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Chapter 7:
Clinical Chiropractic: The Shoulder and Arm
From R. C. Schafer, DC, PhD, FICC's best-selling book:
“Clinical Chiropractic: Upper Body Complaints”
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Clinical Briefing Shoulder Pain The Complexities in Treating Shoulder Complaints Differential Analysis Acromioclavicular and Related Sprain Bicipital and Supraspinatus Tendinitis Bicipital Transverse Ligament Sprain Calcific Tendinitis Deltoid Strain Palsy of the Arm Periarthritis (Frozen Shoulder) Recurrent Glenohumeral Dislocation Rotator Cuff Strain Shoulder Girdle Neuralgia Shoulder-Hand Syndrome Subacromial or Subdeltoid BursitisChapter 7: The Shoulder and Arm
CLINICAL BRIEFING
Shoulder Pain
Shoulder pain can be deceiving. As in so many musculoskeletal disorders, consideration of pain in the shoulder should not give priority to sudden trauma whether it be of intrinsic or extrinsic origin. Thorough investigation of the history may reveal that trauma did not initiate the first attack or that an injury was just a precipitating event that revealed an underlying degenerative disorder. Besides trauma, shoulder pain may have an inflammatory, a neurologic, a psychologic, a vascular, a metabolic, a neoplastic, a degenerative, a congenital, an autoimmune, or a toxic origin. See Table 7.1.
Table 7.1. Classic Causes of Shoulder PainNeurologic Traumatic Inflammatory Psychologic Vascular Metabolic Cervical IVD Bursitis Cervical Angina pectoris Gout syndrome Cholecystitis spondylosis Arterial thrombosis Pseudogout Cervical sub- Epidemic myalgia Neuralgia Aseptic bone necro- luxation Fibromyositis Neuritis sis Contusion Herpes zoster Neurosis Buerger's disease Dislocation Osteomyelitis Shoulder-hand Coronary insuffici- Fracture Periarthritis syndrome ency Posttraumatic Pericarditis Subluxation Dissecting aneurysm trigger point Phlebitis syndrome Myocardial infarc- Sprain Pleurisy Trigger point tion Strain Pneumonia Thrombophlebitis Traumatic neu- Purulent arthritis Vasculitis roma Rheumatic fever Viscus rupture Subphrenic abscess Syphilis Tendinitis Trichinosis Tuberculosis Neoplastic Degenerative Congenital Autoimmune Toxic Carcinoma Osteoarthritis Cervical dysplasia Dermatomyositis Drug reaction Cord tumor Spondylosis Cervical rib Lupus erythemato Autointoxication Lymphoma Hemophilia sus Pancoast's KlippelFeil syn- Periarteritis no- tumor drome dosa Sarcoma Scalenus anticus Rheumatoid arthritis syndrome
The Complexities in Treating Shoulder Complaints
Many practitioners would be happy if another patient with a shoulder complaint did not enter their offices. There are five major reasons for this:
The shallow shoulder joint is highly unstable. Its stability is provided by muscles rather than the strong ligament straps provided in most other joints. This makes recurring disorders common. The answer is therapeutic exercise, but many patients soon get bored with such regimens and the prescribed exercises are stopped long before adequate strength is acquired. Thus thorough counseling and monitoring are required.
The shoulder area is unique in its wide extremes in range of motion. There is abduction, adduction, downward rotation, upward rotation, and depression in the shoulder girdle. The shoulder (glenohumeral joint) expresses abduction, adduction, elevation, extension, external rotation, flexion, horizontal abduction, horizontal adduction, and internal rotation. Thus, a thorough knowledge of shoulder kinematics, neurology, angiology, myology, and kinesiology is required for proper treatment to be applied.
Cases presenting with what initially appears to be the result of minor trauma are often misdiagnosed. The shoulder and arm are common sites of referred pain from the cervical spine, lungs, heart, mediastinum, diaphragm, liver, and gallbladder. Sometimes a lesion in the wrist or elbow will refer pain to the shoulder. As tenderness also can be referred, a thorough diagnostic workup is required in almost all cases of shoulder pain, tenderness, paresthesia, and weakness. This must incorporate a thorough knowledge of referred pain patterns and reflexology.
The sternoclavicular, acromioclavicular, glenohumeral, and scapulo-thoracic joints form the shoulder girdle complex. A primary disorder in one articulation invariably has its effects on all other joints in this complex kinematic chain. Functionally, the cervical and upper thoracic spine are also part of this complex. Thus attention must be directed to multiple joints and the interconnecting biomechanical, neurologic, and myologic implications. If the underlying cause is a joint fixation, it is rarely the site of complaint. Rather, compensating hypermobile link(s) will be the first be express symptoms of overstress. Thus, knowledge of normal versus abnormal kinematics and motion palpation techniques for each of the many joints in the complex is required. Of course, intraarticular fixation is not the only cause of inhibited joint motion. Joint arthritis, calcification, spasm, contractures, dislocation, subluxation, paralysis, scar tissue, and tumors must be ruled out.
There may be unavoidable occupational stress in the clinical picture that is aggravating the condition and delaying healing. How should the patient react when a doctor says "avoid overhead work" and the patient makes his living as a painter or pipefitter of ceiling sprinkler systems? Temporary rest can be provided but not permanent relief from such occupational stress. It may have taken the patient many years of apprenticeship to reach his present status. This is not easily put aside.
Differential Analysis
With the patient's associated symptoms at hand, the examiner can use inductive and deductive reasoning to arrive at a logical diagnosis. For example, the age of the patient may be an aid as some shoulder conditions have a high incidence in infants while others are more common to the elderly. Roentgenography is often a help in identifying bone and joint swelling, congenital deformities, and tumor and tumorlike conditions. The existence of soft tissue pain or swelling also aids differential diagnosis. In further differentiation, there are some lesions that produce both neck and shoulder pain, certain disorders that produce pain predominantly in the shoulder, and some that typically produce shoulder pain with radiation into the arm. Nerve compression syndromes also have their unique characteristics. See Tables 7.2 and 7.3.
Table 7.2. Upper Extremity Musculoskeletal and Related DisordersBone and Joint Swelling Congenital Deformities Below the Shoulder Infectious arthritis Arthrogryposis Nonpyogenic arthritis Congenital trigger thumb Pyogenic arthritis Constrictions Tuberculous tenosynovitis Finger deformities Cinarthrosis Noninfectious arthritis Polydactylism Avascular necrosis Syndactylism Fracture complications Floating thumb Kienbock's disease Megalodactylism Osteochondritis dissecans Radial club hand Preiser's disease Radioulnar synostosis Gouty arthritis Posttraumatic arthritis Primary hypertrophic arthritis Psoriatic and lupus arthritis Rheumatoid arthritis Osteomyelitis (acute and chronic) Lesions Producing Neck and Shoulder Pain Cervical spondylosis Cervical subluxations Diseases of the abdominal or thoracic viscera Fibrositis Postural strains Snapping scapula Lesions Producing Pain Predominantly in the Shoulder Abdominal pathology Arthritis of the glenohumeral, acromioclavicular, and sternoclavicular joints Bicipital tenosynovitis Local subluxations Subdeltoid bursitis Tears of the rotator cuff Thoracic pathology Tumors Lesions Producing Shoulder Pain with Radiation into the Arm Angina Cervical root syndrome Neurovascular compression syndromes Shoulder-hand syndrome Nerve Compression Syndromes Median nerve Anterior interosseous nerve syndrome Carpal tunnel syndrome Pronator syndrome Radial nerve Complete radial palsy Posterior interosseous nerve syndrome Ulnar nerve Cubital tunnel syndrome Guyon's canal compression Shoulder Problems in Children Birth trauma Congenital deformities Infections Soft-Tissue Pain or Swelling Infection Abscess Felon Olecranon bursitis Palm infection Perionychium infection Tendon sheath suppuration Webspace infection Inflammation De Quervain's syndrome Tennis elbow Trigger or snapping finger Tumor and Tumor-Like Conditions Carcinoma of the nailhead Chondroma Dupuytren's contracture Epidermoid cysts Epithelioma Ganglion Xanthoma Trauma Dislocation Fracture Sprain/strain Subluxation
Table 7.3. Shoulder Girdle Pain and Associated SymptomsSyndrome: Shoulder Pain + Primary Suspect Disorders Cough and expectoration Pancoast's tumor Pneumonia Pleurisy Tuberculosis Fever Cholecystitis Purulent arthritis Pericarditis Subphrenic abscess Pneumonia Tuberculosis Mass (neck or shoulder) Actinomyocosis Hydradenitis suppurativa Carcinoma Lipoma Cellulitis Lymphadenitis Cyst Ruptured biceps Epithelioma Sebaceous cyst Hodgkin's disease Tuberculosis Neck or shoulder swelling Arthritis Fracture and tenderness Cellulitis Sprain Contusion Strain Dislocation Subluxation Radiating ache Angina pectoris Rib subluxation Bursitis Scalenus anticus syndrome Capsule adhesions Shoulderhand syndrome Fracture Spinal cord tumor IVD syndrome Spondylosis Pancoast's tumor Subluxation (cervical or Periarthritis shoulder)
Acromioclavicular and Related SprainThe acromioclavicular joint serves as a roof for the head of the humerus. Any force great enough to spring the clavicle from its attachments to the scapular can cause severe sprain of the acromioclavicular, coronoid, coraco clavicular, coracoacromial, and trapezius ligaments and the meniscus between the clavicle and sternum unless the clavicle fractures beforehand.
Background
Severe sprain is usually the result of the unique anatomical leverage that can be applied. The ligament complex of the acromioclavicular joint is normal ly loose so that the scapula can raise the glenoid fossa. If the scapula is forced during overstress or a fall to rotate around the coracoid, the process serves as a fulcrum. In other instances, a strong downward force pushes the clavicle against the 1st rib (which acts as a fulcrum). In either situation, the result is often a spontaneously reduced dislocation.
As with any sprain, pain, acute tenderness, swelling, weakness, restricted motion, and disability can be associated. Acromioclavicular sprain is highly painful during to associated capsule tearing. The severe pain occurs because the acromioclavicular ligament forms a large part of the joint capsule. Joint capsules are richly endowed with sensory nerves.
Class III sprains usually require referral for surgical repair. However, because medical treatment is often discontinued when work can be resumed, chiropractic management should be continued once a month for many months to assure against posttraumatic arthritis thus avoiding years of recurring symptoms.
Diagnostic Workup
Conduct a thorough physical examination and consider the following workups according to clinical judgment:CBC and differential Sedimentation rate Spinal roentgenography Chest xray Serum acid phosphatase Thermography ECG Serum alkaline phosphatase Tuberculin test EMG Serum calcium Urinalysis RA test Shoulder girdle films VD serologyMotion palpate the entire shoulder girdle and upper extremities bilateral ly and the spine, and relate findings with the patient's complaints. Confirm findings with appropriate orthopedic and neurologic tests (Tables 16.13, 16.16; Fig. 16.1). Check pertinent tendon and superficial reflexes (Tables 16.2), and grade the reaction (Table 16.3). Check involved joint motion and muscle strength against resistance, and grade resistance strength (Table 16.9). Interpret resisted motion signs (Table 16.6). Test for autonomic imbalance (Table 16.7) if suspicions of vagotonia or sympathicotonia arise.
Articular Adjustment
A contributing spinal major will likely be found at C5. Mobilize any fixations found especially in the shoulder girdle and involved upper extremity. Avoid the injured joint for it is hypermobile. After relaxing the tissues and adjusting the subluxated/fixated segments, apply deep highvelocity percussion spondylotherapy over segments C7–T4 for 34 minutes (Table 16.20).
Adjunctive Therapy
To restore further neurologic homeostasis and enhance healing:
Treat acupoints LI–10, LI–11, LI–15, SI–9, HT–1, GB–21 (Table 16.21).
Treat auriculopoints 34, 55, 64, 65, 95 (Figs 16.3 4).
Treat contralateral hand points LI–4, SI–3 (Fig. 16.5).
If the Valleix gallbladder, liver, or heart reflex areas in the feet are tender, massage each to patient's tolerance for 20 seconds (Fig. 16.2).
Treat trigger points discovered, especially those found in the coracobrachialis, infraspinatus, subscapularis, supraspinatus, pectorals, teres, and upper and mid trapezius muscles (Tables 16.2831).
If Chapman's gallbladder, liver, or heart points are tender, deeply massage each to patient's tolerance for 10 seconds while simultaneously holding firm fingertip contact against the respective spinal area with your other hand (Fig. 16.6).
These points are summarized in Figure 7.1.
Nutritional Therapy
Supplemental nutrients B1, C, D, P, calcium, and magnesium are recommended. Counsel the patient to avoid appropriate antivitamin and antimineral factors (Tables 16.56 and 16.58).
Elective Procedures
Other helpful forms of treatment include cryotherapy (Tables 16.32 16.33) and iontophoresis with hydrocortisone (Table 16.43) in the early stage, followed by moist heat (Tables 16.34 35) or shortwave diathermy (Table 16.36), ultrasound (Table 16.37) for heat and massage at the cellular level, hot needlespray showers, interferential therapy (Tables 16.39 41), local vibrationpercussion (Tables 16.19 20), alternating current (Table 16.27), highvoltage therapy (Table 16.38), or tendon friction massage of involved muscles (lubricate the skin with oil of wintergreen).
Taping or at least an arm sling may be necessary in the early stage to rest the joint and enhance healing. After the acute stage, demonstrate progressive therapeutic exercises to strengthen weakened muscles and/or stretch contractures.
Bicipital or Supraspinatus TendinitisBicipital tendinitis is the effect of bicipital overstress (usually shoulder adduction against resistance, working overhead, or heavy lifting) or tendon dislocation if the transverse ligament is lax or torn. In nonathletes, predisposing degeneration is often involved. In contrast, inflammation of the tendon of the supraspinatus muscle is the product of shoulder abduction overstress. It is the most common tendinitis found in the shoulder.
Background
The pain of bicipital tendinitis is aggravated by abduction flexion, internal rotation, and extension. The patient will be unable to use a screwdriver, and turning doorknobs is painful. Pain radiating to the insertion of the biceps on the radius is common. Tenderness is localized over the inflamed tendon in the bicipital groove. In chronic cases, calcification may occur at the tendon's insertion on the radius.
Supraspinatus tendinitis is usually associated with rotator cuff strain, subdeltoid bursitis, or subacromial bursitis. A diffuse ache and point tender ness over the inflammation are present during rest that is aggravated by abduction. Pain radiating to the insertion of the deltoid on the humerus is common. The sharpest pain occurs at that point in a movement arc when the acromion has its greatest affect on the tendon. In chronic cases, tendon calcification will occur near its insertion at the greater tuberosity of the humerus.
Diagnostic Workup
Conduct a thorough physical examination and consider the following workups according to clinical judgment:CBC and differential Sedimentation rate Spinal roentgenography Chest xray Serum acid phosphatase Thermography ECG Serum alkaline phosphatase Tuberculin test EMG Serum calcium Urinalysis RA test Shoulder girdle filmsMotion palpate the shoulder girdle and upper extremities bilaterally and the spine, and relate findings with the patient's complaints. Confirm findings with appropriate orthopedic and neurologic tests (Tables 16.13, 16.16; Fig. 16.1). Check pertinent tendon and superficial reflexes (Tables 16.2), and grade the reaction (Table 16.3). Check involved joint motion and muscle strength against resistance, and grade resistance strength (Table 16.9). Interpret resisted motion signs (Table 16.6). Test for autonomic imbalance (Table 16.7) if suspicions of vagotonia or sympathicotonia arise.
Eclectic Diagnostic Aids
Check alarm points (Table 16.15), visceral Valleix areas of the foot (Fig. 16.2), and potential contributing trigger points (Tables 16.28 16.31).
Articular Adjustment
Contributing spinal majors will likely be found at C5–C6. Also mobilize any fixations found especially in the shoulder girdle, involved upper extremity, upper thoracics, ribs, and scapula. After relaxing the tissues and adjusting the subluxated/fixated segments, apply deep highvelocity per cussion spondylotherapy over segments C7–T4 for 34 minutes (Table 16.20).
Adjunctive Therapy
To restore further neurologic homeostasis and enhance healing:
Treat acupoints LI–10, LI–11, LI–15, SI–9, HT–1, GB–21 (Table 16.21).
Treat auriculopoints 55, 64, 65 (Figs 16.3 4).
Treat contralateral hand points LI–2, SI–3 (Fig. 16.5).
If the Valleix gallbladder, liver, or heart reflex areas in the feet are tender, massage each to patient's tolerance for 20 seconds (Fig. 16.2).
Treat trigger points discovered, especially those found in the supraspinatus, upper and mid trapezius muscles, coracobrachialis, infraspinatus, and subscapularis (Tables 16.2831).
If Chapman's gallbladder, liver, or heart points are tender, deeply massage each to patient's tolerance for 10 seconds while simultaneously holding firm fingertip contact against the respective spinal area with your other hand (Fig. 16.6).
These points are summarized in Figure 7.2.
Nutritional Therapy
Supplemental processed brain extract and nutrients B1, C, RNA, calcium, and magnesium are recommended. Counsel the patient to avoid appropriate antivitamin and antimineral factors (Tables 16.56 and 16.58).
Elective Procedures
Other helpful forms of treatment include cryotherapy (Tables 16.32 16.33) and massage with eucalyptus oil in the early stage, followed by spray and stretch, and tendon friction massage of involved muscles. Helpful modalities during rehabilitation are moist heat (Tables 16.34 35) or shortwave diathermy (Table 16.36), ultrasound (Table 16.37) for heat and massage at the cellular level, hot needlespray showers, interferential therapy (Tables 16.39 41), iontophoresis or phonophoresis with proteolytic enzymes (Table 16.43), local vibrationpercussion (Tables 16.19 20), alternating current (Table 16.27), or highvoltage therapy (Table 16.38).
Taping or at least an arm sling may be necessary in the early stage to rest the joint and enhance healing. After the acute stage, demonstrate progressive therapeutic exercises to strengthen weakened muscles and/or stretch contractures.
Bicipital Transverse Ligament SprainThe bicipital transverse ligament may become loosened or ruptured to the point that the long head of the biceps is not held within the bicipital groove during shoulder motion. Heavy lifting, arm wrestling, or a slip while carrying a heavy object is the common mechanism of injury. The incidence is high in racket sports. However, it also may be an early sign of systemic connective tissue degeneration.
Background
The pain of transverse bicipital ligament sprain mimics that of bicipital tendinitis to a large degree because an overstretched (loose, lax) ligament leads to tendon inflammation and dislocation. Thus, the pain is aggravated by abduction flexion, internal rotation, extension, and other expressions of bicipital tendinitis.
The transverse tendon can be felt and often heard to snap as the patient forward flexes his arm and then extends it. This sensation will vary from a gliding or jumping motion, depending on the amount of instability (degree of tear). The patient is unable to remove his wallet from his ipsilateral back pocket, and point tenderness will especially be acute at the superior aspect of the bicipital groove. If a Class III sprain is involved, referral for corrective surgery is likely necessary.
Diagnostic Workup
Conduct a thorough physical examination and consider the following workups according to clinical judgment:Blood platelet level Liver function studies Shoulder girdle films BUN RA test Spinal roentgenography CBC and differential Sedimentation rate Thermography Chest xray Serum acid phosphatase Tuberculin test ECG Serum alkaline phosphatase Urinalysis EMG Serum calcium VD serologyMotion palpate the shoulder girdle and upper extremities bilaterally and the spine, and relate findings with the patient's complaints. Confirm findings with appropriate orthopedic and neurologic tests (Tables 16.13, 16.16; Fig. 16.1). Check pertinent tendon and superficial reflexes (Tables 16.2), and grade the reaction (Table 16.3). Check involved joint motion and muscle strength against resistance, and grade resistance strength (Table 16.9). Interpret resisted motion signs (Table 16.6). Perform tests for autonomic imbalance (Table 16.7) if suspicions of vagotonia or sympathicotonia arise.
Articular Adjustment
Contributing spinal majors will likely be found at C5–C6. Also mobilize any fixations found especially in the shoulder girdle, involved upper extremity, upper thoracics, ribs, and scapula, and reset the tendon if subluxated. After relaxing the tissues and adjusting the subluxated/fixated segments, apply deep highvelocity percussion spondylotherapy over segments C7–T4 for 34 minutes (Table 16.20).
Adjunctive Therapy
To restore further neurologic homeostasis and enhance healing:
Treat acupoints LI–10, LI–11, LI–15, SI–9, HT–1, GB–21 (Table 16.21).
Treat auriculopoints 34, 55, 64, 65, 95 (Figs 16.3 4).
Treat contralateral hand points LI–2, SI–3 (Fig. 16.5).
If the Valleix gallbladder, liver, or heart reflex areas in the feet are tender, massage each to patient's tolerance for 20 seconds (Fig. 16.2).
Treat trigger points discovered, especially those found in the biceps, deltoid, upper and mid trapezius muscles, coracobrachialis, and infraspinatus muscles Tables (16.2831).
If Chapman's gallbladder, liver, or heart points are tender, deeply massage each to patient's tolerance for 10 seconds while simultaneously holding firm fingertip contact against the respective spinal area with your other hand (Fig. 16.6).
These points are summarized in Figure 7.3.
Nutritional Therapy
Supplemental processed brain extract and nutrients B1, C, RNA, calcium, and magnesium are recommended. Counsel the patient to avoid appropriate antivitamin and antimineral factors (Tables 16.56 and 16.58).
Elective Procedures
Other helpful forms of treatment include cryotherapy (Tables 16.32 16.33) in the early stage, followed by tendon friction massage of involved muscles. Other helpful modalities during rehabilitation are shortwave diathermy (Table 16.36), ultrasound (Table 16.37) for heat and massage at the cellular level, hot needlespray showers, interferential therapy (Tables 16.39 41), iontophoresis or phonophoresis with proteolytic enzymes (Table 16.43), or high-voltage therapy (Table 16.38).
A sort period of support with taping is invariably necessary to rest the stretched tendon. After the acute stage, demonstrate progressive therapeutic exercises to strengthen weakened muscles and/or stretch contractures.
Calcific TendinitisOssification in the shoulder area usually involves the supraspinatus, deltoid, or triceps brachii, but any muscle subjected to chronic trauma (especially overstretch) may be involved. When it occurs, roentgenographic signs are usually greatest near the muscle's insertion. These may not occur until several months after the precipitating trauma.
Background
The pain involved in calcific tendinitis is usually restricted to a certain point in the motion arc. A dull ache may remain even during rest. The sudden pain is usually sharp and debilitating, and point tenderness is acute. At times, the deposits are silent until a particular injury is superimposed. Emphasis should be placed on locating and correcting areas of localized ischemia.
Diagnostic Workup
Conduct a thorough physical examination and consider the following workups according to clinical judgment:CBC and differential RA test Serum calcium Chest xray Sedimentation rate Shoulder girdle films ECG Serum acid phosphatase Spinal roentgenography EMG Serum alkaline phosphatase UrinalysisMotion palpate the shoulder girdle and upper extremities bilaterally and the spine, and relate findings with the patient's complaints. Confirm findings with appropriate orthopedic and neurologic tests (Tables 16.13, 16.16; Fig. 16.1). Check pertinent tendon and superficial reflexes (Tables 16.2), and grade the reaction (Table 16.3). Check involved joint motion and muscle strength against resistance, and grade resistance strength (Table 16.9). Interpret resisted motion signs (Table 16.6). Test for autonomic imbalance (Table 16.7) if suspicions of vagotonia or sympathicotonia arise.
Eclectic Diagnostic Aids
Check alarm points (Table 16.15), visceral Valleix areas of the foot (Fig. 16.2), and potential contributing trigger points (Tables 16.28 16.31).
Articular Adjustment
Contributing spinal majors will likely be found at C6–C7. Mobilize fixations found in the shoulder girdle or involved upper extremity. After relaxing the tissues and adjusting the subluxated/fixated segments, apply deep low velocity percussion spondylotherapy over segments C7–T4 for 12 minutes (Table 16.20).
Adjunctive Therapy
To restore further neurologic homeostasis and enhance healing:
Treat acupoints KI–27, LI–11, UB–11, UB–60, HT–1, GB–21 (Table 16.21).
Treat auriculopoints 55, 64, 65 (Figs 16.3 4).
Treat hand points LI–2, LI–4, SI–3 (Fig. 16.5).
If the Valleix gallbladder, liver, or heart reflex areas in the feet are tender, massage each to patient's tolerance for 20 seconds (Fig. 16.2).
Treat trigger points discovered, especially those found in the coracobrachialis, infraspinatus, subscapularis, supraspinatus, teres, and upper and mid trapezius muscles (Tables 16.2831).
If Chapman's gallbladder, liver, heart, or diaphragm points are tender, deeply massage each to patient's tolerance for 10 seconds while simultaneously holding firm fingertip contact against the respective spinal area with your other hand (Fig. 16.6).
These points are summarized in Figure 7.4.
Nutritional Therapy
Supplemental nutrients B1, C, D, F, and magnesium are recommended. Counsel the patient to avoid appropriate antivitamin and antimineral factors (Tables 16.56 and 16.58).
Elective Procedures
Other helpful forms of treatment include cryotherapy (Tables 16.32 16.33) in the acute stage, followed by ultrasound (Table 16.37), iontophoresis with acetate (Table 16.43), interferential therapy (Tables 16.39 41), local vibrationpercussion (Tables 16.19 20), alternating current (Table 16.27), moist heat (Tables 16.34 35) or shortwave diathermy (Table 16.36), hot needlespray showers, highvoltage therapy (Table 16.38), or tendon friction massage of involved muscles.
An arm sling may be necessary in the early stage to rest the joint and enhance healing. Temporary TENS is often helpful in situations of intractable pain (Table 16.49). After the acute stage, demonstrate progressive therapeutic exercises to strengthen weakened muscles and/or stretch contractures.
Deltoid StrainBecause it is such a powerful abductor and used to some degree in most all shoulder motions, acute and chronic disabilities of the deltoid are common. Strong contractions are known to produce tearing of its attachments to the humerus or clavicle solely from the intrinsic forces produced.
Background
The whole deltoid or its anterior, lateral, or posterior aspects may be singularly involved. As with most strains, pain arises with active motion but not passive motion. After injury, point tenderness, swelling, and disability arise. Grade III strains are not uncommon and require surgical repair if a distinct rupture can be palpated.
Diagnostic Workup
Conduct a thorough physical examination and consider the following workups according to clinical judgment:CBC and differential RA test Serum calcium Chest xray Sedimentation rate Shoulder girdle films ECG Serum acid phosphatase Spinal roentgenography EMG Serum alkaline phosphatase UrinalysisMotion palpate the shoulder girdle and upper extremities bilaterally and the spine, and relate findings with the patient's complaints. Confirm findings with appropriate orthopedic and neurologic tests (Tables 16.13, 16.16; Fig. 16.1). Check pertinent tendon and superficial reflexes (Tables 16.2), and grade the reaction (Table 16.3). Check involved joint motion and muscle strength against resistance, and grade resistance strength (Table 16.9). Interpret resisted motion signs (Table 16.6). Test for autonomic imbalance (Table 16.7) if suspicions of vagotonia or sympathicotonia arise.
Articular Adjustment
A contributing spinal major will likely be found at C5. Mobilize fixations found in the shoulder girdle or involved upper extremity. After relaxing the tissues and adjusting the subluxated/fixated segments, apply deep high velocity percussion spondylotherapy over segments C7-T4 for 34 minutes (Table 16.20).
Adjunctive Therapy
To restore further neurologic homeostasis and enhance healing:
Treat acupoints LI–10, LI–11, LI–15, SI–9, HT–1, GB–21 (Table 16.21).
Treat auriculopoints 64, 65, 55, 34, 95 (Figs 16.3 4).
Treat contralateral hand points LI–2, SI–3 (Fig. 16.5).
If the Valleix gallbladder, liver, or heart reflex areas in the feet are tender, massage each to patient's tolerance for 20 seconds (Fig. 16.2).
Treat trigger points discovered, especially those found in the deltoid, supraspinatus, scaleni, pectorals, upper and mid trapezius muscles, coracobrachialis, infraspinatus, and biceps (Tables 16.2831).
If Chapman's gallbladder, liver, or heart points are tender, deeply massage each to patient's tolerance for 10 seconds while simultaneously holding firm fingertip contact against the respective spinal area with your other hand (Fig. 16.6).
These points are summarized in Figure 7.5.
Nutritional Therapy
Supplemental processed brain extract and nutrients B1, C, RNA, calcium, and magnesium are recommended. Counsel the patient to avoid appropriate antivitamin and antimineral factors (Tables 16.56 and 16.58).
Elective Procedures
Other helpful forms of treatment include cryotherapy (Tables 16.32 16.33) and massage with eucalyptus oil in the early stage, followed by spray and stretch, and tendon friction massage of involved muscles. Helpful modalities during rehabilitation are moist heat (Tables 16.34 35) or shortwave diathermy (Table 16.36), ultrasound (Table 16.37) for heat and massage at the cellular level, hot needlespray showers, interferential therapy (Tables 16.39 41), iontophoresis or phonophoresis with proteolytic enzymes (Table 16.43), local vibrationpercussion (Tables 16.19 20), alternating current (Table 16.27), or highvoltage therapy (Table 16.38).
Shouldercap taping or at least an arm sling may be necessary in the early stage to rest the joint and enhance healing. After the acute stage, demon strate progressive therapeutic exercises to strengthen weakened muscles and/or stretch contractures.
Palsy of the ArmBilateral paralysis of several muscles of the shoulder and arm most often occurs in anterior poliomyelitis and toxic neuritis (eg, alcoholic, lead). Unilateral paralysis is most often seen with lower cervical spine trauma; hemiplegia, with unilateral face and leg involvement; hysteria; cerebral cortex lesions (eg, spaceoccupying masses, thrombosis, embolism, softening); progressive muscular atrophy; neurosis, traumatic; and pressure neuritis (eg, crutch, tumor). When occurring in infants, the cause may be injury from a for ceps delivery.
Background
Rapid atrophy suggests neuritis or an acute spinal cord lesion (eg, poliomyelitis). If it arises centrally from the thumb, the most common cause is progressive muscular atrophy. In such atrophic conditions, the direct cause is something interfering with the nourishing functions that should flow down the nerve; thus distinguishing it from common disuse atrophy. Slowly progress ing atrophy can usually be attributed to a thoracic outlet syndrome, hysteria, or hemiplegia or some other type of cerebral lesion.
Diagnostic Workup
Conduct a thorough physical examination and consider the following workups according to clinical judgment:CBC and differential Sedimentation rate Spinal roentge- Chest xray Serum acid phosphatase nography ECG Serum alkaline phosphatase Tuberculin test EMG Serum calcium Urinalysis Nerve conduction tests Shoulder girdle films VD serology Peripheral vascular testsMotion palpate the shoulder girdle and upper extremities bilaterally and the spine, and relate findings with the patient's complaints. Confirm findings with appropriate orthopedic and neurologic tests (Tables 16.13, 16.16; Fig. 16.1). Check pertinent tendon and superficial reflexes (Tables 16.2), and grade the reaction (Table 16.3). Check involved joint motion and muscle strength against resistance, and grade resistance strength (Table 16.9). Interpret resisted motion signs (Table 16.6).
Eclectic Diagnostic Aids
Check alarm points (Table 16.15), visceral Valleix areas of the foot (Fig. 16.2), Chapman's points (Fig. 16.6), and potential contributing trigger points (Tables 16.28 16.31).
Articular Adjustment
Contributing spinal majors will likely be found at C5–T1. Mobilize fixations found in the shoulder girdle or involved upper extremity. After relaxing the tissues and adjusting the subluxated/fixated segments, apply deep low velocity percussion spondylotherapy over segments C7–T4 for 12 minutes (Table 16.20).
Adjunctive Therapy
To restore further neurologic homeostasis and enhance healing:
Treat acupoints LI–11, LI–15, LU–5, SP–6, ST–36, UB–54 (Table 16.21).
Treat auriculopoints 55, 37, 64, 65 (Figs. 16.3 4).
Treat hand points LI–4, LI–5, SI–3, HT–8 (Fig. 16.5).
If the Valleix gallbladder, liver, or heart reflex areas in the feet are tender, massage each to patient's tolerance for 20 seconds (Fig. 16.2).
Treat trigger points discovered, especially those found in the arm, shoulder girdle, and posterior neck (Tables 16.2831).
If Chapman's gallbladder, liver, or heart points are tender, deeply massage each to patient's tolerance for 10 seconds while simultaneously holding firm fingertip contact against the respective spinal area with your other hand (Fig. 16.6).
These points are summarized in Figure 7.6.
Nutritional Therapy
Supplemental nutrients Bcomplex, inositol, calcium, potassium, and magnesium are recommended. Counsel the patient to avoid appropriate antivitamin and antimineral factors (Tables 16.56 and 16.58).
Elective Procedures
Other helpful forms of treatment include moist heat (Tables 16.34 35) or shortwave diathermy (Table 16.36), ultrasound (Table 16.37) for heat and massage at the cellular level, hot needlespray showers, interferential therapy (Tables 16.39 41), iontophoresis with iodine (Table 16.43), local vibrationpercussion (Tables 16.19 20), alternating current (Table 16.27) for passive exercise, or highvoltage therapy (Table 16.38).
Once passive exercise effects some degree of active motion, demonstrate progressive therapeutic exercises to strengthen weakened muscles and/or stretch contractures.
Periarthritis (Frozen Shoulder)This affliction (sometimes called adhesive capsulitis or Duplay's syndrome) is slow to correct, usually requiring about a year for recovery. The approach of traditional medicine, however, may require 21/2 years or more and leave annoying residual effects.
Background
The earlier the patient is seen with this condition, the faster will be the recovery. The initial cause can often be traced to untreated or poorly treated shoulder sprain (eg, prolonged overuse) with capsulitis. Excessive immobilization is a common factor. Lack of motion fosters retention of metabolites, edema, venous stasis, and ischemia that lead to the development of fibrous adhesions and multiple trigger points.
When mature, periarthritis is a complex problem involving several chronic, diffuse, and degenerative syndromes. Except for an obliterated glenohumeral joint space, roentgenographic signs are usually negative. Scapulothoracic motion is not restricted in the early stage, but normal rhythm will be progressively involved. This must be viewed from the posterior.
Because of capsule and rotator cuff thickening and constriction, all arm motion is restricted but it will affect adduction and internal rotation the most. Upper arm pain and tenderness is diffuse anteriorly and laterally, and use aggravates the symptoms. In time, the bicipital tendon becomes cemented in the groove and adhesions thicken all which bind the capsule to bone. The capsule "dries" and the head of the humerus is pulled tightly against the glenoid fossa. Arm muscle progressively atrophy.
Because accessory muscles are overworked, posterior shoulder and neck muscles will often exhibit a chronic ache that is relieved by rest and warmth.
Diagnostic Workup
Conduct a thorough physical examination and consider the following workups according to clinical judgment:CBC and differential Sedimentation rate Shoulder girdle films Chest xray Serum acid phosphatase Spinal roentgenography ECG Serum alkaline phosphatase Tuberculin test EMG Serum calcium Urinalysis RA test Serum uric acid VD serologyMotion palpate the shoulder girdle and upper extremities bilaterally and the spine, and relate findings with the patient's complaints. Confirm findings with appropriate orthopedic and neurologic tests (Tables 16.13, 16.16; Fig. 16.1). Check pertinent tendon and superficial reflexes (Tables 16.2), and grade the reaction (Table 16.3). Check involved joint motion and muscle strength against resistance, and grade resistance strength (Table 16.9). Interpret resisted motion signs (Table 16.6). Test for autonomic imbalance (Table 16.7) if suspicions of vagotonia or sympathicotonia arise.
Eclectic Diagnostic Aids
Check alarm points (Table 16.15), visceral Valleix areas of the foot (Fig. 16.2), Chapman's points (Fig. 16.6), and potential contributing trigger points (Tables 16.28 16.31).
Articular Adjustment
Check for a superiorly subluxated 1st rib. It is a common contributing factor. Contributing spinal majors will likely be found at C5–T1. Mobilize fixations found in the nonacute shoulder girdle or involved upper extremity. After relaxing the tissues and adjusting the subluxated/fixated segments, apply deep highvelocity percussion spondylotherapy over segments C7-T4 for 34 minutes (Table 16.20).
Adjunctive Therapy
To restore further neurologic homeostasis and enhance healing:
Treat acupoints UB–11, UB–60, TH–5, LI–11, LI–15, ST–36 (Table 16.21).
Treat auriculopoints 55, 64, 65, 37 (Figs 16.3 4).
Treat hand points LI–4, LI–5, SI–3 (Fig. 16.5).
If the Valleix gallbladder, liver, or heart reflex areas in the feet are tender, massage each to patient's tolerance for 20 seconds (Fig. 16.2).
Treat trigger points discovered, especially those found in the biceps, deltoid, coracobrachialis, spinatus group, and subscapularis muscles (Tables 16.2831).
If Chapman's gallbladder, liver, heart, or diaphragm points are tender, deeply massage each to patient's tolerance for 10 seconds while simultaneously holding firm fingertip contact against the respective spinal area with your other hand (Fig. 16.6).
These points are summarized in Figure 7.7.
Nutritional Therapy
Supplemental nutrients A, Bcomplex, C, D, E, calcium, magnesium, pantothenic acid, and sulfur are recommended. Counsel the patient to avoid appropriate antivitamin and antimineral factors (Tables 16.56 and 16.58).
Elective Procedures
Other standard forms of treatment include moist heat (Tables 16.34 35) or shortwave diathermy (Table 16.36), hot needlespray showers, interferential therapy (Tables 16.39 41), ultrasound (Table 16.37) for heat and massage at the cellular level, local vibrationpercussion (Tables 16.19 20), alternating current (Table 16.27) for passive exercise, highvoltage therapy (Table 16.38), or tendon friction massage. Iontophoresis with acetate, hydrocortisone, or iodine is often helpful (Table 16.43),
Full immobilization should be avoided even if it relieves pain. Temporary TENS is often helpful in situations of intractable pain (Table 16.49). Demonstrate slowly progressive therapeutic exercises to strengthen weakened muscles and/or stretch contractures.
Recurrent Glenohumeral DislocationYoung patients suffering glenoidrim fracture or a labrium glenoidale tear often retain a residual capsule weakness (HillSachs deformity) and abnormally wide range of motion encouraging recurrent glenohumeral dislocation. The recurrent luxation is almost always subcoracoid, but snapping posterior displacements are sometimes seen.
Background
The clinical picture exhibits classic but mild symptoms and signs of dislocation. These features disappear in 12 days after reduction. Repeated glenohumeral dislocation is most often seen with males in the 2040 age group. Under traditional medical care, recurrences appear in 90% of patients under the age of 20; 12% in patients over the age of 40. Too early or severe mobilization following the primary dislocation is sometimes a major factor in this condition.
Replacement of a recurrent dislocation is usually simple to perform and frequently painless. Many patients learn to achieve this themselves. Thus, the major problem is not the corrective adjustment as much as it is strengthening the holding elements to inhibit recurrence.
Diagnostic Workup
Conduct a thorough physical examination and consider the following workups according to clinical judgment:CBC and differential Serum acid phosphatase Spinal roentgenography EMG Serum alkaline phosphatase Urinalysis Sedimentation rate Shoulder girdle filmsMotion palpate the shoulder girdle and upper extremities bilaterally and the spine, and relate findings with the patient's complaints. Confirm findings with appropriate orthopedic and neurologic tests (Tables 16.13, 16.16; Fig. 16.1). Check pertinent tendon and superficial reflexes (Tables 16.2), and grade the reaction (Table 16.3). Check involved joint motion and muscle strength against resistance, and grade resistance strength (Table 16.9). Interpret resisted motion signs (Table 16.6).
Eclectic Diagnostic Aids
Check alarm points (Table 16.15), visceral Valleix areas of the foot (Fig. 16.2), Chapman's points (Fig. 16.6), and potential contributing trigger points (Tables 16.28 16.31).
Articular Adjustment
Contributing spinal majors will likely be found at C5–T1. Mobilize fixations found in the shoulder girdle or involved upper extremity. After relaxing the tissues and adjusting the subluxated/fixated segments, apply deep low velocity percussion spondylotherapy over segments C7–T4 for 12 minutes (Table 16.20).
Adjunctive Therapy
To restore further neurologic homeostasis and enhance healing:
Treat acupoints LI–10, LI–11, LI–15, SI–9, HT–1, GB–21 (Table 16.21).
Treat auriculopoints 55, 34, 13, 22 (Figs 16.3 4).
Treat hand points LI–2, LI–4 (Fig. 16.5).
If the Valleix gallbladder, liver, or heart reflex areas in the feet are tender, massage each to patient's tolerance for 20 seconds (Fig. 16.2).
Treat trigger points discovered, especially those found in the coracobrachialis, infraspinatus, subscapularis, supraspinatus, pectoral, teres, and trapezius muscles (Tables 16.2831).
If Chapman's gallbladder, liver, or heart points are tender, deeply massage each to patient's tolerance for 10 seconds while simultaneously holding firm fingertip contact against the respective spinal area with your other hand (Fig. 16.6).
These points are summarized in Figure 7.8.
Nutritional Therapy
Supplemental nutrients C, B6, manganese, potassium, and zinc are recommended. Counsel the patient to avoid appropriate antivitamin and antimineral factors (Tables 16.56 and 16.58).
Elective Procedures
Other helpful forms of treatment include alternating current (Table 16.27) for passive exercise, ultrasound (Table 16.37) for heat and massage at the cellular level, hot needlespray showers, interferential therapy (Tables 16.39 41), iontophoresis with zinc (Table 16.43), or local vibration percussion (Tables 16.19 20).
Taping or casting is necessary in the early stage to rest the joint and enhance healing. After the acute stage, demonstrate progressive therapeutic exercises to strengthen weakened muscles and/or stretch contractures.
Rotator Cuff StrainThe rotator cuff consists of five muscles that lie about the glenohumeral joint. They are two external rotators (infraspinatus, teres minor), two internal rotators (subscapularis, teres major), and the supraspinatus, which pulls the humerus into the glenoid fossa and abducts the humerus 1015 degrees after which the deltoid takes over and the supraspinatus acts as a stabilizer.
Strains of the rotator cuff have a high incidence in baseball pitchers, but the injury many also arise in occupations and recreational activities producing similar motions to an excessive degree for unconditioned muscles. Heavyload lifting or pushing, direct shoulder trauma, or a fall on the outstretched hand are other common precipitating actions.
Background
The major features of rotator cuff strain are painful active external rotation and abduction (especially between 4590*, where the tuberosity arcs under the acromion process). The lesser tuberosity will be acutely tender, and an abnormal depression will usually be felt at the fossa of the supraspinatus and infraspinatus muscles. Weakness, edema, subacromial crepitus during passive motion, a history of recurrent "bursitis," a positive armdrop test, possible hematoma, a dull ache during rest, and absent motion restriction during passive movements are also typical.
Repeated injury leads to bone erosion, tendon ruptures, and a thick fibrotic subacromial bursa. Palpable ruptures should be referred for surgical repair with followup chiropractic care to assure optimal recovery.
Diagnostic Workup
Conduct a thorough physical examination and consider the following workups according to clinical judgment:CBC and differential Serum acid phosphatase Spinal roentgenography Chest xray Serum alkaline phosphatase Thermography EMG Serum calcium Urinalysis Sedimentation rate Shoulder girdle filmsMotion palpate the shoulder girdle and upper extremities bilaterally and the spine, and relate findings with the patient's complaints. Confirm findings with appropriate orthopedic and neurologic tests (Tables 16.13, 16.16; Fig. 16.1). Check pertinent tendon and superficial reflexes (Tables 16.2), and grade the reaction (Table 16.3). Check involved joint motion and muscle strength against resistance, and grade resistance strength (Table 16.9). Interpret resisted motion signs (Table 16.6).
Check potential contributing trigger points (Tables 16.28 16.31).
Articular Adjustment
Contributing spinal majors will likely be found at C5–T1. Mobilize fixations found in the shoulder girdle or involved upper extremity. After relaxing the tissues and adjusting the subluxated/fixated segments, apply deep high velocity percussion spondylotherapy over segments C7–T4 for 34 minutes (Table 16.20).
Adjunctive Therapy
To restore further neurologic homeostasis and enhance healing:
Treat acupoints LI–10, LI–11, LI–15, SI–9, HT–1, GB–21 (Table 16.21).
Treat auriculopoints 64, 65, 55, 34, 95 (Figs 16.3 4).
Treat contralateral hand points LI–2, SI–3 (Fig. 16.5).
If the Valleix gallbladder, liver, or heart reflex areas in the feet are tender, massage each to patient's tolerance for 20 seconds (Fig. 16.2).
Treat trigger points discovered, especially those found in the deltoid, supraspinatus, scaleni, pectorals, upper and mid trapezius muscles, coracobrachialis, infraspinatus, and biceps (Tables 16.2831).
If Chapman's gallbladder, liver, or heart points are tender, deeply massage each to patient's tolerance for 10 seconds while simultaneously holding firm fingertip contact against the respective spinal area with your other hand (Fig. 16.6).
These points are summarized in Figure 7.9.
Nutritional Therapy
Supplemental processed brain extract and nutrients B1, C, RNA, calcium, and magnesium are recommended. Counsel the patient to avoid appropriate anti vitamin and antimineral factors (Tables 16.56 and 16.58).
Elective Procedures
Other helpful forms of treatment include cryotherapy (Tables 16.32 16.33) and massage with eucalyptus oil in the early stage, followed by spray and stretch, and tendon friction massage of involved muscles. Helpful modalities during rehabilitation are moist heat (Tables 16.34 35) or shortwave diathermy (Table 16.36), ultrasound (Table 16.37) for heat and massage at the cellular level, hot needlespray showers, interferential therapy (Tables 16.39 41), iontophoresis or phonophoresis with SOD (Table 16.43), local vibration percussion (Tables 16.19 20), alternating current (Table 16.27), or high voltage therapy (Table 16.38).
Shouldercap taping or at least an arm sling may be necessary in the early stage to rest the joint and enhance healing. After the acute stage, demonstrate progressive therapeutic exercises to strengthen weakened muscles and/or stretch contractures.
Shoulder Girdle NeuralgiaNeuralgia arising in the shoulder girdle is usually caused by a cervical lesion, 1st rib subluxation, or a subacute thoracic outlet neurovascular impairment. The pain is usually perceived lateral to the upper thoracics or in the deltoid area. A degree of fibrositis and multiple trigger points is often associated, especially in the suprascapular and rhomboid areas.
Background
Features include a stabbing, paroxysymal, remittent pain with slow relief on rest. The pain may radiate down the upper extremity or to the neck, or both. Severe spasm may occur during the height of an episode. Besides the causes previously listed, etiologies often include extraspinal nerve entrapment, spinal cord or column disease, subacute neuritis (eg, toxicosis), carcinomatous invasion, or a lung tumor.
Diagnostic Workup
Conduct a thorough physical examination and consider the following workups according to clinical judgment:CBC and differential Peripheral vascular studies Shoulder girdle films Chest xray Sedimentation rate Spinal roentgenog- ECG and EMG Serum acid phosphatase raphy RA test Serum alkaline phosphatase Thermography Nerve conduction Serum calcium Urinalysis studies Serum uric acid VD serologyMotion palpate the shoulder girdle and upper extremities bilaterally and the spine, and relate findings with the patient's complaints. Confirm findings with appropriate orthopedic and neurologic tests (Tables 16.13, 16.16; Fig. 16.1). Check pertinent tendon and superficial reflexes (Tables 16.2), and grade the reaction (Table 16.3). Check involved joint motion and muscle strength against resistance, and grade resistance strength (Table 16.9). Interpret resisted motion signs (Table 16.6). Test for autonomic imbalance (Table 16.7) if suspicions of vagotonia or sympathicotonia arise.
Eclectic Diagnostic Aids
Check alarm points (Table 16.15), visceral Valleix areas of the foot (Fig. 16.2), Chapman's points (Fig. 16.6), and potential contributing trigger points (Tables 16.28 16.31).
Articular Adjustment
Contributing spinal majors will likely be found at C5-T1. Mobilize fixations found in the shoulder girdle or involved upper extremity. After relaxing the tissues and adjusting the subluxated/fixated segments, apply deep high velocity percussion spondylotherapy over segments C7-T4 for 34 minutes (Table 16.20).
Adjunctive Therapy
To restore further neurologic homeostasis and enhance healing:
Treat acupoints LI–11, LI–15, UB–11, UB–60 (Table 16.21).
Treat auriculopoints 55, 64, 65, 106 (Figs 16.3 4).
Treat contralateral hand points LI–4, LI–5 (Fig. 16.5).
If the Valleix gallbladder, liver, or heart reflex areas in the feet are tender, massage each to patient's tolerance for 20 seconds (Fig. 16.2).
Treat trigger points discovered, especially those found in the deltoid, supraspinatus, infraspinatus, teres, upper trapezius, levator scapulae, subscapularis, and serratus posterior superior muscles (Tables 16.2831).
If Chapman's gallbladder, liver, heart, or diaphragm points are tender, deeply massage each to patient's tolerance for 10 seconds while simultaneously holding firm fingertip contact against the respective spinal area with your other hand (Fig. 16.6).
These points are summarized in Figure 7.10.
Nutritional Therapy
Supplemental nutrients B1, B6, pantothenic acid, calcium, and magnesium are recommended. Counsel the patient to avoid appropriate antivitamin and antimineral factors (Tables 16.56 and 16.58). Catnip tea has a calming effect.
Elective Procedures
Other helpful forms of treatment include cryotherapy (Tables 16.32 16.33) and massage with peppermint oil during an attack. Rehabilitation therapies include moist heat (Tables 16.34 35) or shortwave diathermy (Table 16.36), ultrasound (Table 16.37) for heat and massage at the cellular level, hot needlespray showers, epsom salts baths, interferential therapy (Tables 16.39 41), iontophoresis with magnesium (Table 16.43), local vibration percussion (Tables 16.19 20), alternating current (Table 16.27), highvoltage therapy (Table 16.38), or tendon friction massage of involved muscles.
Temporary TENS is often helpful in situations of intractable pain (Table 16.49). Demonstrate progressive therapeutic exercises to strengthen weakened muscles and/or stretch contractures.
Shoulder-Hand SyndromeThis symptom complex features upperextremity pain, shoulder stiffness, and ipsilateral hand pain, tenderness, redness, coldness, and swelling. These symptoms often follow myocardial infarction but they are not restricted to a cardiac disorder.
The literature describes this complex under such labels as upperextremity causalgia, Sudeck's atrophy, algodystrophy, and reflex neurovascular dystrophy.
Background
An infarction may have occurred but be unknown to the patient until the history is deeply probed (eg, an attack of chest pressure, faintness, cold sweating, etc). Seek a neurologic or neurovascular cause. An upper thoracic, upper rib, or sternocostal subluxation may mimic infarction, especially if the autonomics are involved. Similar symptoms also may be referred from the stomach, diaphragm (eg, hernia), or liver. Infrequent causes include mild stroke, drug toxicosis, and various spinal cord lesions involving the autonomics.
In the late stage, the skin of the involved hand(s) is glossy, the finger and wrist joints are extremely stiff, and muscle atrophy is advanced. Hyperhidrosis is common because of the autonomic involvement.
Diagnostic Workup
Conduct a thorough physical examination and consider the following workups according to clinical judgment:CBC and differential Sedimentation rate Spinal roentgenography Chest xray Serum acid phosphatase Thermography ECG and EMG Serum alkaline phosphatase Urinalysis Nerve conduction Serum calcium VD serology RA test Serum uric acid Peripheral vascular Shoulder girdle filmsMotion palpate the shoulder girdle and upper extremities bilaterally and the spine, and relate findings with the patient's complaints. Confirm findings with appropriate orthopedic and neurologic tests (Tables 16.13, 16.16; Fig. 16.1). Check pertinent tendon and superficial reflexes (Tables 16.2), and grade the reaction (Table 16.3). Check involved joint motion and muscle strength against resistance, and grade resistance strength (Table 16.9). Interpret resisted motion signs (Table 16.6). Test for autonomic imbalance (Table 16.7).
Eclectic Diagnostic Aids
Check alarm points (Table 16.15), visceral Valleix areas of the foot (Fig. 16.2), Chapman's points (Fig. 16.6), and potential contributing trigger points (Tables 16.28 16.31).
Articular Adjustment
Contributing spinal majors will likely be found at C6–T2. Mobilize fixations found in the shoulder girdle, anterior thorax, or involved upper extremity. After relaxing the tissues and adjusting the subluxated/fixated segments, apply deep low-velocity percussion spondylotherapy over segments C7–T4 for 12 minutes (Table 16.20).
Adjunctive Therapy
To restore further neurologic homeostasis and enhance healing:
Treat acupoints LI–11, LI–15, PC–6, UB–11, UB–60 (Table 16.21).
Treat auriculopoints 51, 55, 64, 67 (Figs 16.3 4).
Treat contralateral hand points LI–4, LI–5, SI–3 (Fig. 16.5).
If the Valleix liver, lung, or heart reflex areas in the feet are tender, massage each to patient's tolerance for 20 seconds (Fig. 16.2).
Treat trigger points discovered, especially those in the upper thoracic (anterior and posterior) muscles (Tables 16.2831).
If Chapman's liver, heart, or lung points are tender, deeply massage each to patient's tolerance for 10 seconds while simultaneously holding firm finger tip contact against the respective spinal area with your other hand (Fig. 16.6).
These points are summarized in Figure 7.11.
Nutritional Therapy
Supplemental processed liver and nutrients C, E, niacin, calcium, and iron are recommended. Counsel the patient to avoid appropriate antivitamin and antimineral factors (Tables 16.56 and 16.58).
Elective Procedures
Other helpful forms of treatment include moist heat (Tables 16.34 35) or shortwave diathermy (Table 16.36), hot needlespray showers, interferential therapy (Tables 16.39 41), local vibrationpercussion (Tables 16.19 20), or highvoltage therapy (Table 16.38). Demonstrate progressive therapeutic exercises to strengthen weakened muscles and/or stretch contractures.
Subacromial or Subdeltoid BursitisInflamed subdeltoid and subacromial bursae are common but rarely primary. Of the 140 bursae of the body, none have more trouble than the subdeltoid. The subdeltoid and subacromial bursae are described in this section together as their innervation, circulation, and drainage are the same. Clinical signs are similar except the location of tenderness. Thus, the general therapeutic regimen is similar.
Background
The pain of shoulder bursitis is sharp, deep, and fairly localized. Disability occurs on active motion, especially with abduction. The involved bursa will be acutely tender, swollen, and readily palpable. Muscles passing through the involved bursa will test weak. An underlying degenerative process (eg, connective tissue) often predisposes the initial attack.
In chronic disorders, the capsule will be contracted, adhesions will restrict passive and active motion, and calcium deposits will show on radiographs. Swelling will be minimal or absent in the late stage, but warmth and redness of the overlying skin may persist.
Diagnostic Workup
Conduct a thorough physical examination and consider the following workups according to clinical judgment:CBC and differential Serum acid phosphatase Shoulder girdle films EMG Serum alkaline phosphatase Spinal roentgenography RA test Serum calcium Thermography Sedimentation rate Serum uric acid UrinalysisMotion palpate the shoulder girdle and upper extremities bilaterally and the spine, and relate findings with the patient's complaints. Confirm findings with appropriate orthopedic and neurologic tests (Tables 16.13, 16.16; Fig. 16.1). Check pertinent tendon and superficial reflexes (Tables 16.2), and grade the reaction (Table 16.3). Check involved joint motion and muscle strength against resistance, and grade resistance strength (Table 16.9). Interpret resisted motion signs (Table 16.6). Test for autonomic imbalance (Table 16.7) if suspicions of vagotonia or sympathicotonia arise.
Eclectic Diagnostic Aids
Check alarm points (Table 16.15), visceral Valleix areas of the foot (Fig. 16.2), Chapman's points (Fig. 16.6), and potential contributing trigger points (Tables 16.28 16.31).
Articular Adjustment
Contributing spinal majors will likely be found at C5-T1. Mobilize fixations found in the shoulder girdle or involved upper extremity. After relaxing the tissues and adjusting the subluxated/fixated segments, apply deep high velocity percussion spondylotherapy over segments C7-T4 for 34 minutes
(Table 16.20).
Adjunctive Therapy
To restore further neurologic homeostasis and enhance healing:
Treat acupoints LI–11, LI–15, LU–7, UB–11 (Table 16.21).
Treat auriculopoints 55, 64, 65 (Figs 16.3 4).
Treat contralateral hand points LI–2, LI–4, LI–5, SI–3 (Fig. 16.5).
If the Valleix gallbladder, liver, lung, or heart reflex areas in the feet are tender, massage each to patient's tolerance for 20 seconds (Fig. 16.2).
Treat trigger points discovered, especially those found in the subscapularis, biceps, coracobrachialis, infraspinatus, supraspinatus, scaleni, and upper trapezius muscles (Tables 16.2831).
If Chapman's gallbladder, liver, lung, or heart points are tender, deeply massage each to patient's tolerance for 10 seconds while simultaneously holding firm fingertip contact against the respective spinal area with your other hand (Fig. 16.6).
These points are summarized in Figure 7.12.
Nutritional Therapy
Supplemental protein, B1, B12, C, RNA, and magnesium are recommended. Counsel the patient to avoid appropriate antivitamin and antimineral factors (Tables 16.56 and 16.58).
Elective Procedures
Other helpful forms of treatment include cryotherapy (Tables 16.32 16.33) in the early stage, followed by ultrasound (Table 16.37) for heat and massage at the cellular level, interferential therapy (Tables 16.39 41), iontophoresis (early, hyaluronidase; late, acetate) (Table 16.43), alternating current (Table 16.27), highvoltage therapy (Table 16.38), or tendon friction massage of involved muscles in the nonacute stage.
An arm sling may be necessary in the early stage to rest the joint and enhance healing. After the acute stage, demonstrate progressive therapeutic exercises to strengthen weakened muscles and/or stretch contractures.
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