When evaluating a patient with shoulder or neck pain, it is important to consider all of the structures that may contribute to their current symptoms. These structures include local muscles, peripheral or central nervous system dysfunction, soft tissue stabilizing structures, among others. Next, use this information in combination with other portions of the subjective history (mechanism of injury, description of symptoms, and pattern of symptoms) to identify the one or two primary causes of the problem.

Since muscle atrophy was present (without signs of a single muscle trauma or strain), it is important to investigate other muscles with the same segmental and peripheral nerve contributions. This will determine if the weakness is localized or present in multiple muscle groups. Below I review the pectoralis muscle with a special emphasis on the sternocostal fibers. 

Later in the evaluation, the patient remembered that his biceps brachii and pectoral muscle strength had gradually decreased on his right (involved side) versus his left over the past few months while strength training.  

This statement is very important because it most likely ruled out a muscle strain, and ruled in nervous system dysfunction. Further physical examination helped rule out red flags for cervical myelopathy. Additionally, muscle strength testing found weakness in other C5, C6, and C7 muscles. At this point, I concluded that he was safe for treatment, but needed regular reassessment to ensure no further progression of neurological symptoms. 

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PHYSICAL THERAPY PHASE (0-3 months)
During the first 12 weeks following trauma or onset of symptoms, patients are generally improving. From a physiological perspective, collagen is maturing, remodeling, and getting stronger. In this stage patients are almost solely attending physical therapy and performing corrective exercises. At the end of 12 weeks, patients likely will feel 60-70% back to their prior level of function. Individuals who perform desk jobs should be back at full duty; more strenuous jobs are still on partial duty.

COMBO GYM + CONTINUED PHYSICAL THERAPY REHAB (3-6 months)
From 3-6 months the patient usually begins their normal gym routine (strength training and cardiovascular exercise) while performing rehabilitation concurrently. I generally think of this phase as someone attending PT 1x/week and performing their gym routine 3-4x/week. In this phase, the individual is starting to feel significantly better, but they have not reached full strength yet. They still have some discomfort (not necessarily pain), and transitional movements, such as getting out of bed and getting up from a chair are still not normal. Ultimately, they still need more work! 

FULL RETURN TO NORMAL ACTIVITY/SPORT (6-12 months)
From 6-12 months, the patient has typically stopped their formal rehabilitation program. They are now performing their normal gym routine and daily activities. The individual continues to progress strength, mobility, flexibility, but now has all the tools needed to be independent. The occasional flare up may occur (especially if a novel training movement is incorporated), but is not anticipated. At the end of the 9-12 months, they should have reached life as usual.

Many patients do NOT realize how long post-surgery rehabilitation takes. In my active cash-based population, many of my patient's have self proclaimed high pain tolerances and feel better relatively quickly. Despite subjectively feeling strong, practitioners must remember that scar tissue continues to mature and remodel for 2+ years! Strengthening and retraining movement patterns will take months (even after the patient feels better). Reaching 100% pain free and 'normal' activity generally takes longer than someone will anticipate. Being honest and giving appropriate education early on can change a patient's outlook on their condition. Use this graph when educating your patients!
​-Jim Heafner PT, DPT, OCS

In an earlier post, Jim went over how to differentiate between cervical myelopathy and radiculopathy, or an upper motor lesion and lower motor lesion. Once you have made that differentiation, you have to determine where that lesion is: peripheral nerve, plexus, or spinal nerve. In this post, we're going to go over specifically how to differentiate between peripheral neuropathy and radiculopathy.  I am going to focus on the upper quarter region, but the same concept will apply to the lower quarter as well.  Below are a couple pictures of the peripheral nerve layouts and dermatomal patterns that I will reference throughout this post