Right shoulder pain for six months

RECORD OF FIRST VISIT

Date of First Visit: 20/08/2008 Name: xxx

Date of Birth: 47 Gender: male

Chief complain: Right shoulder pain for six months

Descriptions (4 Diagnostic methods)

A) Asking

Present illness history: The patient has been suffering from shoulder pain for six months. The pain is around shoulder and scapular region with stabbing pain on fixed area. It occurs gradually without any injury since he started new business which involve physical work using right hand continuously. The pain is more severe in the morning and evening. He feels pain when he abduct arm and some limitation of movement in retro-flexion of his arm. Aggravated by cold weather. No chill & fever, normal sweating, good appetite, normal defecation & urination, good sleep, thirsty and dry mouth, prefer to drink cold water.

Past illness history: Hypertension (medication for 4 years)

Life style: Busy, no smoking & alcohol

Family history: Father : cirrhosis

Mother : hypertension

Menstruation, marital & obstetrical history: Married with two children

B) Inspection

General: medium height, dim complexion, vitality 8/10

Tongue: Purple body with red tip, crack in center, thin yellow coating

C) Auscultation/Olfaction

Sound: Nothing abnormal detected

Odours: Nothing abnormal detected

D) Palpitation

Body areas: Sharp pain feeling if press the center of scapular

Pulse: L: weak, specially on chi position R : wiry, rapid

CASE SUMMARY

Definition

Sprain and contusion refer to the injuries of soft tissues such as skin muscles, tendons and ligaments, at limbs, joints and body trunk without fracture, dislocation and skin wound. The folk name is “injury of tendons”.

WMS

A sprain is an injury which occurs to ligaments caused by being over stretched beyond their normal capacity and possibly torn. Muscular tears caused in the same manner are referred to as a strain. In cases where either ligament or muscle tissue is torn, immobilization and surgical repair may be necessary.

Degrees

Although some signs and symptoms can be used to assess the severity of a sprain, the most definitive method is with the use of magnetic resonance imaging (MRI) Sprains are graded in four degrees.

• The first degree is only a minor tear or stretch of a ligament.
• The second degree is a tear of a ligament, which is usually followed by pain or swelling..
• The third degree is a complete rupture.
• The fourth degree is the most severe and actually breaks the ligament, along with some small bones if severe enough, and requires surgery to repair.

Signs and symptoms

The typical signs and symptoms associated with a sprain are the cardinal signs of a sprain.

• inflammation
• localized pain
• swelling
• loss of function
• loss of normal limb function
• elasticity of ligament decrease

Although any joint can experience a sprain, some of the more common include:

• the ankle. It is the most common, and has been said that sprains such as serious ankle sprains are more painful and take longer to heal than actually breaking the bones in that area.
• The knee.
• The wrist.
• The toes.

Prevention

Sprains can best be prevented by proper use of safety equipment (wrist, ankle guards), warm ups and cool downs (including stretching), being aware of your surroundings and maintaining strength and flexibility. Physical conditioning is the best way to avoid or lessen the degree of sprains.

Treatment

• Rest: The sprain should be rested. No additional force should be applied on site of the sprain. If, for example, the sprain were an ankle sprain, then walking should be kept to a minimum.

• Ice: Ice should be applied immediately to the sprain to minimize swelling and ease pain. It can be applied for 20-30 minutes at a time, 3-4 times a day. Ice can be combined with a wrapping to minimize swelling and provide support.

• Compression: Dressings, bandages, or ace-wraps should be used to immobilize the sprain and provide support.

• Elevation: Keeping the sprained joint elevated above heart level will also help to minimize swelling.

Ice and compression will not completely stop swelling and pain, but will help to minimize them as the sprain begins to heal itself. Careful management of swelling is critical to the healing process as additional fluid may pool in the sprained area.

TCM Etiology and Pathogenesis

Due to ill posture of carrying heavy things, improper movement, falling, bruising, traction and over-twisting, tendons, and joints are injured, the circulation of Qi and blood is stagnated in the local region and meridians and collaterals are obstructed.

TCM diagnosis

A) Diagnosis: sprain on right shoulder

B) Syndrome Differentiation: Qi and blood stagnation on local area

C) Explanation:

Sprain and contusion refer to the injures of soft tissues such as skin muscles, tendons and ligaments at limbs joints and body trunk without fracture, dislocation. So, . circulation of qi and blood is stagnated in the local region and meridians and collaterals are obstructed. This patient is using his arm all the time for his job, especially right arm which lead to injures of soft tissues by over using. So, he feel the pain or limitation of the movement. The pain is aggravated in the working or cold weather.

Treatment

A) Treatment principles:

Activate the meridian, dredge the collateral, promote circulation of qi & blood to relieve pain

B) Treatment methods

1. Needling: filiform

Points: Jianjing(GB21), jianzhen(SI9), jianyu(LI15), tianzhong(SI11), waiguan(SJ5)

Explanations :

-Jianjing : the crossing point of sanjiao, gallbladder, stomach, yang link vessel stimulate to treat shoulder pain

-Jianyu : the crossing point of large intestine and yang heel vessel. , locally to release the shoulder & scapular problem, unblock the meridian

-jianzhen : locally to release the shoulder & scapular problem, unblock the meridian

-tianzhong: locally to release the shoulder & scapular problem, unblock the meridian

-waiguan: luo connecting point, one of the eight confluent point that link with the yang link vessel. along the meridian to relieve the upper arm muscle pain and clean the internal heat

( All points are right side)

2. cupping

points: Ashi point, Tianzhong(SI11), Jianyu(LI15), Jianjing(GB21)

Explanations : Activate the meridian, dredge the collateral & stop pain

Life style advice

- Mild exercise which manipulate shoulder muscle before starting work and take

regular breaks from working position.

- Keep the shoulder warm

- Rest. no additional force should be applied on site of the sprain

Follow up consultations

Patient name : treatment number: 2,3

TCM Diagnosis: sprain on right shoulder

TCM disease: Qi and blood stagnation on local area

Date: 03 / 09/ 08, 10 / 09 /08

Current condition/changes:

2^nd treatment: The pain area was some changed from medial side of shoulder pain to lateral side of shoulder and around nape

3^rd treatment: back to medial side shoulder pain and scapular area pain

Treatment principle: Activate the meridian, dredge the collateral, promote circulation of qi & blood to relieve pain

Prescription:

2^nd treatment : – Jian yu, + Jianwaishu, Jianlao, tianzhu

3^rd treatment: - Jianwaishu, Jianlao, tianzhu+ Jianyu,

Explanation: The pain area was changed. So the point was changed accordingly.

Case Conclusion

when patient first visit, the patient feels pain when he abduct arm and some limitation of movement in retro-flexion of his arm. After 2^nd treatment, he can do retro flexion freely and the patient satisfied the treatment. When he came back 3^rd treatment, there’s no more limitation of the movement, but pain was back again.

This case is my first one for shoulder pain, through this, I realize that require some technique about how to do the examination about the pain & movement and I found acupuncture clinic is very effective and I will use the same techniques and methods to other patients again if symptom is same.