Question
I fell down 9 steps a few years ago. I had a bruised bone in my elbow with fluid around it. My whole arm was sore due to the extent of the injury. My elbow has bothered me off/on since, especially if I do heavy work. However, in the last few
months I've had an ache that starts just below my left shoulder and at times it feels tingly. I have no chest pain, no neck pain and occasionally have dull pain in my lower shoulder blade. I've had xrays of my neck, shoulder and elbow and they are all normal. I am a diabetic and I do work on a computer most of the day. I was wondering does this appear to be related to the fall or to my work or even the diabetes.

Answer
Dear Tracy,

These symptoms are probably a combination of all your suspected reasons. The reason I say this is because previous trauma will often set a person up for long term consequences in the associated areas of the body where the original trauma was experienced.  This long-term symptoms may be on and off, and may be mild or severe depending on the initial insult and the amount of tissue damage and scar tissue experienced.  Although many physicians try to look at the body as separate and distinct anatomical regions, we cannot forget that the function and physiology of the system as a whole is completely interconnected.

Some issues to consider: altered arm motion or elbow function due to pain or residual limitation will affect function of the shoulder and rotator cuff as well as the scapulothoracic motion of the shoulder region;  deconditioned postures, such as experienced by desk and computer dominated workers, alters the function of the shoulder and neck leading to chronic stress in the neck and upper back which can lead to muscle spasms;  the fact that you are a dibetic reduces your body's overall immune function even if only slightly which predisposes you to longer healing times and greater susceptibility to chronicity.

So what is the direction to move?  

First of all, make sure that you keep your diabetes in check...I am sure you are well aware of how to do this...keep the anatomical system clean.

Second, start by making sure that you work station is set up in an appropriate manner.  Get a supportive chair with arm rests that allow your arms to rest comfortably without holding them up while on the computer, and try to keep your shoulders back which reduces stress in the upper arm and upper back musculature  Get your computer monitor up high enough that you do not need to look down...the direct center of your screen should be at or above eye height while looking straight ahead.  

Third, get to a musculoskeletal specialist and have the area of complaint examined.  I would obviously suggest a chiropractic physician rather than a medical doctor because your symptoms imply functional soft tissue problem rather than frank neurological compromise.  Although you are having neurological symptoms such as tingling, this is often due to the above mentioned issues and nerve compression is rarely the true issue.  Furthermore, trigger points/muscle spasms and soft tissue injuries/dysfunction often create referred pain which is poorly understood by many medical physicians because this is not their chosen forte in healthcare.

Lastly, I am going to attach a 2 documents I give to many of my patients on the work environment and how to abate the daily stress of desk postures, as well as pain referral.  With a little proper planning and implementation, I think you can get some quick resolution.

Attachment #1:  Training for Stability of the Neck and Back匩ot What You Think!

A brief look around any boardroom, construction site, grocery store etc?will provide any observer an insight into poor posture and de-conditioning syndrome. A deconditioned individual has only one option for lasting pain relief which is increasing their functional capacity. The average teenager and adult have pronounced spinal displacements due to chronic poor ergonomics of basic living, poor posture, and constrained working environments.  Back or neck pain is the number one reason for a visit to the chiropractic physician and medical doctor!  Shouldn抰 you work to prevent injury and strain?  The obvious answer is yes!

The most common reasons for back and neck pains are poor lifting techniques, abnormal posture, and repetitive micro-strain coupled with the lack of stability within the muscular system, and trauma.  It is sometimes difficult to avoid trauma, but if you eliminate poor technique, improve the ergonomics of your work station, and train your spine for stability, you significantly reduce your risk of injury.  Remember that we live in a gravity controlled environment and all muscular actions are in direct opposition to gravity.  We stabilize bridges and buildings so they won抰 buckle or break, you need to do the same for your spine.  

That being said, conventional strength training with free weights and isolation machines will give general overall gains in muscular strength if utilized properly, but won抰 necessarily target stability of the core or the spine.  Muscles to target are the multifidus, rotatores, intertransversales, transverse abdominis, and the pelvic floor.  Moreover, it is important to train for balance and symmetry thereby reducing abnormal weight bearing on all joints of the body.  

Lifting technique is important for optimal health and the reduction of injury.  To execute a lift properly, the back should be fairly straight while maintaining the normal lordosis (forward arch of the low back).  This position will activate the musculature properly for stability while not recruiting the ligaments for support.  Squatting is optimal, due to its neutral spinal position and the ability to use the muscles of the legs to accomplish the lift.   Stooping should be avoided, especially with repetitive movements.  Stooping creates an unstable configuration for the disk with increased tensile pressure on the posterior portion of the disk due to increased compression on the anterior portion of the disk.  This can easily result in a rupture of the disk.  In addition, objects should not be lifted if they are placed awkwardly which may require twisting and or bending, weights should be held close to the body, and jerky movements are only appropriate for highly trained individuals such as advanced athletes under the supervision of a trainer.  The last key is to create contraction of the abdominal musculature before the lift. This provides greater stabilization the spine, and your entire core.  You can easily accomplish this by sucking the belly button in toward the spine.  This activates the transverse abdominus muscle which is key for all movements.

One of the most deleterious activities people engage in is sitting. Sitting increases disk pressure more than standing and encourages abnormal flexion (forward bending) of the neck and upper back in addition to slumping in the chair.  These postures chronically load the disks, ligaments and musculature of the spine creating micro-injury and dysfunctional movement patterns.  

Many of us spend the majority of our days at a desk, computer or workstation.  We need to consider and modify our workspace carefully.  Adding a support for the lumbar spine reduces disk pressures.  A seatback angle of 5-15 degrees from vertical will reduce low back muscle activity and disk pressure.  Proper desk height is approximately 30 centimeters from the seat of the chair.  Arm rests are important in limiting strain on the upper muscular complex of the back and neck to include the trapezius, rhomboids, and levator scapulae.  The shoulders should be able to relax with the elbows bent at 90 degrees while the hands rest on the desk surface.  

Forward movement of the head on the neck is extremely problematic. For every inch forward the head moves in relation to the neck and shoulders, the compressive forces on the lower neck increase by the entire weight of the head, 10-16 lbs. Think about the difference in holding a bowling ball close to the body, or away from the body. This illustrates the differences in muscular work needed to support the weight and the ligamentous strain.  Computer monitors should be elevated so that the center of the screen is at eye level while looking straight ahead.  This will reduce eye strain; further reduce muscular tension of the neck while limiting the forward flexion of the head, therefore reducing the abnormal loading of the ligamentous complex.  This will also help reduce those 搘ork headaches?  Placing the monitor higher to induce a slight extension of the head is permissible.

Now that you have proper technique, and your workstation is optimal, structural and functional training of the musculature on the back of your body and your core is the key.  You must have a balanced and relaxed spinal cord for optimal function.  That being said, specific training is the way to achieve spinal balance and stability, and you don抰 have to go to the gym to achieve it.  If you can appreciate that we spend most of our days in a flexed position, the way to relieve that cumulative stress is to train the small stability muscles in an extended position.  

Most people are flexed forward at the hips/pelvis, have rounded shoulders, and a forward head and neck, this is called Global Flexion.  Extending the head backwards, opening up the chest by turning the palms of your hands outward and stretching your arms backwards relieves this global flexion.  The last step is to stand up and bend backwards at the waist approximately 20 degrees. You have just accomplished the task of Global Extension.  If you flex or tighten up all you muscles while in this position it further accentuates the value of the exercise and also promotes increased blood flow and oxygen delivery to the body.  This is a relief position that everyone should use frequently throughout the day to abate cumulative postural stresses.

Moving on, posture is the next consideration.  Your posture should not be a conscious task, but with the level of deconditioning in the population, conscious postural improvements are necessary.  This is mostly common sense, and your mother has telling you to do this since you were a child.  Exercise your postural muscles while walking.  Stand up straight, hold your head up high and walk with confidence looking ahead of yourself, not at the ground.  Pull your shoulders back, breathe deeply, and take confident long strides.  This alone will bring more oxygen to your body by fully opening up the lungs, increasing blood flow, and reducing abnormal stress on spinal structures.  You can also practice this position on a physio-ball or thera-ball to improve your seated posture and balance.  Complex postural issues and stability issues need to be addressed by a professional.

Remember that weight training, aerobic activity, and general fitness types of activities are only good for you if done with proper form, balance, control and stability.  If you don抰 have good posture and spinal symmetry, a traditional workout program will only make those problems worse.  It is essential to incorporate stability into your spine and your life before starting any exercise program.  You should see a medical or chiropractic physician before starting a fitness regime to make sure you are in good health and able to handle the rigors of increased physical activity.  If you have any cardiovascular issues, a stress test should be performed.  Many subsequent doctor visits are caused by improper fitness activities; it is better to see you doctor before rather than after.

All chiropractic physicians will be able to teach you about postural imbalances and how to improve your own posture, but many chiropractors have additional post-doctoral training in advanced postural biomechanics and structural correction to help you attain improved spinal dynamics.  Ask your chiropractic physician to tell you about their training, and provide written documentation about their qualifications.  To learn more about postural correction check out www.idealspine.com. In addition, a Certified Pilates instructor, www.nypilates.info, www.pilates-trainning.com or Certified Personal Trainer www.nsca-lift.org, www.ncsf.org  can have great benefit.  Remember to check their qualifications as well.

Attachment #2: The Misunderstood Pain:  Sclerotogenous Referral Pain

Presenting Situation:  The patient states, 揑 have back pain that shoots into my leg? but the neurologist states the NCV (Nerve Conduction Velocity) EMG (Electromyogram) and MRI (Magnetic Resonance Imaging) are all normal. Is the patient embellishing? The answer is probably no. While it is true that some patients magnify their symptoms, they are usually not sophisticated enough to feign symptoms into a specific reproducible pattern. Why then were the imaging and electrodiagnostic tests negative? The answer is simple. The tests are either not sensitive enough to demonstrate the lesion, not designed to find the existing lesion or improperly performed and interpreted. For example, a negative MRI may suggest that there is no visualized compression of neural structures by discs or bone spurs. Negative NCV抯 and EMG抯 may suggest that there was insufficient compression or no compression of the large diameter nerves, which would result in a measurable abnormality.  But what about the small diameter sensory nerves, what about ligament tearing, is there fatty infiltration of the muscle fibers, what about the other soft tissue structures?  The truth is that researchers have shown an association between low back pain or leg pain and the lumbar facet joints many times, which is not generated by the disc, spinal nerve or spinal cord (1,2,3).

In fact, patients with referred pain often do not have nerve compression. Sounds good, right? Unfortunately it抯 not that simple. The most common referred pain seen in trauma cases are vascular, neurologic, visceral and sclerotomal. Neurologic pain (dermatomal pain), such as seen with disc herniations and nerve root compression, is the most frequently looked for type of pain. Less common are the vascular referred pains such as those seen with thoracic outlet syndromes. Visceral referred pain can happen with contusion to the body抯 organ systems. However, the most common and frequently overlooked origin of referred pain is from the soft tissues of the spine, also known as sclerotomal or sclerotogenous pain. An example: referred pain experienced with myofascial trigger points. While trigger points are common they are only one of the many sources of sclerotomal pain. Other sources would include the disc itself, facet joint capsules, facet joint cartilage, tendons, ligaments, etc?br>
Sclerotomal:  The name suggests pain can come from any tissue of the same embryonic origin. A sclerotome is an embryonic region, which during fetal development differentiates into a variety of different body structures. These parts may or may not be neurologically connected but are understood to have some physiological relationship. Researchers have demonstrated these relationships repeatedly over the years and mapped out their referral distributions quite well. In fact, sclerotomal referral patterns have been published in many indexed medical journals beginning with the early work of Kellgren in 1939, Inman and Saunders in1944, and Feinstein et al. in 1954. One of the most well respected anatomical researchers, Bogduk, confirmed earlier findings in 1988.

Sclerotomal/referred pain has some unique characteristics. For example, in the lumbar spine (lower back) a Sclerotomal pain is usually more severe than dermatomal pain. Sclerotomal pain may not radiate down the entire leg and will usually stop at the knee or calf. There is no weakness or muscle atrophy with scerotomal pain. Referred pain can often be reproduced by applying pressure to the tissue site. In the cervical spine (neck) referral patterns to the cranium, chest, upper extremities and thoracic spine (upper and middle back) are common.

Referred pain has been overlooked as a source of pain by many clinicians because of the difficulty in treatment and diagnosis. Defense doctors, independent medical examiners, file reviewers, and insurance carriers, who have little or no experience with managing these types of injuries, often classify patients as malingerers or symptom magnifiers, and limit their treatment by cutting insurance benefits. Over time these patients may become chronic pain patients and eventually develop symptoms consistent with Fibromyalgia and Chronic Fatigue Syndrome.

Early Discovery:  Many years ago Kellgren (4) conducted his now-classic research into the nature of referred pain. He injected hypertonic saline into paraspinal and other soft tissues and observed that the volunteers felt not only a local pain at the site of injection, which was to be expected, but also a pain radiating some distance away. Volunteers often complained of deep somatic pain or autonomic symptoms such as sweating, pallor, or palpitations. Kellgren mapped these referred patterns and found that there was a fair amount of consistency from one person to the next.

Rediscoveries:  Some time later, Inman and Saunders (5) conducted similar research, again injecting fluid into the paraspinal tissues and documenting the patterns and nature of the resultant referred pain.  In both instances they found that fairly consistent patterns of referred pain could be reproduced. Usually this referred pain began shortly after the injection and grew gradually. Most volunteers described it as gripping, aching, burning, heavy, or cramp-like. The important findings of Inman and Saunders are listed below.

Findings of Inman and Saunders
1.   A time lag of minutes to several hours between injection and referred pain existed.                                           
2.   Volunteers had difficulty localizing the stimulus.         
3.   Periosteum and its attachments were most sensitive; muscle was least sensitive.         
4.   Greatest radiation occurred when periosteum or attachments were stimulated.    
5.   Muscles in referral areas were tender and sore.     
6.   Autonomic symptoms occurred when thoracic areas were stimulated.  
7.   The pain could last for several days.                                                                                                             

Refinements:  In an elegant experiment, Feinstein et al. replicated the earlier work of Kellgren, Inman and Saunders (6). They injected the brachial plexus of one volunteer with procaine. The complete regional block that resulted also included the autonomic nervous system (ANS), as evidenced by the temporary Horner's syndrome that was produced. In this way they had removed both the peripheral nervous system (PNS) and the autonomic nervous system from the list of contributors to the pain. Another paraspinal injection of saline solution into this volunteer's neck resulted in the same referred arm pain experienced before the regional block. Therefore, this mechanism of referral was not mediated or conveyed by either the ANS or the PNS, but was in fact a central phenomenon.  The findings of Feinstein et al. are summarized below.

Findings of Feinstein et al.
1.   Upper cervical stimulation resulted in head pain.                
2.   A segmental relationship existed, whereby injection of a muscle whose innervation was C5-6 would result in soreness in other muscles innervated by those levels.    
3.   Muscle soreness and spasm was noted in referred pain areas.      
4.   Hypesthesia was noted over referred areas.   
5.   Phantom limb pain could be reproduced in amputees (even in those who had not experienced it at the time of their amputation).     
6.   **The ANS and PNS are not mediators of the pain.                                                                          

Perhaps most interesting about this referred or sclerotogenous pain, is the observation that the levels of referral, while reproducible from patient to patient, do not seem to follow known dermatomal or myotomal patterns. In fact, the body maps created by Feinstein and coworkers are re-created in Foreman and Croft抯 Textbook:  Whiplash Injuries: the cervical acceleration/deceleration syndrome [3rd edition, pp 396-404].  These body maps demonstrate that, very often, injection at one spinal level results in pain referral to areas innervated two to four spinal segments away. And often, referral is to not one, but several segment levels. This serves to confuse the issue all the more. For example, an injection at C7 may result in referred pain in areas innervated by C5, C6, C7, C8 and T1.

Since it is most common for clinicians to view the human body with the neurogenic pain model, a ligamentous injury at C7, resulting in the above referred pain pattern, might confuse the uneducated physician.  Diagnostic options may include: multiple disc lesions, brachial plexopathy, thoracic outlet syndrome, or outright malingering, which is often the impression many doctors arrive at.  The patient is branded a faker, and left without answers.

Non-classical neurological findings in CAD/whiplash trauma are common (7) and should not be used to suggest that patients are disingenuous. These non-dermatomal sensory abnormalities, as common as they are, qualify one for a DSM-III psychiatric diagnosis! Some have argued that they are common in Multiple Personality Disorder. As stated previously, anatomical studies and electrodiagnostic studies will generally be normal, although plain films often demonstrate some instability.  Again, this only serves to confound the uneducated physician, and muddle diagnosis.

Recent Corroboration:  Bogduk and Marsland (8,9) demonstrated that cervical facet joints could be the source of neck pain. Over 50% of their chronic CAD injury group had facet pain (8,10). Dwyer et al. (11) injected the cervical facet joints of human volunteers with saline solution and dye and recorded their responses. They found that the upper cervical joints, C2-3, were associated with suboccipital headaches when injected (they did not inject C1-2 or OCC-C1, but presumably these would have resulted in headaches as well). Lower levels were productive of neck and shoulder pain, not surprisingly. In part II of their study (12), they used the pain maps created from injecting normal volunteers to predict the spinal levels involved in a group of patients who complained of neck and/or shoulder pain. Their success rate with this method was 100% (Limitations- fairly small study group).

Although this work by Bogduk and Marsland (9) and Dwyer et al. (11) seems to suggest that discrete scleratomes exist in the cervical region, the high degree of overlap at lumbar levels noted by some observers precludes the description of such a construct there. Kellgren (4) and Inman and Saunders (5) described discrete scleratomes at lumbar levels, but more recent researchers have been unable to confirm such consistency (13,14). McCall et al. (15), for example, injected facet joints at L1-2 and L4-5 and found much overlap even though a general pattern of flank pain was seen at upper levels, whereas buttock and groin pain was seen at lower levels. In essence, these studies argue against 搕rue scleratomes," in the lumbar spine while the phenomenon of scleratogenous pain is still very real. Scleratomal pain, it turns out, was a poor term for the phenomenon.  Nevertheless, Bogduk and Lord (16) continue to use the term and give a good review of pain and whiplash injury. The figure below points to the differences between dermatomal and scleratomal pain.

The broadly referring pattern of facet joints is at least partially explained by a recent set of experiments. Ohtori et al. (17) used retrograde neurotracing methods with Fluoro-Gold (FG), to trace the level of dorsal root ganglions (DRGs) innervating the C1-C2, C3-C4, and C5-C6 facet joints and their pathways in rats. Neurons labeled with FG were present in the DRGs from C1 through C8 in the C1-C2 group, from C1 to T2 in the C3-C4 group, and from C3 to T3 in the C5-C6 group, which illustrates the redundancy of innervation at multiple levels. No wonder an injured facet joint may refer pain so broadly.

The prognosis for sclerotogenous pain from traumatic insult is dependent upon many factors. The extent of damage, pre-exiting illnesses, compliance with care and early detection by the physician, all contribute to the potential outcome. Damaged soft tissues tend to heal in a disorganized manner even with regular management. Active care protocols applied in a controlled manner are essential in managing the resultant scar formation in sclerotogenous structures and reducing chronic pain.  The fibrotic replacement tissue is never as competent as the original tissue and is prone towards re-injury and hypersensitivity. Even with prompt attention the prognosis for complete recovery may be only fair to poor.

References:
1.   Carrera GF: Lumbar facet joint injection in low back pain and sciatica.  Neuroradiology 137:665-667, 1980
2.   Fairbank JCT, Park WM, McCall IW, O'Brien JP: Apophyseal injection of local anesthetic as a diagnostic aid in primary low-back pain syndromes. Spine 6(6):598-605, 1981.
3.   Destouet JM, Gigula LA, Murphy WA, Monsees B: Lumbar facet joint injection: indication, technique, clinical correlation, and preliminary results.  Radiology 145:321-325, 1982.
4.   Kellgren JH: On distribution of pain arising from deep somatic structures with charts of segmental pain areas.  Clin Sci 4:35-46, 1939.
5.   Inman VT, Saunders JBdeCM: Referred pain from skeletal structures.  J Nerv Ment Dis 99:660-667, 1944.
6.   Feinstein B, Langton JNK, Jameson RM, Schiller F: Experiments of pain referred from deep somatic tissues.  J Bone Joint Surg 36A(5):981-997, 1954.
7.   Bogduk N: Post whiplash syndrome. Aust Fam Phys 23(12):2303-2307, 1994.
8.   Barnsley L, Lord S, Wallis BJ, Bogduk N: The presence of chronic cervical zygapophyseal joint pain after whiplash. Spine 20(1):20-26, 1995.
9.   Bogduk N, Marsland A: The cervical zygapophyseal joints as a source of neck pain.  Spine 13(6):610-617, 1988.
10.   Lord SM, Barnsley L, Wallis BJ, Bogduk N: Chronic cervical zygapophyseal pain after whiplash. Spine 21(15):1737-1745, 1996.
11.   Dwyer A, Aprill C, Bogduk N: Cervical zygapophyseal joint pain patterns I: a study in normal volunteers.  Spine 15(6):453-457, 1990.
12.   Aprill C, Dwyer A, Bogduk N: Cervical zygapophyseal joint pain patterns II: a clinical evaluation. Spine 15(6):458-461, 1990.
13.   Hockaday JM, Whitty CWM: Patterns of referred pain in the normal subject.  Brain 90(3):481-496, 1967.
14.   Sinclair DL Jr, Feindel WH, Weddell G, et al.: The intervertebral ligaments as a source of pain. J Bone Joint Surg 30B:515-525, 1948.
15.   McCall IW, Park WM, O'Brien JP: Induced pain referral from posterior lumbar elements in normal subjects. Spine 4(5):441-446, 1979.
16.   Bogduk N, Lord SM: Cervical spine disorders. Cur Opin Rheumatol 10:110-115, 1998.
17.   Ohtori S, Takahashi K, Chiba T, Yamagata M, Sameda H, Moriya H. Sensory innervation of the cervical facet joints in rats. Spine 26:147-150, 2001.

Hope this helps Tracy, I know that some of the information is technical and dense, but I wanted you to be exposed to the information.

Respectfully,
Dr. J. Shawn leatherman
www.suncoasthealthcare.net