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Asking Patients the Right Questions
When was the last time you asked a patient a question? Maybe 30 seconds ago? But, are you asking the right questions to elicit valuable and useful information? As a healthcare provider, you've likely spent hundreds of hours learning to ask the right questions to gather critical health information from your patients.
Energy: For Life and For Death
Energy is a deep topic in Traditional Chinese Medicine. Qi is understood to underlie all of existence, animated or not, and the qi of the living is studied with special attention.
Essentials of Assessment: The Squat
The squat is a simple, fast and functional tool to evaluate patient symmetry and function. As simple and easy as it is to implement, it can yield considerable amounts of valuable, clinically relevant information.
The Power of Eccentric Exercise: Hamstring Injury Prevention and Rehab
For almost 20 years, I've worked with professional athletes who make a living by running really fast. It goes without saying that hamstring injury (HSI) prevention and rehabilitation is a big part of what they expect from a sports chiropractor.
An Interview with Amanda Shayle
JW: Can you share with us some of your history and how you became an acupuncturist? What did you do prior to becoming an acupuncturist? Where did you go to school?
The Art of Listening
One of the most important clinical concepts for me was voiced by the legendary physician William Osler. "Listen to your patient, he/she is telling you the diagnosis." After treating literally thousands of patients, it can become almost second nature to quickly discover clues which reveal the underlying diagnosis.
Business Lesson #1: Adapt or Else
My wife and I recently enjoyed an excellent meal at a restaurant recommended by some friends. We often have concerns about restaurant recommendations, as many have been disappointing.
Health and Wellness Partnership
Yo San University of Traditional Chinese Medicine and The Wellness Center at the LAC + USC Historic General Hospital recently joined forces to extend care to the residents of Boyle Heights area of Los Angeles.
Building Relationships and Referral Networks with Allopathic Practitioners
Dr. Doug, an orthopedist of 20 years, had heard stories from patients who tried acupuncture. While he was able to address many of their complaints effectively, some appeared to gain additional benefit when their care included TCM.
Vitamin D Fails to Help Knee OA? The Proper Perspective
The March 8, 2016 issue of JAMA includes a study about vitamin D supplementation for osteoarthritis of the knee. This is a really weird study.
The Rest of the Patient Story
I've written previously about allowing a patient to tell you their story – about taking the time to listen and engage all the aspects of their case history, the injury in question, and the related issues.
Transparency is Key at ASA First Annual Meeting
On March 4th and 5th the American Society of Acupuncturists (ASA) held a successful first annual meeting in Albuquerque, New Mexico.
Recording and Appropriate Billing of Timed Physical Medicine Services
There is a common misunderstanding about timed therapy services and although you do have some knowledge of timed service documentation, based on your comment on the 8-minute rule, your understanding is correct, but incomplete.
NCCAOM Launches New Membership Organization
The National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) recently launched a new national membership organization, the NCCAOM Academy of Diplomates.
Constructing Our Reality: The Primary Channels and Perception, Part 1
My favorite topic of discussion within Chinese medicine is the acupuncture channel systems. First of all, each of us have them. They are part of our bodies; not something external to us. To learn about the acupuncture channels is to learn about ourselves.
Filling the Gap: The Role of Alternative Practitioners in a Broken Health Care System
I have been asked many times what got me into alternative medicine. My answer is simple: I want to truly help and make a difference in people's health.
News in Brief
A Moment of Silence for Dr. Stephen Press; New ACA President Elected; F4CP Offers New MemBership Benefit.
Musculoskeletal Disorders Take Center Stage
Looking for the latest on the musculoskeletal pain epidemic and the increasing premium placed on preventive strategies including chiropractic? Check out The Impact of Musculoskeletal Disorders on Americans – Opportunities for Action.
Roots in the Community, Branches Far Beyond
The Jung Tao School of Classical Chinese Medicine (JTS) was founded in 1998 by Sean Christian Marshall in Sugar Grove, North Carolina, a small community near Boone in the state's westernmost mountains.
The Value of Melatonin in Breast Cancer Prevention and Adjunctive Treatment
Although melatonin (MLT) is best known for its sleep-aid properties and as a natural remedy to prevent jet lag, extensive experimental studies suggest it possesses anticancer activity through several biological mechanisms.
The IME System: A Current Public Health Risk and Solutions That Are Working
I strongly believe in the independent medical examination (IME) system. There are far too many doctors in every profession who are not following E&M protocols and never claim MMI (maximum medical improvement) has occurred for their patients, which has caused financial stress for many private and public carriers.
November, 2008, Vol. 08, Issue 11
Subscapularis: Overlooked and Undertreated
By David Kent, LMT, NCTMB
The subscapularis is an often neglected and/or undertreated cause of posterior shoulder pain with restricted range of motion (ROM). According to Travell and Simons, "Differential diagnosis of subscapularis TrPs includes C7 radiculopathy, thoracic outlet syndrome, adhesive capsulitis and 'impingement syndrome.'" In this article, I will review how you can determine when the subscapularis muscle is responsible for causing shoulder pain and restricted ROM, as well as review its anatomy, function, trigger-point patterns and treatment options.
Intake and health history forms will help you identify some common factors that may contribute to the formation and perpetuation of trigger points, as well as the shortening of the subscapularis muscle. According to Travell and Simons, some of these factors include the following:
Taking a photo of your client in front of a postural-analysis grid chart is an effective method of evaluating, documenting, educating and ultimately showing a client their postural progress over a series of treatments. For example, a constant slumped, forward-head, adducted-scapulae posture will perpetuate trigger points and the shortening of muscles, such as the subscapularis, by continually keeping the humerus in a position of medial rotation.1 (Figure 1)
Trigger Points: When trigger points are present in the subscapularis muscle, they produce referred pain "in the posterior deltoid area ...down the posterior aspect of the arm, and then skip to a band around the wrist."1 (Figure 2) Remember that referred pain is a symptom; we want to address the cause. So intake forms, postural analysis evaluations, range-of-motion and orthopedic assessments, and being familiar with trigger-point patterns are all helpful to designing and implementing a customized therapy plan. But treating a trigger point is only part of the solution. We need to avoid a recurrence in the future. It is therefore necessary to demonstrate to your client which muscles need more lengthening and which ones need more strengthening so that all of the joints are properly aligned and moving through their full range of motion.
Anatomy: The subscapularis is one of four muscles that make up the rotator cuff, along with the supraspinatus, infraspinatous and the teres minor muscles. In my dissection seminars, I always highlight the subscapularis, which is the most anterior of the rotator cuff muscles. (Figure 2) It is a thick triangular muscle that attaches medially on the anterior or costal surface of the scapula on the subscapular fossa; it forms part of posterior wall of the axialla. Laterally, it attaches on the lesser tubercle of the humerus and the lower half of the shoulder joint capsule.
Actions: The subscapularis is primarily responsible for medially rotating and adducting the arm. It also helps to hold the humeral head in the glenoid cavity. To check for shortening in the subscapularis it is necessary to evaluate both abduction and external rotation.
Abduction: According to Travell and Simons, when evaluating a shoulder with restricted abduction, it is first necessary to determine if the restriction is being caused by the inability of the scapula to move on the rib cage, the humerus to properly articulate in the shoulder (glenohumeral) joint, or a combination of the two.1 The difference can be easily determined by placing your hands on the client's scapula to prevent its movement while asking the client to abduct their humerus. (Figure 3) When the subscapularis is involved, it restricts glenohumeral movements like abduction and lateral rotation, but it does not restrict scapular movements on the rib cage. If scapular movements are restricted, it is necessary to evaluate muscles that run from the torso to the scapulae, such as the pectoralis minor, serratus anterior, trapezius and the rhomboids.1
Lateral Rotation: When checking lateral rotation at the shoulder, adduct the arm by placing the elbow at the side. Then bend the elbow 90 degrees to show the amount of rotation at the shoulder joint. (Figure 4) The arm should be able to laterally rotate 90 degrees. In addition to the subscapularis, other synergistic muscles such as the teres major, latismus dossi and pectoralis major also adduct and medially rotate the arm. These muscles must also be evaluated and treated. Keep in mind that the antagonistic muscles are weak and over-lengthened, so they need strengthening. Muscle movement charts can aid in quickly identifying the muscles involved and show the normal range of motion for the muscles and joints being evaluated. (Figure 5)
Treating the Subscapularis: While there are many different approaches to treating the belly of the subscapularis muscle, I find one particularly effective. However, some clients may only be able to tolerate static pressure versus movements with this method, such as with-fiber or cross-fiber techniques.
Before the session ends, advise your client that they will receive the most benefit from your therapy session by actively engaging in self-care stretching techniques, such as the doorway stretch, which will further help improve muscle length, and create and maintain balance in the shoulder. (Figure 10)
You have now identified several factors associated with subscapularis pain and discomfort with the help of assessment aids and tools such as intake forms, charts and postural analysis photos. Continue to study and broaden your skills with hands-on seminars and DVD programs. You can share your tips and experiences in the treatment room by dropping me a line at .
Click here for more information about David Kent, LMT, NCTMB.
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