History and Presenting Symptoms
A 43-year-old female presents with persistent pain in and around her left shoulder, accompanied by tightness extending into her middle back region. Upon further discussion, she recounts a history of a right carpal tunnel syndrome that was treated surgically, with only partial improvement. She has also had several episodes of left elbow tendinitis. She denies any obvious traumas or injuries to her upper extremities. Because of her various upper extremity problems, she is unable to participate in any regular physical activity, and has gradually gained weight over the past ten years. She is an independent real estate agent.
Exam Findings
Vitals.
This self-employed woman weighs 158 lbs, which, at 5’6’’, results in a BMI of 26; she is overweight, but not obese. She is a non-smoker, but does drink alcohol (one to two glasses of wine) daily. Her blood pressure and pulse rate are in the normal ranges.
Posture and gait.
Standing postural evaluation finds noticeable unleveling of her shoulders, with the left shoulder carried lower and more forward than the right. The left scapula is protracted, and her left arm is internally rotated. While her head is well-balanced, and the spinal curves appear normal, she demonstrates an obvious pelvic tilt, with her right iliac crest lower than the left. When standing and walking, there is medial bowing of the right Achilles tendon, accompanied by calcaneal eversion, a low medial arch, and the tendency to toe out (foot flare) on the right side.
Chiropractic evaluation.
Motion palpation identifies moderate limitations in segmental motion at T3/T4 and T4/T5 with local tenderness, as well as restriction of rib motion at the associated costotransverse joints on the left. Cervical and lumbar ranges of motion are generally full and pain-free. Examination of her wrists, elbows and shoulders finds no ligamentous instability, and all upper-extremity joint ranges of motion are full and pain free. The sole exception is the left humerus, which is restricted in external rotation with moderate tenderness and loss of endrange mobility. Manual testing finds moderate weakness of the left teres minor and infraspinatus muscles, along with shortening of the left pectoralis muscles.
Imaging
Upright, weight-bearing X-rays of the cervicothoracic and lumbopelvic regions demonstrate a discrepancy in femur head heights, with the right femur 6mm lower. There is a very slight lateral curvature of the lumbar spine (4°), with the convexity to the right. No significant degenerative changes are noted.
Clinical Impression
Chronic mechanical dysfunction of the left shoulder associated with muscular imbalance and asymmetrical biomechanics in the pelvis and lower extremities. By history, there is a pattern of several upper extremity conditions, which are consistent with these identified asymmetries and imbalances.
Treatment Plan
Adjustments.
Specific chiropractic adjustments for the sacroiliac and thoracic spinal regions were provided as indicated, along with respiratory mobilization of the affected ribs.
Support.
Flexible, stabilizing orthotics were custom-made to support the arches, decrease calcaneal eversion, and support the functional leg length discrepancy.
Rehabilitation.
This patient was shown dynamic resistance exercises using elastic tubing for the external rotator musculature of the left shoulder, accompanied by door stretches for the left pectoralis muscles. Her program was progressed to include the scapular retractors on the left side, along with postural awareness instruction for daily activities.
Response to Care
This patient performed her home exercises regularly and adapted quickly to her stabilizing orthotics. She responded rapidly to the specific spinal and sacroiliac adjustments and the rib mobilizations. After eight weeks of adjustments (twelve visits) and daily home exercises, her upper extremities and spine were completely symptom-free, and she was released to a maintenance/wellness care program.
Discussion
Whenever a patient has multiple upper-extremity complaints and a thoracic spine involvement, I always want to evaluate the overall balance and function of the spine and pelvis in addition to the local problem. In this case, a previously unrecognized (and asymptomatic) asymmetry of the lower extremities was identified, which was causing a functional short leg. When this type of global malfunction is present, effective chiropractic care must address the lower extremity imbalances while, at the same time, treating the local shoulder dysfunction.
Dr. John J. Danchik is the seventh inductee to the American Chiropractic Association Sports Hall of Fame. He is the current chairperson of the United States Olympic Committee’s Chiropractic Selection Program and lectures extensively in the United States and abroad on current trends in sports chiropractic and rehabilitation. Dr. Danchik is an associate editor of the Journal of the Neuromusculoskeletal System. He can be reached by e-mail at [email protected].