Mrs. H., a spritely woman in her mid-60s, arrived in my office looking a little frustrated, yet hopeful, as she relayed her story.

“I have struggled with my right shoulder for almost two years now. I am an artist, painting with watercolors, and my shoulder really affects my painting. It has progressively gotten worse over time. At this point, I cannot lift it higher than this (she lifted her arm to about 70 degrees of forward flexion and about the same in abduction).  I saw my doctor about two months ago and she took an X-ray of my shoulder. She said that the likely cause of my pain is a bone spur and that surgery is needed to remove the spur. My friend Ron has seen you and suggested I consult you first, as you have helped him and many others avoid surgery or a life on medication. I’d like to do anything I can to avoid surgery.”

At this point, I had a sinking feeling that this may not go well. If any therapeutic approach garners success, it always seems that the second step is overestimation of what is possible.  “Let me explain something,” I said. “If the X-ray shows a bone spur under the acromial shelf, the spur acts like a thorn sticking downward. Every time you raise your arm, that thorn is shredding the tendon of a muscle underneath it. Usually, by the time they try the repair, the tendon is shredded into pieces. The more you lift your arm, the more you shred the tendon.”

“But I want to do everything possible to avoid surgery,” she said, “I just don’t believe in it.”

“The bone spur doesn’t really care if you believe in it or not,” I explained. “It just is. Each time you raise your arm above 90 degrees, the spur comes in contact with the tendon. Soft-tissue work is unlikely to change that.”

Mrs. H. looked disappointed and I felt bad for not having a viable solution for her. I suggested that as long as she was here, we should take a look at the soft tissue anyway. I did this mostly to help her feel attended to, since I did not feel I could solve her problem.

As expected, I found sensitivity in numerous muscles of the shoulder girdle, concentrating on none of them in particular at this point. As she was talking about her artwork, I happened to lift her arm into full flexion and abduction. I think I did this absolutely reflexively, more by default than design. She kept speaking passionately about her artwork, not responding to the movements at all. It took a moment for me to register the full significance of what just transpired. Stopping the treatment, I asked her to sit.

As she sat up, I passively moved her arm into abduction and moved it in multiple positions. No negative response from her at all.

“Do you remember what I said earlier about the bone spur? Everything I said was true, but not for you. Think about it. If the bone spur is the source of your pain, why isn’t it painful when I lift your arm? The spur should still be coming in contact with the tendon. It should hurt you now, but it doesn’t (I was holding her arm at more than 90 degrees of abduction). The pain exists when you actively lift the arm, which means it is a contractile problem, one due to muscles complaining about either length or strength. Lift your arm again, slowly if possible, and tell me where you feel restriction.”

She did this and pointed to the underside of her arm, in the area of the latissimus and teres muscles. Horrified, I wondered why in the world I didn’t do this simple test first. It would have clarified the problem right away, pointing me away from the bone spur as the source of pain. I do this with everyone else; how could I overlook something so simple?

The answer to this question is that I, like the physician, was led down the path provided by the diagnostic image. Just because there is a problem/pathology on the screen does not mean that this pathology is the source of pain. In the case of Mrs. H., this was indeed true. In just three careful 30-minute treatments, she was able to lift her arm without pain. The impediment to great problem solving is often the assumption we accept as true, whether or not it is confirmed by what the client presents to us. The table lesson from Mrs. H. is: assume nothing, question everything, and the final answer should address every facet of symptom presentation and history.

Douglas Nelson is the founder and principal instructor for Precision Neuromuscular Therapy Seminars and president of the 16-therapist clinic BodyWork Associates in Champaign, Illinois. His clinic, seminars, and research endeavors explore the science behind this work. Visit www.nmtmidwest.com or email him at doug@nmtmidwest.com.