not change.
The MRI results combined with her lukewarm results in physical therapy led Ms. V. to consult an orthopedic surgeon. This ultimately led to her decision to undergo surgery: an arthroscopic repair of her rotator cuff.
Following her rotator cuff repair, Ms. V.’s pain was mostly abated. The pain still came back from time to time, but it was “90% better” than before. Instead of being something that prevented her from doing essential activities, it was more of an annoyance.
In late 2021, however, this exact pain started coming back with a vengeance, and again for no apparent reason. Whereas in the early 2010s, it took a few years for the pain to grow to the level where she had to seek care, this time it progressed back to the old intensity that made her get surgery within a month. Thus she decided to consult in physical therapy with us.
Ms. V.’s evaluation and subsequent treatments took place over the course of four sessions, each taken about a week apart. After those four sessions, she was rid of her pain. Following a customary phone call that I do two months after all my discharges, I confirmed that she remained better.
During the evaluation, Ms. V. presented with the signs and symptoms of a torn rotator cuff, as supported by her MRI. However, something interesting I picked up was that she had many signs that indicated the possibility of referred pain.
To test whether her shoulder pain was coming from her spine, in this case, her neck, or not, I did the following test:
1. I evaluated Ms. V.’s baseline condition by observing how she performed certain neck and shoulder movements.
2. I asked her to perform 20 repetitions of a specific neck exercise, in this case, neck retractions and extensions.
3. I re-evaluated Ms. V.’s baselines. After performing the neck retractions and extensions, most of the pain she felt during shoulder movements had completely disappeared.
To explore this further, I asked Ms. V. to continue doing this neck exercise, and only it, for an entire week, about 6 to 8 series of 10 per day. I suspected that since only doing 20 repetitions in our evaluation helped her, perhaps doing 60-80 repetitions every day for a week would help even more.
In session #2, my suspicions were confirmed: Ms. V.’s shoulder was far from being completely pain-free, but her pain had abated by 40%. Keep it mind that this is a pain that had only been getting worse and worse every week, and that it now decreased without her even needing to perform any shoulder exercises or treatment!
We were already on the right path, so our next two sessions consisted of progressing Ms. V.’s neck exercise whenever she plateaued as well as giving her activity-specific shoulder exercises in order to help her return to the sports that she loved.
As explained in the introduction, Ms. V.’s shoulder pain was referred from her spine. This means that there existed neck movements that either decreased or increased her shoulder pain. There are 6 signs that could indicate that a patient’s pain may be referred from the spine: you can read about them in detail in the “What could indicate that I have referred pain?” section of my referred pain article.
Ms. V. had 3 out of the 6 signs:
1. She frequently felt a burning pain in her shoulder.
2. She had a history of neck pain.
3. Her pain had an insidious onset (it did not come due to an accident or trauma).
During the interview, which is how I start all my evaluations, I always listen attentively to the story my patients tell me and aim to identify if they have any signs of referred pain. Since Ms. V. had 3 positive signs, I knew that I had to conduct a thorough spinal screen in order to properly rule out referred pain.
Referred pain is not a common occurrence, but it is something that needs to be ruled out in any treatments, whether through the interview or the baseline assessment explained previously.
It’s very logical: if your shoulder pain were coming from your spine and could be decreased by just performing the right neck exercise, wouldn’t that be preferable to getting a cortisone injection or shoulder surgery?
All of this may sound quite strange. I don’t blame you. You come here trying to get rid of your shoulder pain, and here I am suggesting that we have to look at your spine!
But referred pain is actually more common than you may believe. In a prospective cohort study conducted in 2020, “A study exploring the prevalence of Extremity Pain of Spinal Source (EXPOSS)”, which evaluated 369 patients with pain not originating from a trauma, 43.5% had a spinal source of symptoms.
This number was greatest in the hip, at 71%, and in the forearm, at 83%! Now, we have to keep in mind that the study was not randomized and that it is but one study, but it is still enough to make us consider the spine as a possible source of pain in the arm and leg.
Why did the MRI Ms. V. had in 2016 show a partially torn right rotator cuff? If that is the case, how come her shoulder improved before we even started doing any shoulder exercise?
Well, it turns out that our MRI results are often not the best indicator of how our condition should be treated. According to a paper called “Bilateral magnetic resonance imaging findings in individuals with unilateral shoulder pain”, rotator cuff tendinopathy (degeneration of the tendons in your shoulders) was found 92.7 % of the time in painful shoulders. In comparison, it was found 88.6% of the time in non-painful shoulders.
If rotator cuff tendinopathies can be found even in shoulders with no issue, could it truly be singled out as the cause of Ms. V.’s shoulder pain?
All of this is explained in greater detail, for the shoulder as well as other joints such as the low back and knee, in my colleague Eric-Olivier Sirois’ article on MRI results.
This is why it is important for us healthcare professionals to always treat the patient that is in front of us, and not an image. MRIs are powerful tools with various uses such as ruling out fractures and other red flags, but they are not the end-all-be-all of patient diagnostics. If I had only taken her previous medical history into account, I would have never identified that her shoulder pain originated from her neck and achieved the results that we did.
The last point I would like any reader to take away from this case study is the power of patient autonomy. What I loved doing the most during my work with Ms. V., as well as with any of my other patients, is to empower them to better understand and treat their own conditions.
In order to decrease her shoulder pain by 40% in just a week, she did not need any special manual therapy techniques, any special massaging, or electrical machines. All she needed was an understanding of referred pain and the willingness to try out the exercise.
Our body is our most important material possession, and so it is important for us to make sense of how it works and how to help it recover when we are in pain.
Helping my patients be as autonomous in their recovery as possible is one of the 2 core principles of my physical therapy philosophy. To read more about it, you can check out this article.
If any of the information or stories in this article speaks to you, feel free to check out my profile to read more of my articles or to book a 1-hour private room evaluation with me.
If you’d like to discuss any of the points raised in this article in more detail, I would love to speak to you. You can contact me by email at email@example.com or by phone at 438-801-0417. I currently offer free no-strings-attached 15-minute phone call sessions to discuss how I can best assist you.
Here are some suggestions of articles I have written recently, organized by topics.
Knee pain: case study 1
Shoulder pain: case study 1
Images courtesy of: Harvard Health, Ortho Info, Juniper Publishers, Medical News Today
Rosedale, R., Rastogi, R., Kidd, J., Lynch, G., Supp, G., & Robbins, S. M. (2019). A study exploring the prevalence of extremity pain of spinal source (EXPOSS). Journal of Manual & Manipulative Therapy, 28(4), 222–230. https://doi.org/10.1080/10669817.2019.1661706
Barreto, R., Braman, J. P., Ludewig, P. M., Ribeiro, L. P., & Camargo, P. R. (2019). Bilateral magnetic resonance imaging findings in individuals with unilateral shoulder pain. Journal of shoulder and elbow surgery, 28(9), 1699–1706. https://doi.org/10.1016/j.jse.2019.04.001