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Shoulder problems and headaches related

Health: My neurologist believes that shoulder pain and headaches may be related.

From Jennifer Sersaw
Posted September 26, 2006 at 02:34 PM

I have been searching the discussion boards and have seen a lot of discussion on shoulder pain, but I haven't seen anyone discuss a problem that I have. I injured my left shoulder around 7 or 8 years ago in high school while preparing for a concerto competition. The doctor at that time diagnosed it as a rotator cuff strain. I was sent to physical therapy and told to lighten up on the practicing. When I went onto college, I started getting terrible headaches. They got so bad that I couldn't keep up with my studies and had to take a medical withdrawal. I went back home and tried to see different doctors, but no one could find a solution to my pain. I was still having pain in my left shoulder by the way as well. Then I got married and my husband insisted that I have the problem looked into. I was literally down once or twice a week with terrible headaches that lasted 24 to 48 hours. I then went to a couple of neurologists who tried to diagnose the headaches as migraines, but the preventative medications did not stop the headaches from coming. Finally, I went to a neurologist who is supposed to be one of the best in the area, and he asked me to document some things especially after I told him about my shoulder injury years ago. We realized that most of my headaches are occurring along with the very sharp pain in my left shoulder. He believes that the two are definitely related. I occassionaly get headaches without shoulder pain but those are usually sinus headaches like any normal person will occassionally get. The knock out headaches always include pain in my shoulder as well. My shoulder pain has never gone away despite all relaxation techniques, physical therapy, etc.I am now going to one of the best shoulder doctors in our area on Friday. I will be curious to see what he says about my shoulder. I would hate to think that perhaps an injury years ago was misdiagnosed or not treated properly and that caused me to have to stop my undergraduate studies. Hopefully, we can finally get this resolved so that I can eventually go back and finish my degree. Has anyone else ever heard of something like this and does anyone have any advice?

From Lisa Golec
Posted on September 26, 2006 at 02:41 PM
Have you tried accupuncture? You might want to try this before surgery.

I have heard of rotator cuff injuries in violinists most recently in the Whole Notes Magazine (Toronto based) where there was an add for a string group where one of its members was off because of rotator cuff surgery. I will try and find the musicians name and get back to you. All the best.

Lisa

From Jennifer Sersaw
Posted on September 26, 2006 at 02:55 PM
I have thought about it. I do know that when I have the headache in the back part of the left side of my head and my shoulder also hurts, when we put pressure on the exact spot where my shoulder is hurting, the magnitude of the pain from the headache goes down as well. Unfortunately, we can't apply pressure forever. If I could have constant shoulder massage 24 hours a day, I would probably be pain and headache free. Unfortunately, since my husband is a teacher, our healthcare is managed by the state of Kentucky and doctors have to go through all kinds of red tape to get things such as alternative treatments like acupuncture covered.
From Kevin Huang
Posted on September 26, 2006 at 04:10 PM
A board certified Western physician should have done a full history and physical and taken note that you're a violinist.

That physician would understand that shoulder pain often affects the neck as well. The symptoms you are describing lead me to believe that there is some amount of cervical involvement. After all, violinists spend so much time with their heads to the left.

A licensed massage therapist can work wonders.

From Jennifer Sersaw
Posted on September 26, 2006 at 06:31 PM
I distinctly remember when I first injured myself in high school, the doctor saying maybe I should just stop playing violin. He didn't seem to have an understanding of what had happened and was rather laid back about it all. He just prescribed physical therapy and ordered me to limit my practicing, so I ended up totally dropping out of the concerto competition. My neurologist was the first person who ever put it all together and took into account that I am a violinist.He also did check for scoliosis and did find a slight curve in the neck and not the back and couldn't believe that no one had ever checked for that in the diagnosis process, but he really doesn't think that scoliosis in itself could be the cause of the pain, which is why he wants me to go to this shoulder specialist and have him check my shoulder.He believes that if I truly just had had a rotator cuff strain years ago, it shouldn't still be bothering me today. The neurologist says that my left shoulder is higher than my right shoulder which is why he did the check for scoliosis. He wants to see what the shoulder specialist says about my shoulder and then go from there because he truly believes that my shoulder problem and headaches are related, and it won't do him any good to treat the headaches as migraines if the shoulder could be the source of the problem.
From Pauline Lerner
Posted on September 26, 2006 at 10:13 PM
I've had very similar problems. The first healthcare professional to connect head and shoulder pain with playing the violin was a physical therapist. The second was a dentist who specialized in TMJ/myofacial pain. Many dentists have told me that I will never get rid of the pain unless I stop playing violin. "Oh, well. You can learn to play another instrument." Most healthcare professionals, and particularly physicians, have very, very narrow views. The things I have found most helpful are frequent, extensive stretching and multiple tactics for alleviating myofacial pain, but there is no such thing as a complete cure. I have a violin student with shoulder rotator cuff injury, and I have worked long and hard with her to find alterrnative techniques for playing the violin. Her boyfriend is a PT, and he loosens up her shoulder when it hurts when she practices. I recommend a good PT and TMJ/myofacial pain specialist, as well as training in massage therapy for your husband. Massage training institutes and other organizations often sponsor weekend workshops in massage training for couples. They cost a bundle, but they might help.
From Jennifer Sersaw
Posted on September 26, 2006 at 10:33 PM
My mother has TMJ. Thankfully I do not have that. We have had me checked over and over again for that one. My husband has said he should go into massage therapy. It does seem like massage is one of the most effective remedies.
From Stephen Brivati
Posted on September 26, 2006 at 10:55 PM
Greetings,
first and foremost I woudl recommend Alexander lessons. At this stage your use of the body to compensate for the pain you have experienced is going to be compeltely skewed and may even be the root of the problem. If you wnat a quick and cheap overview of AT then I suggets you buy a small book called `Principles of Alexander Technique` by Jerermy Chance. It is easy to get on Amazon.com. Jeremy chance is one of the worlds leaidng experts on AT. Its a very down to earth little book with immediate application as well.
Second, something even supposedly healthy violinist fail to recognize is thta playing the violin is intrinsically damaging to the body unless some compensatory measures are taken.. It does not matter how good your posture is, how relaxed your technique, blah, blah. the end result of playing the violin is muscular imbalance leading to deep rooted problems and injuries such as yours over time. The only way to redress the imbalance is to exercise those tiny muscles in the back and rotator cuf f which are not being used and become progresisvely weaker as the body`s trength shifts to the front.
This is why one has to be very careful about some of the prescriptions being offered by lay people /trainers and physiotherapists. More specifically, the danger area is weight tarining. I don`t know if working with weights has been suggested ot you, but most of the standard exercises will exacerbate the problems created by playing the violin. Especially, back training, bench press . curling and so forth.
If you wish me to send you a copy of the exericse recommended in the Musician as Athlete, a tome ratehr hard to get these day then you can e mail me at
brivati@gw7.u-netsurf.ne.jp.
Cheers,
Buri
From Lisa Golec
Posted on September 27, 2006 at 03:19 PM
Dear Jennifer,

There is also a book out I have seen called, "Playing less hurt". There may be some references and contact information that might aid you in the book.

I know that your issue seem more complicated but as a new student to violin and a member of the healthcare profession I am truly surprised that there isn't more emphasis put on appropriate set up.

I was surprised to find that there are few resources to get assistance in determining the best shoulder rest, the best chin rest etc, for your specific physical characteristics. It seems to be that "whatever the teacher" uses is the predominant theme here.

Being a particular person I am on my 4th chin rest (waiting for the 5th to be shipped from the UK) and 3rd shoulder rest in the quest for the best "fit" so that I am comfortable playing for long periods of time. I have analysed my problems based on what little information I can find on the web and my body characteristics. This has been very educational but I would have gladly paid for an assessment and some set-up expertise from a professional.

I have come to beleive that a lot of the damage is done in childhood because people don't take the set-up seriously for kids. My 6 year old has gone through 3 chin rests (not many options for children making it all the more difficult) for me to find one that works. I had to go to 3 different violin shops to find one that would stradle the tailpiece that would fit a 1/8th and was high enough for her long neck. The difference is amazing. She does not complain at all about pain anymore, plays longer, is focused, her sound it infinitely better and her teacher told me last week she loved her set up.

So if you were playing for many years with a less than optimum set up through childhood and adolescence when your body was still growing it is no wonder to me that you have such a serious problem.

I hope you can find a solution and return to playing.

All the best,

Lisa

From Jennifer Sersaw
Posted on September 27, 2006 at 06:08 PM
Thank you everyone for your insight. I am very familiar with the Alexander Technique. They came and did a workshop on that, and my professor had me go. I still have all of the handouts from that class. I do agree with the fact that a lot of injuries are started in childhood because of improper set-up or just the violin and the problems it can cause with the body in general, but I was very lucky to have a teacher from the very beginning who was very concerned with issues such as that. We all really believe that this problem is srictly injury related, though we could be proven wrong. I did use a different violin up until just a month or so before the initial injury, and it was a heavier violin and I am a smaller person. It is possible that it had already been doing damage. Thanks to my husband, I have a really nice violin now that is light and just right for me. I do still play violin and sometimes professionally. When I do, I just play through the pain especially if it is a gig that I can't just get up and leave. Sometimes I am amazed at what I have been able to play while hardly being able to see because of a headache. My husband just really wants me to get this resolved if possible before I go back to school and finish my degree. It was so bad when I was in school that I just couldn't keep up with all of the demands and requirements. I am not going to take any drastic measures such as surgery unless the doctor can really prove that is is absolutely necessary. Once again, thank you everyone for all of the advice and insight.
From Stephen Brivati
Posted on September 27, 2006 at 10:44 PM
Greetings,
I have been innundated with request by email for the exercise I mention above. Sorry I cannot snail mail it to mor ethna one person. I will put an explanation of it up on my blog as soon as I can but I am extremely busy for the next week so please be patient.
Cheers,
buri
From Bink Williams
Posted on September 28, 2006 at 01:18 AM
This is the type of physical problem specifically addressed by Certified neuromuscular therapists who are licensed massage therapists with specific advanced training. Judith Walker has an institute in St. Pete, FL and probably maintains a worldwide list of certified practitioners. The two volume set by Dr. Janet Travell on Neuromuscular pain is the seminal work. Trigger points in muscles often radiate pain into different areas and headaches from shoulder muscle spasm is common and can be corrected in an understandable non-invasive manner. Good luck and keep us posted. Bink
From Alain Lefebure
Posted on September 28, 2006 at 10:10 AM
Shoulder pains associated to headache probably reveal cervical problem.Assuming that neurological physical examination , X-ray of the cervical spine and eventually magnetic resonnance examinationare normal a bad eyes convergence has to be ruled out. Bad position of the head on the violin,thumb squeezing the fingerboard,overpressure of the fingers on the finger,wrong fingers movements on bowing action,psychological stress are causes of tension in the neck which might explain your problem.
If Alexander's technic is not efficient ,you should consult a physician specialized in arts medicin
Best luck
From Kevin Huang
Posted on September 28, 2006 at 12:43 PM
The Auer technique solved this problem 100 years ago.

This is why masters like Ricci (studied with Piastro), Rosand, Milstein, Elman, and many other Auer violinists continued to concertize at a very high level well into their 70s without pain.

From Susan Guise-Bagley
Posted on September 28, 2006 at 12:41 PM
I had TMJ problems in my late 40s (pain on opening to eat, daily headaches) and have had this resolved through double jaw surgery, which is a kind of last resort if you have skeletal problems, which I did (upper jaw overgrown, lower jaw undergrown, etc). Now I only have occasional headaches, and very rarely, migraine auras (visual disturbances but no headache). It makes sense that problems in the upper back, neck and shoulders would translate into headache - everything is really interconnected.

Anyway, during the course of ortho treatment in preparation for surgery, I came across a variety of alternative therapies which I found quite effective: cranial-sacral therapy, MLD therapy (manual lymph drainage - for swelling), homeopathy, acupuncture (Japanese style) and Bowen therapy. I also had regular massage and chiropractic care, but I've stopped going to these, and now only see the acupuncturist 3x a year (for tuneups) and have occasional thai yoga masssage (I'm also a thai practitioner and do regular yoga practice). My posture is better than it's ever been.

A friend of mine (not a violinist) had a rotator cuff injury and went to see our acupuncturist (who also does Bowen) - with one treatment this problem was resolved and she hasn't had to go back. Apparently he also corrected another problem - one leg was longer than the other. I've had some Bowen therapy along with acupuncture, and I've been pleased with the outcome.

I just thought I would mention this therapy as I haven't seen it discussed here. The cost of a one hour treatment is C$75, and quite often a single treatment is enough to correct the problem.

From Jennifer Sersaw
Posted on October 1, 2006 at 05:30 AM
Well, I believe that my doctor nailed the problem. Apparently I have what is called snapping scapula. Snapping scapula is caused by problems in the soft tissues or bones of the scapula and chest wall. It can start when the tissues between the scapula and shoulder blade thicken from inflammation. The inflammation is usually caused by repetitive movements. Certain motions of the shoulder done over and over again, such as the movements of pitching baseballs or hanging wallpaper, can cause the tissues of the joint to become inflamed.

In other cases, the muscles under the scapula have shrunk (atrophied) from weakness or inactivity. The scapula bone then rides more closely to the rib cage. This means the scapula bumps or rubs on the rib bones during movement.

Changes in the alignment or contour of the bones of the scapulothoracic joint can also cause snapping scapula.(He thinks it may be a bit of this problem since a bone spur developed) When a fractured rib or scapula isn't lined up just right, it can cause a bumpy ridge that produces the characteristic grind or snap as the scapula moves over the chest wall.

He believes that somehow when I received the initial injury back in 1998 the actual injury was overlooked. It caused a ridge to develop and a bone spur. Unfortunately, because it has gone untreated and undiagnosed for so long, it has had time to get worse instead of better.

Snapping scapula is actually a rare condition and not that many people know about it. It also has an affect on the muscles in the surrounding area and is very close to a nerve (imagine that) that goes up into the back of the head (where I get my headaches).

There are three treatments for snapping scapula. Anti-inflammatory medications, physical therapy, and surgical correction. He is 95% sure that the first, anti-inflammatory medications is not going to solve the problem since a lot of times I really don't have inflammation. Snapping scapula causes a hardening of the muscles in the surrounding area which is why I always feel like I am tense in the shoulder, even when I am not. You can actually hear and feel the snapping whenever I move my shoulder, which is why I knew it had to be something. So, we are going with treatment number 2 for now. I am being sent to a very specific type of orthopaedic physical therapist who specializes in these kind of conditions. She is the only one in our area who knows how to work with this condition. We are hoping that we can retrain the muscles to work around the bone spur and everything else related to the problem and get the muscles to stop hardening, but since it has been existent for so long and had a lot of time to get worse instead of better, we have a tough road ahead of us. We are giving it four weeks to see if we can get any improvement, then we will go back and discuss what to do after that.

Personally, I want to do the physical therapy first, but I am not afraid of surgery. I know all of the risks involved and know about weakening of the shoulder muscles etc; however, I am still young so healing and strenghthening of muscles will not be as difficult for me as it would be for some others. I am so tired and ready for the headaches to stop, that I am open to something such as surgery if it is my last and only option. For now, I will be doing the physical therapy and will go from there. Both the doctor and physical therapist know I am a violinist so everything we do will be keeping that in consideration. If anyone knows any violinist who has ever had this problem, please let me know.

From Jennifer Sersaw
Posted on October 16, 2006 at 07:35 PM
Ok, I have been doing physical therapy and have been given several exercises working on all of the muscles that we don't usually use that often. The good news is that I am not getting nearly as many headaches. The bad news is that my shoulder and now left arm (I never have problems with my left arm and hand) are extremely sore. I am hoping that as the muscles stengthen the soreness will go down. It was so bad on Wednesday that I couldn't even play. After working on the muscles with heat and then working all knots etc. out of the muscles, the physical therapist actually moves my shoulder blade to where it should be. Apparently the muscles pull it forward causing the snapping and everything else. I think they believe that if they can strenghten and retrain the muscles, then they can eventually get rid of the cause of the pain. I do hope so, but is all of the pain and discomfort that I am having to go through in the process good? Does anyone know of other violinists that have had this exact condition themselves? It was diagnosed as snapping scapula.
From al ku
Posted on October 16, 2006 at 08:19 PM
hello,

not trying to sound inconsiderate, but since it has been a long time, the chance of complete recovery is rather slim. you have a chronic condition, snapping scapula or not which is a vague complex of symtoms as a label.

also, not trying to probe, but when you do visit you next doctor, you may want to clearly tell him/her the specific nature of that accident in which you injured your "shoulder". how? from a height? high speed/low speed? what symptoms or associated symptoms you can remember then, etc. we do not need to know here but that is very important for your doctors to establish a background on the soft tissue pain syndrome that is established.

assuming imaging studies have not revealed anything other than the suggested clinical diagnosis of soft tissue involvement, you have been going through the right approach for rehab but you may have not have been lucky enough to find the right environment to heal.

anything that puts physical/mental/emotional stress on you may manifest itself through your shoulder region and possibly with radiating pain into your head region. it is very challenging to rid of all stresses in one's life and we have to deal with the hand we are dealt with the best we can, right?

the current literature has 2 recommendations that are almost consistently agreed upon. 1. increase physical conditioning. 2. sparing usage of elavil/amytriptline, at very low dosage, not as an antidepressant, but as a chronic pain antigonist. there is evidence the medicine may help relax muscle-muscle junction.

now, in terms of exercises, do what you can and do not overdo it to the point that you may add new injuries to the old ones, in the name of getting the region stronger. use common sense. if that area is sore, lay off, and simply increase your conditioning by fast walk/slow jog. this is not my idea, but research after research indicates that when they survey chronic pain patients retrospectively, those who do more exercises experience less pain.

overall, your acupucturists/massage therapists/physical therapists/neurologists do not know what you really go through each day, as a violinist, a wife, a mother, a person in agony. your condition may be such that because of the location of the problems, the smartest physician can pinpoint correctly but may not have a ready solution for it. therapy? sure. trigger point injection? may be. surgery? hell no. medication? well, those that will really knock the pain out will also knock you out.

if i were you, i would depend less on what the doctors say on diagnosis at this juncture because you have heard it many times. it is going to be scupular something. migraine something.

try swimming, long walks, practice and play violin with moderation. do things in life because you want to, that you find enjoyable. accept the pain as part of you. ACCEPT IT. tell the pain you are going to respect it and work with it. the pain is not in your head, but,imo, your mind has a lot to do with how successful you will be in containing it to a tolerable degree.

wish you the best of luck in creating an environment to heal better and look at the bright side of things not for fun but for quality of life.

best regards.

From Patricia Baser
Posted on October 18, 2006 at 01:41 AM
Maybe you just need to ease into the physical therapy a little more? I had an overuse problem (similar to tennis elbow) in college, and I had to be very gentle with what I did. My therapists really encouraged not to go straight to the pain killers, so I could really figure out what worked best. My husband does Feldenkrais to help with some issues he has from a couple of herniated discs in his neck. While stress can always play a part, I do not agree with the last post that saying you can never get over the pain and that it must be all in your mind. It is encouraging that your doctor was able to finally give you a better diagnosis-now you can get treatments tailored to your condition.
From Ray Randall
Posted on October 18, 2006 at 02:36 AM
You've been at this for so many years I would opt for the OR. Cut and be done with it.
Has an MRI been done?
From Susan Guise-Bagley
Posted on October 18, 2006 at 02:32 PM
I've never heard of snapping scapula before. In Thai massage, we do quite a few movements (depending on the client's needs, of course) in the scapula area, working the muscles around the scapula from various positions. This should help with the tightness, but not with the bone spur. It may be, as al ku says, something that you have to live with.

I also take amitryptyline, in a very low dose (10 mg at night) for sleep disorder, the med that al ku mentioned. It's widely prescribed for people that have jaw clenching problems since it can act as a muscle relaxant. It also might help with this problem.

I'm not a fan of surgery or meds, they are a last resort in my books. I do wish you relief from your suffering.

Susan

From al ku
Posted on October 18, 2006 at 02:40 PM
hello, allow me to respond to some points raised in several posts.

however discouraging it may sound, soft tissue pain lasting more than 6 month duration has a slim chance for complete recovery. complete recovery means 100%; that does not mean people cannot reach 90%. we are all pathological one way or another after the age of 30 something when the body starts to show signs of wear and tear. but we suck it in and carry on.

however, in some cases, the pain is just too lasting and uncomfortable to bear, to the point it is interfering with daily activities.

and we want answers, why, what is causing the pain? sometimes, it is an easier route to take when the xray shows a fracture and it heals in several months unremarkably. when xray and mri are not revealing, however, everything is put in a basket called soft tissue injury. the physician's clinical judgement comes into play. he "thinks" it is a scapular dysfunction based on his experience (or lack of) or deduction. however, the arrival of a diagnosis, even a correct one, does not necessarily mean a guarantee in successful rehab outcome with soft tissue cases. every scapular dysfunction is different and every affected person is different.

but the common theme is to increase overall physical conditioning for more optimal function. swimming/aquatic exercise is an excellent exercise for the scapular region against gentle resistance. exertion using weight against specific muscles around scapular before they are sufficiently built up may not be a great idea. as another poster has related, elavil may also be of help since it improves quality of sleep for people with chronic pain which may promote better healing of soft tissue during deeper, more restorative sleep. anatomical studies have shown that in patients with chronic pain there are often trigger points which when dissected and put under microscope show area of ischemia, meaning some soft tissue does not get good blood supply. why do people with heart attack have pain in the chest? because part of the heart muscle does not get blood when circulation is blocked.

the pain signal is received in the brain. if you prick your finger once, you say ouch. how does the brain react if the finger is pricked continuously for more than 6 months? the brain adapts. there is a phenom called phantom pain in which a person loses a limb but still feels the pain of the lost limb long after.

the mind-body connection in soft tissue injury has long been observed but still poorly understood. the stigma is that the affected are crazy, that the problem is in their heads. not true and in fact that perception make things worse when they feel misunderstood and nobody can do anything about it.

that is why i call for some effort in establishing a better healing environment in which in face of facts,known findings and uncertainties people are supportive and understanding. lets not talk in terms of cure but function and symptom improvement. unfortunately not many health care providers are great healers these days when they are rushed to cut cost and save time. the last time i saw somebody (not a psychiatrist i swear, not yet) he did not even bother to sit down, so how was i going to be comfortble telling my story when i thought he was about to sprint out of the door in any seconds?

soft tissue injury is a huge social problem. many people with unremarkble imaging studies have real pain, under recognized, wrongly or poorly diagnosed. on top of that, poorly treated. often they are even labelled as fraud in the medicolegal system.

in summary, as much as i hesitate to state the general prognosis, i want to draw the distinction between realistic outcome and false hope because i believe the latter may cause more grief in time. good luck and good day.

Ilya Gringolts

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