One of the primary lessons I have learned over the years in clinical practice is that things are never what they seem when it comes to musculoskeletal pain. We often get mired in chasing pain and treating symptoms without looking deeper into other causative factors. It's the "site versus source" conundrum.
Barring traumatic onsets such as slips, falls or impact injuries; the site of pain is usually a compensation point for the underlying non-symptomatic source of pain located in a seemingly unrelated anatomical region of the body. The take-away lesson from this is to stop chasing pain! Pain does not tell you what or where the problem is, it only tells you there is a problem. There is a thought process to understanding compensation pain and implementing an effective treatment strategy. So-called "cookie cutter" care programs (everyone gets the same protocols) no longer apply. Each person and each pain syndrome is unique and therefore must be treated individually. Let's take a deeper look at this chasing pain thought process by reviewing a case of chronic lateral epicondylitis.
Patient XYZ is a 35-year-old female complaining of chronic right elbow pain. She was diagnosed by her primary care physician with tendinitis (lateral epicondylitis). She has completed several months of physical therapy with minimal success and had two cortisone injections, which helped temporarily. She also went to another chiropractor for treatments of her spine because a friend suggested the arm pain might be coming from her neck.
OK, so what are you going to do differently with this patient? First, stop looking at the elbow as the primary problem. It's not! If it were the problem, all the other therapies would have helped by now. Think on a more global scale in terms of how the rest of her body postures affect the arm. Search for the kinetic connection of dysfunctional movement patterns as they relate to arm function.
The arm does not just hang out in space doing its own thing. Its proper function is intricately connected to how well the rest of the body does or doesn't move. Is there adequate mobility (movement) and stability (control of movement) in the areas that contribute to elbow function?
Begin with a detailed case history and interview. Ninety percent of your diagnosis can come from a proper case history. Listen to understand, not just to hear. What type of therapies did she have done before? How did they make her feel? What prior injuries or pain syndromes has she suffered in all areas of the body? Ask about her profession, hobbies, daily habits and lifestyle. Spend adequate time documenting a detailed history. The last thing you want to do is what everyone else has done; obviously it didn't work.
Do not simply perform an isolated examination of the elbow. Yes, you can and should do the necessary orthopedic, range-of-motion and palpatory exams of the painful area. However, also look at other regions of the body:
- Examine the cervical, thoracic, and lumbar spine range of motion. You will typically discover asymmetrical thoracic spine rotation and thoracic decreased extension, which will alter scapula-thoracic motion.
- Assess bilateral hips for mobility and stability as they correlate with cross-body myofascial links to the latissimus and scapulae.
- Evaluate stability of the scapulae during glenohumeral motion. Faulty patterns will overload the fascial arm lines and cause snags or pulls in fascial connection points via the elbow.
- Check for trigger points in the supraspinatus, scalenes, triceps brachii, and forearm extensors for pain radiation referrals to the elbow.
- Examine postural muscles for trigger points, tightness and adhesions, which will cause compensation overload in the arm (pectoralis major/minor, infraspinatus, subscapularis, rhomboids, serratus posterior superior, sternocleidomastoid, latissimus dorsi and contralateral gluteus muscles).
- Evaluate for subluxation in the upper extremity and spinal regions applicable to neurological involvement.
What you are searching for with this type of evaluation is why the forearm is overworking. Why did she get tendinitis on one arm and not the other? What can be done with therapy to help reverse movement dysfunctions?
As chiropractors, it is within our realm to discover the causative factors of musculoskeletal pain. Being attune to what the body is trying to communicate via pain is a key to clinical success. The body does not function in isolated sections and parts. There is an intricate relationship between all parts of the body during movement. You will notice that each condition may have a different presentation when you evaluate it during movement. The compensation system of the body will begin to appear if you know how to find it.
From this moment on, take a step back in your clinical approach to treatments and think outside of the pain. Think to yourself, What other areas may be contributing to the presenting symptom? Stop chasing pain and begin correcting problems.
