The Clinical Coach: Five practitioners. Nine years of pain. How did we solve the unsolvable?

Happy Friday

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On to today’s newsletter

One of my very first patients, we’ll call her Sam, was a 30 year old front desk attendant at a hotel near my office in St. Charles. She was recommended to my office from Reddit.

This is her story.

Sam’s History

Sam was a healthy 30 year old front desk attendant at a hotel near my office in St. Charles. She presented to my office with chronic right shoulder pain with mild neck stiffness and occasional headaches.

As I was going through her intake, something stood out — nine years of pain. 

This is how long she’d been experiencing the same shoulder pain.

She had done about EVERYTHING in the book.

Her PCP sent her to a DPT — completed rehab but pain returned in a few weeks.

Her DPT sent her back to her PCP. She was prescribed muscle relaxants.

These made her drowsy and affected her work.

She went to a DC — pain improved for a few days then came back

She went to a massage therapists. Felt good for a week, then the pain was back.

She went to an Acupuncturist. Completed six treatments and felt nothing.

For nine years, she’d been trying things. With little to no overall benefit to her.

It had been one years since her last visit to a provider in her attempt at solving her shoulder pain.

It was busy season at work and her pain was jumping from a constant 4/10 to an 8/10 everyday. Leading to neck pain, headaches and occasionally a migraine here and there.

When I asked her how she heard about me and my office. Sam mentioned she’d been recommended by someone on Reddit.

Back then I was oblivious at what Reddit was. I made not of it, and continued with our visit.

NOTHING.. and I mean nothing was coming up.

Was there original trauma? No

Was there aggravating movements? No

Was there weakness? numbness? heaviness? No

Did the pain wake her at night? No

The pain was only there when she was awake, and would usually set in about 20-30 minutes after waking.

I ran her through a full SFMA of the upper extremity. Nothing.

I ran her through a battery of orhto’s. Nothing

I ran her through parROM. Finally, something.

During active & resisted shoulder flexion, Sam tends to over use her trap on the right side only.

Could this one thing be the cause of her pain?

For nine years?

Functional Assessments?

I needed more information.

So we tested her traps with manual muscle tests.

• Good muscle tone.

• Good strength

• Great unilateral control.

Was I missing something?

We cued her into the DNS 3 month prone position. What did we find?

• Right trap elevation.

• Inability to depress her scapula

Obviously now I needed more information. So I loaded her up to see how her shoulder reacted.

• Push-up position.

• Goblet Stance position

They all showed the same thing.

When loaded, Sam is unable to control her scapula. Her trap takes over.

The only problem, is Sam wasn’t a fitness enthusiast.

Aside working, and socializing with friends, she didn’t spend much time at the gym or participating in extra curricular sports.

Did I miss something?

As any good clinician I assessed the:

• pec major

• levator scap

• Serratus Anterior

• cervical paraspinals

• thoracic paraspinals

• rotator cuff muscles

• SC, GH and AC joint

• Scapular movement.

Not only to solidify our diagnosis, but to make sure I wasn’t missing anything else.

After I explained what I had found and how it explained a lot of her symptoms she agreed to the treatment plan as follows:

• DNS 3mo prone 20s with specific cues to control scapula/serratus anterior

• Trapezius muscle soft tissue

• Levator scap soft tissue

• C/S adjustment PRN

She went home with two exercises:

• banded pull-aparts

• DNS Plank with same focus as in office

At the end of the visit she reported almost instant relief, but was cautious as she knew relief was expected.

She grabbed her purse, hung it on her shoulder, scheduled her next visit and left.

A few days later she returned.

Pain improved 20% from her initial visit. We did the same treatment.

At the end of the visit she grabbed her purse, hung it on her shoulder, scheduled her next visit and left.

This went on for 3 weeks (a total of 4 visits).

On her fifth visit she noted almost 80% improvement from her initial visit.

But her pain usually ONLY started when she grabbed all her stuff to leave home and drive to work.

The missing link

I asked her if she ever carried a different purse.

She said yes.

Where they all the large tote kind?

She said yes.

Did she always carried it on the same side?

She paused.

She said yes.

Silence took over the room for a few seconds. We both knew what was coming up next.

“I’m pretty sure it’s been your purse all along.” I said.

She fought me for a minute. It couldn’t be the purse. She’d been carrying one forever!

We finished our appointment and I asked her to switch her purse to the other side at least for the next week.

Small changes, HUGE results.

In her sixth visit Sam walked in with a HUGE smile in her face.

“ZERO PAIN!” she exclaimed, as she bursted out laughing. “ZERO!”

I laughed with her and asked what had changed.

Sam had not only switched sides carrying her purse. She had completely switched from a large tote one-sided bag, to a very compact backpack.

The last time she had felt pain. Right before our 5th visit.

Sam had experience zero shoulder pain, zero neck pain, and zero headaches for a full week!

She was SOOO excited! (so was I)

Trust builds loyalty

That was her last day in active care. Afterwards she moved on to PRN and decided that she wanted to come in every 3 weeks. Just to keep things in check.

Soon she decided to start working out and joined a CrossFit gym.

For 3 years Sam was a wellness patient at my office in St Charles. Sometimes the neck would get aggravated, but for 3 years Sam had zero shoulder pain.

There were weeks were she’d just come in to get a “crack” because it felt good.

Clinical Pearls

If you can watch your patients walk in, sit down and then stand up as they walk into your treatment room, you’ll learn a ton more about how they truly move, about how they carry themselves and most important about how the items they carry might be influencing their pain.

Every patient is unique.

Make sure you take the time to understand them.

Until our next issue!

In health and strength,

P.S. If you have questions or comments, feel free to respond to this email. I reply to all emails personally.

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