Physiotherapy: a case study
Specialist musculoskeletal physiotherapist and strength and conditioning coach Uzo Ehiogu explains the role of a physiotherapist
Consider the case of a patient referring themselves with shoulder pain. This is a case which on face value should be relatively easy to manage by most competent healthcare professionals. However, now add in the fact that the patient is a triathlete and also has occasional pain traveling from the shoulder into the neck and down into the elbow. This is not an uncommon situation.
An isolated shoulder condition has been transformed into a complicated condition. It could in the worst case require a surgical procedure because of the patient’s hobby and potentially sinister neck and elbow symptoms. Add to this the fact that the patient has had neck pain while riding tri bars for over six months, has trained through the pain and is training for a half Ironman in four months.
Firstly, the physiotherapist must establish the correct diagnosis in order to design the right treatment plan. They must first determine which structures in the shoulder are injured if indeed the symptoms are located in the shoulder at all! The injured part could be one of four joints comprising the shoulder complex, over four tendons of the rotator cuff and many other muscles geographically close to the shoulder that can refer pain to the elbow and beyond. It could be any one of four peripheral nerves passing close to the shoulder complex.
Then the physiotherapist must assure themselves that your symptoms are not referred pain from the neck joints which can refer symptoms to your shoulder and elbow. So this needs to ruled out as a potential source of your symptoms by examining those areas or at least enquiring about them during the initial interview.
And there is more!
The expert also needs to medically screen the triathlete because they will always have an index of suspicion about serious illnesses that can mimic neck, shoulder and elbow symptoms.
Many patients are blissfully unaware that the lungs, gall bladder, diaphragm, heart, spleen and cancerous tumours in the lungs can refer pain to the shoulder and elbow when they are inflamed.
Now assuming this is a straight forward case of shoulder and neck pain which can only be established after a comprehensive interview and physical examination. We must explore the behaviour of the problem to determine the treatment procedures and their application. We know the neck and shoulder are persistent and longstanding, so there will invariably be secondary problems associated with this disorder.
For example, persistent shoulder pain can be the cause of reduced shoulder elevation at the forward reach phase during swimming because of reduced thoracic spine mobility. This can cause excessive movement at the shoulder region leading to overload of the local tendon tissues. In another example excessive abdominal muscle tightness caused by prolonged riding on tri bars can cause neck pain during swimming.
Abdominal tightness from riding in a flexed position can reduced thoracic spine expansion during swimming. This reduces head and neck rotation during the hand exit phase of the swimming stroke. This can cause neck pain and tension headaches. Sustained and repetitive postures can cause biomechanical or movement errors that may contribute to the injury or continue to delay its recovery.
Therefore, as you can see a comprehensive diagnostic examination is without question one of the most important steps in the physiotherapist’s management of sports injuries.