I’ve had two patients referred to me recently with difficult neck and shoulder pain issues. Their complaints were of the typical pain distribution–from the base of the skull down the neck to the shoulder blade and across the top of the shoulder as well as pain in the front of their shoulders. MRIs and X-Rays were negative for disc or other pathologies. They had been through several specialists and felt no relief other than with steroids and Vicodin.

After examining both women, I found they had very similar problems in that the shoulder blades were sitting too low on the trunk (Figure 1.).

Figure 1. Depressed Right Shoulder Blade (Copyright Boone Publishing. 2009)

Also the  humeral head was sitting too far forward in the shoulder socket (Figure 2) causing pain in the front of the shoulder. I taped both the humeral head and the shoulder blades in a corrected position and their pain was eliminated–until the tape was taken off a few days later. This told me my diagnosis was correct. But how could I get them to hold these corrected positions on their own? Our attempts at specific corrective strengthening only met with irritation of their pain.

Figure 2. Humeral Anterior Glide (Copyright Boone Publishing. 2010)

Because the shoulder blades’ position on the trunk is partially determined by ribcage orientation, I revisited this aspect of their pain and found that by elevating their rib cages, pain was eliminated. This did two things: 1. it reduced the anterior tilting of the shoulder blade and, 2. activated key scapular positioning muscles that were deficient. The other maneuver I discovered to be of great help was asking them to place their painful side’s hand on the opposite shoulder. This elevated the painful shoulder blade and posteriorly  glided (pushed back) the humeral head into a corrected position in the shoulder socket. Both felt about 80-99% relief from their symptoms during the following week.

Both are now able to begin their strengthening program without pain. If  irritation does occur, they know exactly how to eliminate it, finally giving them a means to control their own pain.

Both of these women had one more issue in common. They were self-conscious of their breast size and therefore slouched  their shoulders. Over time, I believe this established the environment for these mechanical issues to become painful. Both commented that upon fixing their posture, they felt they were sticking their chests out too much, drawing attention to themselves. They clearly saw the mechanical connection, however, as their pain returned after resuming their slouched postures (Figure 3). Ultimately they needed to come to terms about their personal issues of drawing attention to themselves in order to be better.

Figure 3. Posture & Shoulder Blade Position (Copyright Boone Publishing. 2010)

This reinforces to me that, although my point of view focuses more on the mechanical causes of chronic pain, there are also significant emotional or psychological causes. I believe often there exists a combination of dietary, musculoskeletal, and psychological issues that contribute to chronic pain. There are probably others as well. Each person’s pain is a function of a different combination of these issues. My training is in understanding the musculoskeletal aspects of pain but occasionally I bump into someone with more psychological issues instead.