Right shoulder pain

RECORD OF FIRST VISIT

Date of first visit: 20/09/08 Name: Tong K Gender: male

Date of birth: xx/xx/1963 age: 45

Chief complaints: Right shoulder pain for more than 2 years

Descriptions

a) Asking:

He had been suffered from right shoulder pain more than 2 years and recurrence for 2 weeks. When he was young he lifting wet heavy blanket, he hears the bone crack and then the pain start in the upper back mainly in scapular. Sometime he feels pain on the right side in the anterior (front) aspect of the shoulder. He still has shoulder pain since.

His pain getting worse when he tries to do some work or play golf. The pain redial to scapular , is strapping pain ,He feeling numbness in the finger, feeling tight on the shoulder ,and sometime feel pain in back and legs.

He feels tired, feel headache and dizziness. No chill no fever, no sweating,

Stool is soft, urine are 4-5 times a day. Good sleep. Normal appetite.

Family history: Bother & mother had Asthma

Past history: High Blood pressure more than 3 years

Menstruation, Marital and Obstetrical history: married; have three children

b) Inspection

General: energy level 6 /10

Tongue: Pale tongue body, White tongue coating, swollen tongue & teeth mark

c) Auscultation/Olfaction

Sound: normal

Odors: normal

d) Palpation

Body area: Pain on the right side of the body

Pulse: Rapid on the left, weak on the right side

CASE SUMMARY

DEFINITION: Pain in the shoulder due to an injury or disease. Shoulder pain involves any pain in or around the shoulder joint.

The shoulder is the most mobile joint in the human body. The joint includes four tendons. The purpose of a tendon is to hold muscle to bone. Together, these four "rotator cuff" tendons stabilize the upper arm bone to the shoulder socket and allow a wide range of motion in the shoulder.

Any swelling, inflammation, tearing, or bony changes around these tendons causes pain when a person tries to move the arm above the head, behind the back, or straight out in front. Most shoulder problems involve either overuse or underused.

Possible cause of shoulder pain

Sports injury (pitching, throwing, tackling, swinging)
* Car accident (especially whiplash)
* Overuse and/or repetitive motions (lifting and reaching)
* Arthritis (aging, normal wear and tear)
* Old injury from childhood
* Sleeping in awkward position
* Long-standing spinal or emotional stress

TCM DIAGNOSIS: Shoulder pain

TCM AETIOLOGY & PATHOLOGY:

Chronic pain in the shoulders can be caused by bone tuberculosis, tumors, injuries, and bi (qi and blood stasis). Etiology of pain is qi stagnation, blood stagnation, or both. The cause of shoulder pain can be trauma, over strain, wind, cold, dampness, etc. and can be deficiency of Zongfu or Qi & blood.

TCM DIFFERENTIATION: Qi stagnation & blood stasis with liver yin deficiency

EXPLANATION

Qi is energy the circulate thought out the body, the qi flow through the channel & meridian, If qi stagnation can lead to blood stagnation, the location of stagnation of qi & blood will become to pain, If the qi stagnation long enough its will make the muscle tight, compacted and the muscle begins to really manifest that stagnation in the form of lumps pain, and also blood circulation occur. Liver is store blood when the liver fails to nourish a part of the body can feeling dizziness, headache and also tongue body shown pale. The swollen tongue and teeth mark also indicate qi stagnation. Patient have long term problem can also affect liver as well as hypertension.

TREATMENT PRINCIPLE: activate the channel, promote the circulation of the qi and blood, release pain, relax tendons, and stop the pain. Nourish liver yin

POINTS & THERAPIES: Houxi, Jianzhen, Tiaokou, Binao, Quchi, Hegu

Jianyu, Jianlioa ,Yanglingquan and tiaokou

Ashi point around scapular

PRINCIPLE OF THE POINT:

Houxi- Stiffness and pain of the neck,

Binao- painful obstruction of the upper arm and shoulder,

Jianyu- Eliminates wind and regulates qi and blood

Jianzhen- Expels wind and benefits the shoulder. Activates the channel and alleviates pain

Quchi- Clears heat

Jianlioa- Dispels wind-damp. Alleviates pain and benefits the shoulder joint

Hegu- expel wind-cold or wind-heat and to release the exterior

Tiaokou- Pain and stiffness of the shoulder

Yanglingquan-Regulates Liver Qi to regulate Blood

LIFESTYLE ADVICE:

a) No cold food and drink, keep body warm

b) More exercise

FOLLOW UP TREATMENT:

1. 22/09/08 shoulder pain needling cupping

2. 25/09/08 shoulder pain same needing and cupping

CASE CONCLUSION:

Patient need more exercise, he feel better.