The patient came because of the right shoulder. When the doctor tested the muscles on the right side one by one, from the hand and arm down to the thigh and lower leg, every muscle that met resistance trembled, gave way and felt sore and tight. The fall had happened five months earlier, with the right shoulder hitting the ground. Since then the shoulder had felt loose, clunked with every movement, and felt heavy and droopy. The web between the right thumb and index finger, the fleshy part between the two fingers, ached and was sometimes swollen, and gripping objects was difficult. The clinic shares this case with the patient’s permission, with identifying details removed.
One side of the body trembles under resistance
The painful shoulder and the painful web of the hand were places the patient could point to. The weakness running from arm to leg only showed up with testing, and that is what changed the direction of the examination. Muscle weakness after a blow usually stays around the spot that was hit. When a whole chain of muscles on one side trembles together, the doctor reads it as a sign that the nervous system is holding back the entire chain, something a bruised shoulder joint alone can hardly explain.
In the clinical experience of Applied Kinesiology, this kind of one-sided weakness often leads back to two places: the upper neck, where the skull rests on the spine, and the pelvis, where the trunk rests on the legs. In this patient, the examination found that both areas were not working properly.
How muscles can keep working out of balance months after the tissue has healed is discussed in more detail in our article the injury has healed but the muscle is still tight (Vietnamese). Another patient, with neck pain spreading to the shoulder, only got real relief after the pelvis was treated. That case is in our article two cases rooted in the pelvis (Vietnamese).
Weakness on one side after a fall: the brain and cervical spinal cord come first
The patient above came in five months after the fall. For anyone who notices one side of the body getting weaker after a fall, brain and cervical spinal cord injury must be ruled out before looking at the upper neck or the pelvis: a thorough neurological examination, plus X-rays, a CT scan or an MRI when the doctor orders them.
After a fall, a headache that keeps getting worse, vomiting, drowsiness, sudden numbness or weakness on one side of the body, or difficulty speaking are reasons to call emergency services right away. Don’t stay home waiting to see whether it gets better on its own.
Emergency departments in Canada use two sets of criteria to decide who needs imaging after an injury to the head or neck (Stiell and colleagues, 2001). For the cervical spine, people aged 65 or older, those who had a dangerous impact, and those with numbness or tingling in the arms or legs after the accident all belong to the group that needs X-rays. For a minor head injury, repeated vomiting, not being fully alert two hours later, signs of a skull fracture, or being 65 or older are reasons for a CT scan.
At the shoulder, a deformed joint or being unable to lift the arm after a fall calls for an X-ray to rule out a fracture, dislocation or torn tendon before any technique is done on that joint. Older adults who fall often should also read our article preventing falls in older adults (Vietnamese).
When you fell, what hit the ground first?
At the first visit, Dr. Dinh Ngoc Duc (MD, MSc in Traditional Medicine) wants to know what hit the ground first when you fell, whether you managed to put a hand out, whether your head was struck, and whether you felt dizzy or sick at any point afterwards. The doctor looks at both shoulders while you stand, and asks you to raise your arm forward, out to the side and around behind your back to see which movements catch and which ones click. Then the doctor checks sensation and reflexes in both arms and both legs.
Next comes muscle testing on both sides of the body, from the hands down to the feet. Only by comparing the painful side with the other side does weakness running down one whole side of the body show up. When checking the upper neck and the pelvis, the doctor may ask you to put your hand on the back of your neck or on one hip while a weak muscle is being tested, to find out which area needs treatment first.
The doctor holds the joint, you do the moving
The main treatment in this case was the Mulligan technique, which the medical literature calls mobilization with movement. The doctor places a hand on a joint and holds a gentle gliding force in one direction while you yourself make the movement that has been catching or hurting. When the direction is right, the movement eases at once, while you are doing it, and you feel it at the same moment as the doctor.
Which joint and which direction are chosen by muscle testing. This time, the doctor worked on the upper neck and the pelvis.
After the course of treatment, the right arm and leg no longer trembled or gave way under resistance, the web of the hand stopped hurting, and the shoulder no longer felt heavy and loose as before. This is how one patient progressed; it is not enough to promise the same to anyone else who has fallen on a shoulder.
At the shoulder joint, this technique has been studied in a fair number of trials. The review by Satpute and colleagues (2021) found that in people with frozen shoulder (adhesive capsulitis), adding the Mulligan technique reduced pain and increased forward arm raising by about 11.7 degrees and sideways arm raising by about 13.1 degrees. In people with shoulder pain and restricted movement, the range of forward arm raising increased by about 18.5 degrees. Compared with a sham procedure, the review by Dias and colleagues (2023) also found less pain on movement and about 12.7 degrees more sideways arm raising in the first six weeks.
Those trials all worked directly on the shoulder joint and do not yet have long-term data.
Worth keeping
- Write down what hit the ground first when you fell, whether your head was struck, and whether you felt dizzy or vomited afterwards;
- After a fall, if a headache gets worse, or you vomit, feel drowsy, have numbness or weakness on one side of the body, or have difficulty speaking, call emergency services right away;
- If the shoulder looks deformed or you cannot lift the arm, get an X-ray before any technique is done;
- If one side of the body is weak or trembling after a fall, have the brain and cervical spinal cord checked first, and only then look at the upper neck or the pelvis;
- If the shoulder still clicks or the web of the hand still hurts after a few weeks, see a doctor, and remember to bring the images taken after the fall.
References
- Satpute K, Reid S, Mitchell T, Mackay G, Hall T (2021). Efficacy of mobilization with movement (MWM) for shoulder conditions: a systematic review and meta-analysis. J Man Manip Ther 30(1):13-32. https://doi.org/10.1080/10669817.2021.1955181
- Dias D, Neto MG, Sales SDSR, Cavalcante BDS, Torrierri P, Roever L, Araújo RPC (2023). Effect of Mobilization with Movement on Pain, Disability, and Range of Motion in Patients with Shoulder Pain and Movement Impairment: A Systematic Review and Meta-Analysis. J Clin Med 12(23):7416. https://doi.org/10.3390/jcm12237416
- Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio VJ et al. (2001). The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 286(15):1841-1848. https://doi.org/10.1001/jama.286.15.1841
- Stiell IG, Wells GA, Vandemheen K, Clement C, Lesiuk H, Laupacis A et al. (2001). The Canadian CT Head Rule for patients with minor head injury. Lancet 357(9266):1391-1396. https://doi.org/10.1016/s0140-6736(00)04561-x
