“Where you think it is, it ain’t.” I came across this quote from Ida Rolf while in grad school and it has stuck with me ever since. It’s a simple statement, but in the world of pain and injuries, it proves so often to be true. Let’s break this one open, shall we? We are going to present this one in two parts.
When patients come in, especially patients in a great deal of pain, it can be so easy to fall into the trap of putting all our attention and focus on the area that hurts. After all, if you come into my office complaining about pain in your shoulder and I don’t actually treat your shoulder, there’s a high probability (if I do not educate you properly on your condition following a thorough history and examination) you’re going to think I’m a moron. I’m with you on this one. However, it isn’t always that simple. Allow me to explain…
Let’s start with a list (not all-inclusive) of things that could cause you to feel pain around your shoulder: heart attack (that’s a biggie…you probably don’t want your doctor treating your shoulder pain with that one), neck pathology such as disc herniations or compressed spinal nerves, restricted or “stuck” joints of the cervical spine, entrapped nerves and or blood vessels between the tight nooks and crannies anywhere from the neck down to the shoulder, trigger points from muscles in the area of the neck and shoulder, acromioclavicular (AC) joint pathology, and of course shoulder pathology such as rotator cuff tears and labral tears. Oh boy, this is confusing. I know, that’s why you need a solid physical exam to determine what your “pain generator” is.
So why are there so many structures, besides my shoulder, that could be causing me to feel pain there? Great question! I’m so glad you asked. A big reason has to do with your nervous system, how you’re wired and how your brain interprets pain from noxious stimuli (damage or threat of damage to tissues). You see, all the previously mentioned structures have sensory fibers detecting what’s going on out in the periphery and sending those signals back to your brain. Your brain then determines whether this is a real threat and whether you feel pain. Here’s where it gets good. A lot of these nerves in the periphery jump on the same “nerve highway” coming back to your brain via the spinal cord. Your brain gets these signals and it likes to play the odds. Side note, your brain is very efficient and one of the ways it stays efficient is taking best guesses based upon information in the past. Your brain is going to cause you to sense pain in the area of your body most likely to hurt based upon past experiences and the amount of information it receives from that area.
So, let’s return to the heart attack example. You are now having a heart attack (not really, don’t call 9-1-1). There is actual damage occurring to your heart because certain parts are not receiving adequate blood supply to keep the tissues alive. This damage causes signals to be sent to the brain so that you act immediately and keep yourself alive. This is a real threat!!! However, the sensory fibers from your heart share part of their path to the brain on the same highway as the sensory nerve fibers from your shoulder and arm. When your brain gets these signals, it does its thing and plays the odds. It’s not very common for your brain to receive sensory feedback of the pain sort from your heart, but it is very common to receive sensory input from your arms and shoulders because you’re using them all the time. Your brain now interprets the heart pain as arm pain. This is called referred pain and it happens all the time.
Here are a few examples of referred pain we see quite often: disc injuries from the neck causing pain and/or numbness and tingling in the arm, disc injuries in the low back causing a sciatica (pain down the leg), restricted joints in the cervical spine referring pain to the head causing headaches, restricted joints where your ribs and vertebrae connect referring pain to your chest/sternum or around your ribs, and trigger points in the musculature around your jaw giving you toothaches (my wife is a dentist, so this one isn’t all that uncommon in my world).
My hope is you’re beginning to see the complexity that is the world of pain. Simply because your shoulder hurts, does not mean you have a problem with the shoulder. We will go into this a little deeper in part 2 of “Where you think it is, it ain’t.” For now, please consider a good quality physical examination that seeks to reproduce your symptoms and rule in/out possible “pain generators”. Please do not just simply rely on medical imaging such as x-rays and MRI’s to diagnose the problem. This will begin to make a little more sense in our next post. Until then, hang tight.
If you’re struggling to find a resolution for your pain, please feel free to schedule an appointment with us and we will help you figure out what is causing your pain and point you in the direction of the best care option possible.