CHAPTER 7: The Shoulder and Arm
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 Bursitis

Chapter 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 Pain
                                   Neurologic
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:

  1. 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.

  2. 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.

  3. 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.

  4. 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.

  5. 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 Disorders
Bone 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 Symptoms
Syndrome: 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 Sprain

The 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 serology

Motion 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 C7T4 for 34 minutes (Table 16.20).

      Adjunctive Therapy

To restore further neurologic homeostasis and enhance healing:

  • Treat acupoints LI10, LI11, LI15, SI9, HT1, GB21 (Table 16.21).

  • Treat auriculopoints 34, 55, 64, 65, 95 (Figs 16.3 4).

  • Treat contralateral hand points LI4, SI3 (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 Tendinitis

Bicipital 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 films

Motion 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 C5C6. 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 C7T4 for 34 minutes (Table 16.20).

      Adjunctive Therapy

To restore further neurologic homeostasis and enhance healing:

  • Treat acupoints LI10, LI11, LI15, SI9, HT1, GB21 (Table 16.21).

  • Treat auriculopoints 55, 64, 65 (Figs 16.3 4).

  • Treat contralateral hand points LI2, SI3 (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 Sprain

The 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 serology

Motion 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 C5C6. 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 C7T4 for 34 minutes (Table 16.20).

      Adjunctive Therapy

To restore further neurologic homeostasis and enhance healing:

  • Treat acupoints LI10, LI11, LI15, SI9, HT1, GB21 (Table 16.21).

  • Treat auriculopoints 34, 55, 64, 65, 95 (Figs 16.3 4).

  • Treat contralateral hand points LI2, SI3 (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 Tendinitis

Ossification 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    Urinalysis

Motion 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 C6C7. 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 C7T4 for 12 minutes (Table 16.20).

      Adjunctive Therapy

To restore further neurologic homeostasis and enhance healing:

  • Treat acupoints KI27, LI11, UB11, UB60, HT1, GB21 (Table 16.21).

  • Treat auriculopoints 55, 64, 65 (Figs 16.3 4).

  • Treat hand points LI2, LI4, SI3 (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 Strain

Because 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    Urinalysis

Motion 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 LI10, LI11, LI15, SI9, HT1, GB21 (Table 16.21).

  • Treat auriculopoints 64, 65, 55, 34, 95 (Figs 16.3 4).

  • Treat contralateral hand points LI2, SI3 (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 Arm

Bilateral 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 tests

Motion 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 C5T1. 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 C7T4 for 12 minutes (Table 16.20).

      Adjunctive Therapy

To restore further neurologic homeostasis and enhance healing:

  • Treat acupoints LI11, LI15, LU5, SP6, ST36, UB54 (Table 16.21).

  • Treat auriculopoints 55, 37, 64, 65 (Figs. 16.3 4).

  • Treat hand points LI4, LI5, SI3, HT8 (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 serology

Motion 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 C5T1. 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 UB11, UB60, TH5, LI11, LI15, ST36 (Table 16.21).

  • Treat auriculopoints 55, 64, 65, 37 (Figs 16.3 4).

  • Treat hand points LI4, LI5, SI3 (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 Dislocation

Young 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 films

Motion 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 C5T1. 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 C7T4 for 12 minutes (Table 16.20).

      Adjunctive Therapy

To restore further neurologic homeostasis and enhance healing:

  • Treat acupoints LI10, LI11, LI15, SI9, HT1, GB21 (Table 16.21).

  • Treat auriculopoints 55, 34, 13, 22 (Figs 16.3 4).

  • Treat hand points LI2, LI4 (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 Strain

The 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 films

Motion 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 C5T1. 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 C7T4 for 34 minutes (Table 16.20).

      Adjunctive Therapy

To restore further neurologic homeostasis and enhance healing:

  • Treat acupoints LI10, LI11, LI15, SI9, HT1, GB21 (Table 16.21).

  • Treat auriculopoints 64, 65, 55, 34, 95 (Figs 16.3 4).

  • Treat contralateral hand points LI2, SI3 (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 Neuralgia

Neuralgia 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 serology

Motion 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 LI11, LI15, UB11, UB60 (Table 16.21).

  • Treat auriculopoints 55, 64, 65, 106 (Figs 16.3 4).

  • Treat contralateral hand points LI4, LI5 (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 Syndrome

This 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 films

Motion 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 C6T2. 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 C7T4 for 12 minutes (Table 16.20).

      Adjunctive Therapy

To restore further neurologic homeostasis and enhance healing:

  • Treat acupoints LI11, LI15, PC6, UB11, UB60 (Table 16.21).

  • Treat auriculopoints 51, 55, 64, 67 (Figs 16.3 4).

  • Treat contralateral hand points LI4, LI5, SI3 (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 Bursitis

Inflamed 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               Urinalysis

Motion 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 LI11, LI15, LU7, UB11 (Table 16.21).

  • Treat auriculopoints 55, 64, 65 (Figs 16.3 4).

  • Treat contralateral hand points LI2, LI4, LI5, SI3 (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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