Bilateral Symptoms Driven Centrally

With today's research on pain science, we are moving away from pathoanatomical diagnoses. This is a wonderful development as not only does it minimize the fear of pathology in our patients, but it makes our job easier as well. That being said, it can still be easy to be drawn in excessively by the results of special tests, especially in the extremities.

This past weekend I performed an evaluation of a middle-aged patient, where the script said "bilateral shoulder impingement." Based on the location of the patient's pain and some positive impingement tests, there may have been "impingement," but anytime I see bilateral symptoms I make sure to assess a central component. I'm not saying this always means the symptoms are driven by the spine, if presenting bilaterally, but that there may be an impairment in the trunk that contributes. In this patient's case, his cervical spine had minimal dysfunction, but his thoracic spine and parascapular musculature were significantly involved. He presented with excessive thoracic kyphosis and weak mid/low traps and serratus anterior bilaterally. His RTC presented with 5/5 strength throughout bilaterally. While there are some deficits in the extremities, the primary dysfunction appears to be located more centrally.

In reality, if you are being thorough with your examination and treatment, this shouldn't be a novel concept at all. I always encourage assessing spinal mobility and proximal strength in all my patients. The key then is doing something to address the impairments found. It is not unusual for my foot/ankle patients to be doing lumbar mobility exercises or hip strengthening. We don't always know "why" a patient presented with a form of pain or disability, but we can be sure to address any strength, mobility, biopsychosocial factors with which the patient presents.

-Dr. Chris Fox, PT, DPT, OCS

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