I greeted Mrs. N. in the waiting room, happy to see this energetic, 70-something woman again—it had been a while since our last visit.

“What brings you in today?” I asked. “How is your back doing?”

“My back is doing fine. It has been quite good for many months. I am here today because of my left shoulder. After five months of pain, I am ready for it to end.”

“Was there any event that initiated this pain, or did it escalate slowly over time?” I queried.

“I can’t think of any specific incident, other than painting the two back bedrooms in the house. After a month of pain, I went to see my doctor. She diagnosed it as impingement syndrome and gave me some medication, which makes me tired and doesn’t help very much. After a few weeks, she also referred me to physical therapy. I have been doing the exercises, but it hasn’t helped, and the pain is really starting to wear me down. Is this something you have seen before, and can you help me?”

“I have seen this many times, and there is every reason to think that precise soft-tissue work can help,” I replied. “First, I’d like to check something.”

Putting her humerus into full internal rotation, I passively lifted her arm into forward flexion. As soon as we went past 90 degrees, it recreated the pain in her shoulder. This test confirmed that impingement was likely. At that point, I asked her to lie on her side on my table, so that I might palpate the supraspinatus. 

“Before I forget,” she said,  “I want to ask a question. For years, my husband and I have always slept in the same positions. Unfortunately, that means that I sleep on my left shoulder, which is the one that hurts. I think sleeping on it makes it worse, but changing to lying on my right side messes up our sleeping routine. Is it bad to sleep on my left side?”

Before I opened my mouth to give her an answer that seemed obvious, I thought about a much larger concept that might be far more important.

“Has anyone explained to you what impingement syndrome actually is?” I asked.  “No, not really,” she replied. 

I am not sure how long I hesitated in replying, but the implications of her statement cascaded me into a sea of thoughts. You might make the case that previous health-care providers did explain impingement to her and she didn’t understand or remember, but this is an extremely  bright woman who could not explain it to me now. How can a person know what to do or what not to do without understanding the nature of the condition itself? I have seen countless clients who have been given a diagnosis, yet possess no real understanding of the mechanics of how that translates into real life. In our rush to perform a treatment, we neglect to form a deep understanding of the problem in our clients. The more completely clients understand a problem, the more likely we are to create effective solutions together. 

“Let’s spend a few minutes with my skeletal model before we get on the table,” I said, inviting her to my desk. “Do you see this deep space?” I asked, pointing to the supraspinatus fossa. “That is where a muscle called the supraspinatus is located. It attaches at the top of this bone called the greater tubercle of the humerus. Notice how the tendon has to pass under this bony shelf. If there is too little room, the tendon gets squished, and therefore inflamed.”

“What would cause it to get squished?” she asked. 

“There are two common reasons: a fall or repeated small traumas,” I said. “Watch this.” I raised the humerus into abduction. “Anytime your upper arm is above 90 degrees, you compress the available space. Or, if you fall with your arms outstretched, the humerus is jammed up into the socket, which smashes the tendon and the bursa.”

“Uh oh,” she remarked. 

“Uh oh?” I questioned.

“I did have a little fall before the pain started. I started painting the bedrooms within days of the fall, which might have been the last straw. I was planning on painting the kitchen next. I bet using a brush and roller overhead isn’t going to be a good thing for my shoulder right now.”

“Correct. Plus, what happens to the available space when you lie on that side?” I asked.

“Lots of compression. No wonder that hurts.”

After Mrs. N. left, I thought about how differently she must feel about her shoulder pain. No longer just a condition with a name, she now understood what was happening, why it was happening, and how she could avoid it. That knowledge alone is powerful healing.