Anatomical Sleuthing

Finding Clues for Effective and Efficient Treatment

By Douglas Nelson
[Table Lessons]

I met J.’s father unexpectedly at a social event. A no-nonsense executive, he took me aside to ask if I might treat his teenaged daughter. I met with both of them the next evening.
 “It first began as a pain in my shoulder, somewhere around here,” J. said, pointing to her right upper trapezius area. “I thought it would go away, but it just kept hanging on, getting slowly worse. That’s when we went to see the doctor.”
“The doctor sent us to physical therapy,” her dad said. “They diagnosed it as scapular instability. She has been going for therapy two to three times a week for almost four months. She is getting stronger, but the pain is really about the same as it was in the beginning. J. is a two-sport athlete and a very good one. I don’t want this condition to affect her playing soccer or volleyball.”
J. nodded, showing frustration on her face at the thought of not being able to play the sports she loves.
“OK, I understand this affects your participation in sports,” I said. “But is that when you feel it the most?”
“Yes, at first it only hurt when I was playing. Over time, it kept hurting even when I wasn’t playing. Even now though, it is far worse when I play. I have to severely limit my playing time, if I can play at all.”
“Is there a certain movement or action that makes it hurt the most?” I inquired.
“Yes,” answered J. emphatically, “running.”
“Running,” I restated, looking at both of them.
Like Alice in Wonderland, I was lost down the rabbit hole in a cascade of thoughts. Shoulder instability? I understand this is a common diagnosis for athletes, especially young females, but this makes absolutely no sense if her pain is worse when she runs. Moreover, four months of treatment, multiple times per week, hasn’t helped, which is kind of a clue that instability isn’t the problem. This was hardly effective, or efficient, therapy. Coming back to the moment at hand, I decided to take a different course.
“Could you lie on the table on your left side for me? I want to check something that perhaps no one else has treated. Actually, has anyone actually used their hands to explore the soft tissue of your shoulder?”
“No, I don’t think so,” J. replied, as she got on the table.
The first thought I had that would explain her symptoms was the serratus posterior superior. It often presents as a deep scapular ache, which often refers down the arm. An ancillary respiratory muscle, it would be used in high-volume breathing. I slowly moved J.’s scapula anteriorly to reveal the distal attachments of the serratus.
“Wow, that’s tender,” she exclaimed. “I can feel that all throughout my shoulder.”
Glancing at her father, I could see him widening his eyes, trying to understand what I was doing. I explained to them what this muscle was and why it is a reasonable fit for J.’s pain.
“You mean that we have done months of therapy, but the source of her pain could have been this muscle the whole time?”
“Theories are easy, results are difficult,” I said. “If I’m right, we will see results. If not, that will also be clear. Contact me in four days after she has vigorously exercised.”
Four days and two soccer practices later, there was no appreciable improvement. I scheduled session number two.
“I’m curious to see how that muscle is doing,” J.’s father said.
“I’m not even going to check it,” I replied. “Same game, new strategy.”
“Really?” questioned J.’s dad. “So soon?” There was something in his tone that alluded to a lack of confidence.
“When I don’t get the results I want, I switch strategies. Confidence is also the willingness and openness to change course when the results don’t justify the approach. If I might add, how confident were the therapists that the source of her pain was scapular instability?”
“Very,” he replied sheepishly.
Thinking again about what might be involved in respiration and also running, it occurred to me that I should have checked the posterior scalene. Asking J. if she happened to notice anything else that made the pain worse, she said holding her arms up in the air in volleyball was a trigger. Since the levator scapula is stretched in upward rotation of the scapula, I added treatment of that muscle, too.
Days later, I got a text from her father. J. had played four soccer games and two volleyball practices without pain. Two short treatments; now that’s efficient, and effective, therapy.

Douglas Nelson is the founder and principal instructor for Precision Neuromuscular Therapy Seminars and president of the 16-therapist clinic BodyWork Associates in Champaign, Illinois. His clinic, seminars, and research endeavors explore the science behind this work. Visit or email him at

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