Em Stuart Injuries Clinic

Graduate Sports Therapist Bsc Hons

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Pectoralis Minor…Part 13 of the grumbly muscle blog…

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Pectoralis Minor…Part 13 of the grumbly muscle blog…

What on earth is a pectoralis minor?

As part of the name would suggest, its one of the pectoral muscles in your chest, in fact you’ve got more than one. There is Pectoralis Major (Pec Major), the larger more superficial chest muscle that people are so fond of training in the gym and then there’s ‘lil’ old Pec Minor, which most people haven’t heard of.

What does a Pec Minor do? Well…for such a small muscle, it has a lot of effect on the scapula.

  • It helps 1) stabilise the scapula (along with middle fibres of traps), 2) depress (with help from lower traps and serratus anterior), 3) protract (with serratus anterior), 4) internally rotate and 5) downwardly rotate (with levator scapula and rhomboid major and minor).
  • It elevates the ribs and can help with inspiration (of breath).
  • Pec Major, Minor and serratus anterior work together to provide a wide range of movement of the scapula.

 Anatomy

It sits quietly underneath Pec Major. The muscle originates from the 3rd-5th ribs and inserts just under the outside of the clavicle on the coracoid process. The coracoid process is part of the scapula.

Why does it get grumbly and what happens when it does?

It can become weak, but more importantly, * it can become often shortened*, and a ‘rounded shoulder posture’ can help make this a reality, so too can problems in the shoulder joint and poor breathing.

As I’ve discussed in other blogs, if serratus anterior is weak, pec minor ‘takes over’ and the scapula ‘wings’.

Tightness and shortness of this muscle can also be the cause of thoracic outlet syndrome by decreasing the space in which nerves and blood vessels occupy between the first rib and the coracoid process (where Pec Minor inserts). This leads to either neural symptoms; pins and needles, numbness, burning, tingling or sharp shooting pains, vascular symptoms (constricted blood flow to the hand and arms) or both.

It will also restrict movement of the shoulder joint by constricting the scapula’s ability to move.

Trigger points (hypersensitive areas of muscle) in this muscle cause pain in the front of the shoulder, the inside of the arm, palm, middle, ring and little finger.

What can we do about it?

We can stretch it off regularly and we can perform soft tissue releases on it. As its not a superficial muscle and the pec major muscle is quite large, massage is less effective.

Vastus medialis (oblique) (VMO)…part 12 of the grumbly muscle blog…

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Vastus medialis (oblique) (VMO)…part 12 of the grumbly muscle blog…

So…whats a VMO?

Its one of your quad muscles and sits the inside of your thigh and knee. It’s been described as having two distinct portions: Vastus medialis ‘longus’ (upper part) and the vastus medialis ‘oblique’, the teardrop shaped portion of the muscle on the inside of the knee (lower part). We tend to concentrate on the oblique portion of the muscle because it has double the nerve innervation, different muscle structure and produces more electrical activity than the ‘longus’ part.

What does it do?

  • It helps keep the kneecap ‘on its runner’ and can prevent patella maltracking during knee movements.
  • It is integral to the ‘screw home’ (the knee’s lock-out mechanism) mechanism with help from another quad muscle called vastus lateralis (the one on the outside).
  • Is active throughout knee extension especially the last 15-20 degrees.
  • It helps the other three quads to perform knee extension.
  • Prevents damage to the articular cartilage and subsequent osteoarthritis of the patella and femur and tibia.

Anatomy

It comes from the medial lip if the linea aspera on the inside of the femur.

It joins the quadriceps tendon above the patella (kneecap) and then travels over the knee to insert into a bony protrusion on the centre top of the tibia called the tibial tuberosity.

What happens when it gets grumbly?

Anterior knee pain, patellofemoral pain syndrome (PFPS)  or patella tendinopathy.  If biomechanics of the hip and therefore the knee are ‘off’ it can struggle keeping the kneecap on its track, called the trochlea grove. Why? – Mostly due to a hip muscle called tensor fascia latae (TFL) which feeds into the IT band, which feeds into the ‘retinaculum’ around the kneecap before it inserts onto the head of fibula and Gerdy’s tubercle on the tibia. If the TFL is tight it can shorten, pulling from its origin at the hip, acting upon the knee and the knee cap.

What can we do about it?

We take a two-pronged approach…Restore biomechanics of the hip whilst addressing weakness of this muscle at the knee.

Cupping and its effects…

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Cupping Blog

So…What is cupping?

There are a couple of different types, but it comes down to ‘wet’ and ‘dry’ cupping. ‘Wet’ cupping is where you cut the skin before applying the cups so that blood is drawn up into the cup from the skin and is less commonly practiced. I don’t and won’t do that. ‘Dry’ cupping simply suctions the skin up into the silicone cup. It leaves temporary ‘marks’ where the cups were placed but they mostly fade in a few days.

I’ve heard of cupping but where does it come from?

It’s derived from Eastern medicine and has been used in various forms for centuries, for a large range of medical conditions and we’ve ‘westernised’ it for both sports and therapeutic treatment. Most people first became aware of it from the Olympics and noticing the ‘marks’ on swimmers backs and shoulders.  

What does cupping do?

Cupping is reported to have a few different effects.

  • Reduces pain.
  • Anti-inflammatory effects.
  • Increased blood circulation.
  • Reduce cellular adhesions and revitalize fascia and connective tissue.
  • Reduction in blood pressure.
  • It is also reported that cupping has positive effects on the immune system and the blood itself, but as ever, these are controversial.

From my own experiences of being cupped, it improves my pain significantly. Using just one example, I had chronic tennis elbow in both elbows, I couldn’t even pick up a cup of tea without pain, so myself and another sports therapist did an experiment.  My left elbow we dry needled down the forearm muscles and my right elbow we cupped down the forearm muscles. While neither treatment is curative, both have reduced my pain significantly so that I could rehab without pain.

How does it work?

This is the interesting bit…we have theories about why it works and reduces pain, and my initial thought was that it was probably due to the pain-gate mechanism (Melzac & Wall, 1965) which we’re fairly sure is what massage activates…Simply put, you bang your elbow, you rub it, it feels better for a short time…However, the pain relief from cupping lasts for rather longer and pain-gate is not known last that long, so it’s been theorised that it could from;

  • Improved blood circulation and removal of toxins & waste products which reduce inflammation reducing stimulation of the nerves that transmit the pain signals.
  • We also know that the body can be stimulated to create its own opioids and can produce its own gabapentin, giving long-lasting pain relief.
  • Stimulation of the parasympathetic nervous system; the bodies brake pedal.
  • Research has found cupping to affect the immune system; first by ‘irritating the immune system by causing temporary inflammation, which activates an immune response and attracts immune ’products’ that positively affect the area and strengthen immunity.
  • There is a theory that we all have a ‘pain dial’ called Diffuse Noxious Inhibitory Control (DNIC). Some peoples are high and others low and some theorise that cupping can affect this theoretical ‘dial’ for the better.
  • Removal of oxidants from the area leading to decreased oxidative stress.
  • Positive biomechanical changes in the tissue and decreasing pain thresholds of that area. **This is the one that resonates most with my own experiences of cupping**

There are MANY more theories as to why this treatment is effective, and are not limited to ‘blood detoxification theory’, ‘reflex zone theory’, ‘nitric oxide theory’, ‘activation of the immune system theory’ or maybe all of them together? Ultimately, we don’t yet know for sure. It even be placebo effect, though I find this unlikely based on my own experiences.

Research has been targeted to idiopathic (meaning unknown cause) pain conditions including fibromyalgia, and auto immune diseases which have all shown positive results to cupping. A study in 2005 found that cupping reduced markers for rheumatoid arthritis in trial participants.

While the effects of what cupping does and how it achieves them are the subject of much debate, that cupping promotes well-being is something I think we can all agree on. I was originally underwhelmed when I did the course last year but its effect on me personally have changed my outlook and enthusiasm for it. For most of my clients, I make it part of their sports massage and get great feedback from them too.

Serratus Anterior…Part 11 of the grumbly muscle blog…

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Serratus Anterior…Part 11 of the grumbly muscle blog…

What is a serratus anterior and what does it do?

It’s known as the boxer’s muscle, not least because you can see it clearly defined on boxers with its classic serrated edge viable just below the arm pit, and because it helps protract the shoulder blade (brings the shoulder blade round) so you can punch, reach forward, or push away.

Additionally, it upwardly rotates the scapula (shoulder blade) with assistance from the trapezius (traps) muscle, so we need it when we do pretty much any arm and shoulder movements.

It also helps, again with help from the traps and rhomboids to posteriorly tilt the shoulder blade and outwardly rotate, and also helps to maintain something called the subacromial space, meaning it allows the bones in the shoulder joint to move and not impinge on one another. Reduction in the subacromial space can lead to tendon impingement and this is rather painful.

Finally, it ‘hugs’ he shoulder blade on to the rib cage and can lift the rib cage when we’re out of breath to help our breathing.

Its considered one of the main shoulder stabilizers, along with the traps, and rhomboids.

Anatomy

The muscle originates in a fan shape from ribs 1-8 and sometimes rib 9 as well.

It then inserts on the underside of the scapula.

It’s innervated by the long thoracic nerve which come from the nerve roots of C5-C7 in the neck.

What happens when it doesn’t work properly?

During an initial visual assessment sometimes you can see someone’s scapula ‘winging’, the medial boarder of the shoulder blade will just stick out awkwardly which is called pseudo-winging it’s a sign that the muscle is not functioning properly (see pictures). 

Other times you have to see it in action to spot it. All wall press is usually sufficient to spot dysfunction on this muscle.

When this muscle is weak, other muscles ‘take over’ which is why the scapula is left with an inwards tilt and internally rotated. Left unchecked, a little-known muscle called pectoralis minor makes the anterior tilt somewhat worse. Characteristically, you can see the bottom of the shoulder blade stick out prominently from the rib cage.

If this muscle is weak, it can also lead to altered function of the rotator cuff muscles which can lead to reduction of the sub acromial space and pain from sub acromial pain syndrome (SAPS); in short when you raise your arm, you experience pain and reduced range above 90-120 degrees.

It can refer pain down the inside of the arm and to the ring and little finger.  It can become very tender around the 5th-7th rib, can also refer pain between the shoulder blades and on the inside of the elbow which could make you think you have golfers’ elbow (medial epicondylitis).

What could lead to this happening?

Serratus anterior palsy can be commonly caused by damage to the long thoracic nerve during neck and shoulder surgeries. Other causes include strenuous work, physical trauma, infection, anaesthesia, Parsonage-Turner syndrome, Fascio-scapulo-humoral dystrophy (FSHMD) or idiopathic cause (the cause is unknown). Additionally, you can get neuropraxia of the nerve from stretch injuries or compression.

The muscle can also ‘avulse’ (be torn off) the scapula bone.

What can we do about it?

Strengthen the hell out of it, and the other shoulder stabilisers at the same time! Massage might ease pain around the ribs, but you can’t get to the underside of the shoulder blade and you can’t foam roll it. Strengthen, Strengthen, Strengthen!!

Gluteus Maximus (glute max)…Part 10 of the grumbly muscle blog…

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Gluteus Maximus (glute max)…Part 10 of the grumbly muscle blog…

What’s a glute max?

I’m guessing most of you will have heard of this one and know where it is roughly. It’s the heaviest and largest and should be the strongest muscle in our body and of all the gluteal muscles (yes, you have more than one), the most superficial and covers gluteus minimus and most of gluteus medius.

What does it do?

Other than look good, it is the main hip extensor with help from the hamstrings, it’s how we get up from a seated position, climb stairs, run, it helps out a little in walking and also laterally rotates the hip joint.  The upper fibres help with hip abduction and the lower fibres can adduct the hip.

It also stabilises the hip keeping the pelvis balanced on the femoral heads of your femurs and can help stabilise the medial longitudinal arch of the foot through lateral rotation of the femur…discovering that blew my mind a bit!!

Anatomy

Located posterior to the hip, it’s made up of upper and lower fibres. It originates from the sacro-iliac ligament, sacro-tuberous ligament, lower part of the sacrum and the posterior aspect of the ilium (hip bone).  The muscle also attaches into fascia, known as aponeurosis of latissimus dorsi, erector spinae and multifidus (both muscles run up parallel to the spine). 

The upper fibres run into the iliotibial tract (the IT band) and the lower fibres attach onto the gluteal tuberosity on the femur. 

Why does it get grumbly?

Due to working at desks, driving and other seated activities, glute max is constantly in a stretched position. When muscles are stretched, they can fatigue more easily, and when glute max fatigues, the hamstrings take over, to conserve energy, and become the dominant hip extensor.

There are other ways to affect the strength of a muscle, the nerve that innervates it may be compromised and cause weakness.

It is also synonymous with something called ‘lower cross syndrome’, where there are weak/inhibited glutes and core/abdominal muscles, and their antagonists (muscles that do the opposite) erector spinae and hip flexors are tight. This can cause an anterior tilt on the pelvis exacerbating issues and posture.

Weakness or inhibition of the glutes has been linked to a number of lower limb injuries, these are usually insidious (slow onset) injuries, but I’ll leave that for another blog.

What happens when it gets grumbly and what can we do about it?

From my point of view, I find clients that have weakened glutes often experience tightness, movement dysfunction, painful trigger points and spasming of the muscle, so not only do I release them off with a nice deep tissue massage, soft tissue releases and muscle energy techniques, I would then prescribe strengthening exercises to start progressively addressing it and begin to restore movement patterns…we start off with something nice and easy, then depending on whether a person wants to work out a home or in the gym start challenging the muscle as we improve strength.

Interesting fact!

When you’re in a seated position, the glute max moves up so you’re actually sitting on the sit bones of the lower pelvis (ischial tuberosity), not the glutes, which is why cycling seats and sitting on hard surfaces can be a bit uncomfortable. To be fair, the muscle does try and offload the sit bones while you’re sitting…but I’m not sure how much

Massage

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Massage

I’ve been working on this blog for a little while, and I wanted to write about massage because it constitutes a large portion of what I do as a sports therapist.

Massage has been used as one of the earliest tools to treat musculoskeletal pain and written recorded evidence can be dated back as early as 2350BC.

Swedish massage, which most people will have experienced or heard of, was developed in 18th century by Per Hendrik Ling and is very popular today.

Musculoskeletal conditions constitute the fourth greatest burden on healthcare and massage is used in about 45% of physiotherapy cases to aid improved range of movement.

It can also help with fibromyalgia – recent nuclear magnetic resonance (NMR) studies have suggested the origin of the pain may be from musculoskeletal changes and myofascial trigger points, but more studies are needed to confirm these results. 

Massage is essentially theoretical but is underpinned by science. It’s not curative but it eases our pain and increases our sense of well-being.

Why do we enjoy massage so much?

We use it for both rehabilitation and relaxation. As someone who also enjoys a regular massage, I feel so much more relaxed following a session and its possibly the only bit of self-care I allow myself.

What does it consist of?

Strokes known as effleurage; gentle circular motions used to begin a massage and start to warm the skin and muscles up and increase lymph flow. Petrissage: a deeper stroke which is a kneading of the tissue. frictions: used to increase blood flow and tissue temperature in areas of tension and also used on scar tissue and tapotement; rhythmic percussion including hacking and cupping with the hands which purports to stimulate nerve endings and increase blood flow.  That it increases blood flow in the muscles is controversial in literature, but it does increase the temperature of the muscle and skin.

Benefits of being massaged

Decreases symptoms of stress, promotes relaxation and well-being, decreases muscle tension while improving circulation.  It is also suggested that sleep can be improved following a massage and many of my clients report the same thing, myself included.

We deactivate the sympathetic nervous system (take our foot off the bodies accelerator pedal) and activate the parasympathetic nervous system (put our foot on our bodies brake pedal), which lowers heart rate and blood pressure.

Studies have also shown massage to reduce fatigue, state anxiety, and depression. It also increases removal of blood lactate (what our muscles produce as a waste product), and decreases pain perception, thought to be from activation of the pain-gate mechanism and removal of oedema (swelling), which in itself causes chemical irritation and pain.

Massage of any kind works on a psychological, neurological and physiological level.

Movement dysfunction can come from hypomobile (stiff) tissue?

Mechanical pressure (massage) is believed to increase the compliance of muscle and increase joint mobility by decreasing cell adhesion but studies that show increased flexibility are inherently flawed, however on a personal note, my ankle range of movement increased 2cm following a 5-minute calf massage.

Sports massage

Is used in competition preparation with the aim of improving performance and to reduce post exercise recovery time, symptoms, and fatigue, by improving blood flow leading to improved removal of muscle waste products and potentially able to mitigate high pH levels.  However, studies that have investigated this often has flawed methodology leaving data to support these claims to be lacking.

Does a sports massage hurt?

For my part, I hope that every client that comes into my clinic leaves feeling in less pain, and more relaxed than when they walked in. A sports massage can be both functional and relaxing. Yes, some bits are a little uncomfortable, but I try and blend that in with firm relaxing strokes, so the overall perception is one of comfort and relaxation.

Tibialis Posterior…Part 9 of the grumbly muscle blog

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Tibialis Posterior…Part 9 of the grumbly muscle blog

 

What’s a tibialis posterior?

It’s a deep calf muscle that sits beneath the superficial gastrocnemius and soleus muscles.

 

What does it do?

It plantarflexes the foot (points the toes away from the foot) at the ankle joint and inverts the foot (helps you point the soles of your feet inwards).

It also plays a strong role in stabilising the medial longitudinal arch of the foot.

 

Anatomy

As the name suggests, it starts out life on the proximal posterior (top & back) of the tibia & fibula and the interosseous membrane (the facia between the two bones).

It curves towards the medial malleolus (knobbly bit of bone on the inside ankle) and then inserts onto all five tarsal bones and the bases of 2nd to 4th metatarsals (the three middle toes).

 

What can happen when it gets grumbly?

  • If this muscle isn’t functioning, then we struggle to maintain our foot arches and they can drop (flat foot), this is also known as posterior tibial tendon dysfunction (PTTD).
  • It is also complicit in shin splints, also known as medial tibial stress syndrome (MTSS), repeated traction of the tibialis posterior and soleus on the periosteum of the bone which can further lead to a stress fracture of the tibia if symptoms are ignored.
  • It can also rupture.

 

Why does it get grumbly?

You can get acute injuries but predominantly the muscle suffers from overuse injuries especially repetitive high impact activities like running. Poor biomechanics of the hip may also be involved.

 

Signs that something just isn’t right…

  • Not being able to do a single leg heel lift is a key one. As discussed earlier,
  • A dropped arch compared to the other foot.
  • Pain and or swelling on the medial (inside) of the lower leg or ankle.

 

What can we do about it?

It’s such a deep muscle that massage and foam rolling are not going to affect it a great deal so strengthening it is the main option on the table to sort this one out. Orthotics may be able to help in the interim though.

 

Gout – we’ve all heard of it but what is it?

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Gout is actually a form of arthritis, and anyone can get it.

It’s due to an accumulation of urea crystals in the joint. Normally the kidneys filter uric acid out of the blood but if the body is producing too much then crystals can form in the blood and settle around a joint causing pain and swelling.

It presents as severe and sudden swelling in the joints, often at night with or without a high temperature.

The worst of the pain will be within 4-12 hours after which there is a lingering level of discomfort. Bouts can last a week before subsiding.

Usually, it appears in the knee or big toes, but ankle, wrist, fingers, and elbow can also be affected.  It’s so painful that even a sheet touching an afflicted toe can be unbearable.

It presents with hot, red swollen skin around those joints and the inflammation with decrease the range of movement in the affected joint.

Recurrence is common.

Chronic recurrence can cause deposits, small white lumps, to accumulate under your skin, usually on the backs of your ankles, fingers, or elbows. They are urate crystals are called tophi and can be painful.

Why do some people get it?

  • Diets that have high levels of red meat, fatty poultry, liver, shellfish (these contain purines and can cause flare-ups) or alcohol, particularly beer.
  • Being over-weight can cause you to produce more uric acid.
  • High blood pressure (untreated), diabetes and kidney and heart disease can increase occurrence.
  • Some medications can increase uric acid in the blood – aspirin, beta blockers, anti-rejection drugs, some high blood pressure medicines such as angiotensin-converting enzyme (ACE) inhibitors and diuretics.
  • Men 30-50, males have a naturally higher levels of uric acid and post-menopausal women, which is when uric acid levels increase.
  • Family history of the condition.
  • Hypothyroidism (under active thyroid).
  • Recent trauma, surgery and injury can trigger it.

What should you do?

Go see a doctor!

If left untreated, it can cause permanent damage to the joint. It can also lead to kidney stones.

Your GP will prescribe strong anti-inflammatory drugs like naproxen and/or prednisone, a steroid. Colchicine or allopurinol, a xanthine oxidase inhibitor, will reduce uric acid in the blood.

Keep hydrated, maintain a healthy diet and weight.

Rhomboid’s…Part 8 of the grumbly muscle blog…

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Rhomboid’s…Part 8 of the grumbly muscle blog…

What are they?

They’re actually two muscles, rhomboid major and rhomboid minor, you have two each side and they sit underneath the trapezius muscle. They are important scapula (shoulder blade) stabilisers but when they’re not very happy, they can cause us sharp pain in the area between the shoulder blades from trigger points which are extremely irritable areas of muscle with heightened sensitivity. These trigger points can also refer pain away from the origin of pain.

What do they do?

They primarily help you squeeze your shoulder blades together but also help elevate the shoulder blade and downwardly rotate the shoulder blade when you are moving your arm. Lastly, they work with serratus anterior to suck the scapula to the ribcage during arm movements.

Anatomy

Rhomboid Minor comes from C7 and T1 (spine) and attaches to the upper medial border of the scapula (shoulder blade).

Rhomboid Major comes from T2 – T5 (spine) and attaches to the rest of the medial border of the scapula beneath rhomboid minor.

Why do they get grumbly?

Poor posture is one of the primary reasons. We have large strong muscles at the front of our bodies, the pectoral muscles (pecs) and latissimus dorsi (lats), and while they come from the posterior, they go under the arm and attach close to the pecs on the humerus (the arm) and together contribute to rounded shoulders, placing the rhomboids on a stretch… and stretched muscles are weakened muscles.

They are the muscles that help us row, so throwing and punching can cause strains and tears.

What can we do about it?

  • Strengthen them but stretch off pecs and lats at the same time.
  • Consciously improving posture (pulling your shoulder blades together).
  • Massage or soft tissue release.
  • Stretch.
  • Foam roll.

When is shoulder pain, not shoulder pain?

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When is shoulder pain, not shoulder pain?

Shoulder pain is the third most common musculoskeletal pain experienced by people. However, when you examine someone’s range of movement, there is no pain provoked during testing, and they have full range of movement? What could it be if not related to the shoulder?

Gall bladder – Deep, generalised, non-specific shoulder pain on the right-hand side from irritation of the phrenic nerve (a sensory nerve) you have one on each side which run from the neck (C3-C5), through to and innervates, the diaphragm.

The gall bladder and the right phrenic nerve are in very close proximity to each other. If you have the 4 F’s, then your likelihood of having gall bladder problems is increased.

  • Fifty
  • Female
  • Fat
  • Flatulent

Symptoms include:

  • Worsening shoulder pain and bloating after ingesting high calorie meals.
  • Poo’s that float.

 

Spleen, diaphragm & pancreas

The spleen, diaphragm & pancreas, can refer pain to the left shoulder. Acute pain at the tip of the shoulder above the collarbone, known as Kehr’s sign, can indicate a spleen pathology or irritation of the diaphragm.  The referred pain is due to the phrenic nerve irritation in the peritoneal cavity (abdomen) plus the nerves that supply the collarbone (the supraclavicular nerves) come from the same place in the C spine as the phrenic nerve, C3-C5.  Similarly, the tail of the pancreas which is also innervated by nerves from C3-C5 will refer pain to the left shoulder when something is wrong there.

 

Ovarian cyst or ectopic pregnancy

An ectopic pregnancy or a ruptured ovarian cyst will refer a sharp pain to the tip of shoulder due to swelling and excess fluid in the abdominal area irritating/compressing the phrenic nerve.

Thoracic outlet syndrome (TOS).

There are three types of thoracic outlet syndrome, vascular, neural and arterial.  The condition is from compression of vessels between the clavicle (collar bone) and the first rib (the thoracic outlet) or between the middle and anterior scalene muscles and again the first rib. Referred pain to the shoulder would likely be from compression to the brachial plexus (a group of nerves in that area).

Myocardial ischemia (Heart attack)

When men experience a heart attack, in addition to chest pain, a common symptom is referred pain to the left neck, arm and shoulder, however, this isn’t because of a particular nerve being irritated, but most likely because of a ‘confusion’ of multiple sensory inputs at the spinal cord.

When women experience a heart attack the symptoms can be a little different; Nausea/vomiting, shortness of breath, and back or jaw pain can be experienced.

 

Cervical spondylolysis, cervical arthritis, and cervical disc disease

Age related wear and tear on the cervical discs and the cervical spine (neck). The nerve roots of C3-C8 travel through the shoulder, so compression of any of them in the cervical spine can refer pain to the shoulder and is known as cervical radiculopathy.

Other conditions that can refer pain to the shoulder include reflex sympathetic dystrophy and irritation of the diaphragm.

The above is not an exhaustive list but it’s something I’m aware of if a client’s movement and testing pattern aren’t making sense from a musculoskeletal point of view, this is when I’d be writing a referral letter to the clients GP for further investigation.