Looking for the Source of Pain: 5 Points to Consider

How many of your clients come to you with a diagnosis from their doctor? Let's use the diagnosis of elbow tendonitis as an example. The patient complains of pain on the outside of their elbow. The patient describes their pain; the doctor evaluates the patient and comes up the diagnosis of tendonitis of the elbow. The next steps are usually anti inflamatories for swelling or a cortisone shot and/or a prescription to physical therapy for strengthening, soft tissue work and e-stim for quicker healing. What happens when the drugs and shots do not work? The physical therapist follows the doctor's orders and does the best they can but the patient still does not get better? Keep in mind that the patient has been diligent about staying consistent with their appointments and have continued with the exercises that their physical therapist gave them. Most times the patient's symptoms are a result of an underlying cause that no one addressed. Up to this point everyone was focused on the elbow. That was not the problem. The key point here is to look past the point of pain. Look at the joints beyond the elbow such as the shoulder, mid thoracic spine, cervical spine or even the pelvis. Most times this is where you will find the problem that is causing the elbow pain. Next step is to identify things your client may do during the day that is continually irritating their pain.

Aaron's five key points when looking for the source of pain

1. Check front and back view postural deviations-compare both sides of your client's body to see if they are asymmetrical. Using a plumb line can be very helpful for yourself and to educate your client about the imbalances. If you note an asymmetry note it and put it in your client's file. Yes you should be keeping a file on all of your clients. You should be looking for:

  • head tilt to right or left

  • lateral deviation of cervical spine

  • asymmetrical shoulder heights

  • internal rotation of glenohumeral joint

  • pronation of one hand and forearm

  • elevated pelvis on one side

  • relative adduction of one hip

  • internal or external rotation of hip

  • eversion or inversion of feet

2. Check side posture views again using a plumb line can be beneficial. Make sure to line up the bottom of the line with the lateral malleolus of the ankle. Make sure to note deviations and then compare the two side views to note asymmetries. From this view look for:

  • head forward position

  • shoulder forward rotation

  • torso rotation (transverse plane)

  • pelvic rotation (transverse plane)

  • knee flexion or hyperextension

  • dorsiflexion or plantar flexion of foot and ankle

3. Check movement and range of motion of the joints. Note any restrictions if they are not within normal ranges. You may have to refer out if you are not familiar with this type of testing.

4. Find out what positions or movements feel best and what position or movements feel worse for your client. Once you have this information you now have a starting point in which you can begin pain free movements. If a movement irritates them look at the mechanics and find out why. This is where you should go back and look at your posture notes. Please be very aware of your client 's movements. They should not be compensatory movements just to achieve a movement you ask them to do. You want to make sure they are not developing dysfunctional movements thus creating even further problems down the road.

5. Find out what they do during the day that may be exacerbating their symptoms. You should ask things such as:

  • while on the computer is your torso turned more often in one direction

  • do you only use one arm when performing a work task

  • do you always stand on one leg

  • do you always use the same hand when talking on your cell phone

  • do you always carry your children on one hip

  • do you always carry your purse on one shoulder

  • do you lift objects with you low back flexed instead of extended

When your client has failed with other treatments these five headlines will give you a good start towards identifying your client 's source of pain. Remember you are not diagnosing; only their doctor can do that. What you are doing is filling in the blanks that the other professionals may be missing.

Rachel Jenkins