Complex shoulder pain - how the narrative and red flags paint a different picture

In this episode, Erica talks about how to approach care when a patient has a long history of injuries and a body chart that seems to be "lit up" everywhere. It can feel overwhelming—for both the patient and the clinician. She focuses on the importance of prioritization: identifying what’s most clinically relevant right now. This involves connecting the dots to perhaps an old injury to what the current problem is. In this particular case, frequent bilateral ankle sprains, an ACL reconstruction plus a continued pattern of bilateral issues help you nail down your focus to what is important for you to assess and what is important for the patient to feel.  These patterns not only shape your clinical focus—helping you decide what truly needs assessment—but also give the patient a clearer sense of what their body is trying to communicate.  What is relevant to you may not be important to them. It's up to you to explain to them why. Key takeaways include: ·       Avoiding the trap of chasing every symptom. ·       Establishing a hierarchy of concerns using patient input and objective findings. ·       Acknowledging the complexity of the history without letting it dictate the entire plan.   Related links: Tough To Treat Website Erica’s Website Susan’s Website      

This episode dives into some of the evidence on resistance vs. high-velocity power training in postmenopausal women and its impact on bone mineral density (BMD). Research is highlighted showing that high-speed training protocols may stimulate bone more effectively than traditional resistance training by increasing strain rates and promoting osteogenic adaptation. You’ll learn how moving with speed and control helps strengthen bones and prevents age-related decline better than slow, heavy lifting alone. Some of Erica’s research for her doctoral dissertation is discussed and she then presents a case study of a menopausal patient with insidious-onset shoulder pain and offers some clinical pearls as to why, especially in anyone who has played a racquet sport, the shoulder is not the only driver. She also highlights a few targeted interventions that allowed this woman to weight lift and strengthen her shoulder without feeding into her symptoms.   The content contained therein, including text, images, audio, or other formats, were created for informational purposes only. The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.    Related links: Tough To Treat Website Erica’s Website Susan’s Website        

In this episode, Erica dives into the latest research exploring how menopause affects physical performance in women—highlighting changes in power and strength. These findings are reshaping how we approach exercise and rehab in midlife women. Next, she shares an update on her dissertation, which compares premenopausal and postmenopausal women on key physical performance metrics. Erica discusses early patterns emerging from the data, including potential implications for exercise training and rehab prescription. She wraps up with a clinical case involving a woman in menopause experiencing persistent neck and shoulder pain, along with difficulty breathing. She breaks down the history along with a few clinical pearls outlining how past injuries have and continue to contribute to this woman’s issues. Erica also breaks down her exercise program, discussing the do’s and don’ts of exercise progression.   Hormonal changes can contribute to musculoskeletal tension and diaphragmatic dysfunction- we know this. But do we really educate our patients on this? Many do not. Whether you're a clinician, researcher, or someone navigating midlife changes, this episode offers insight, evidence, and strategies for supporting well-being during menopause.   Related links: Tough To Treat Website Erica' Website Susan's Website

In this episode, we answer the most common questions we get from listeners. We dive into course recommendations, highlighting resources for continuing education, mentoring and evidence-based practices.   A key focus is on clinical reasoning strategies—how to approach complex cases and integrate patient-specific factors into your decision-making. We also discuss the value of spending the majority of your first session taking the patient’s story.   Your patients will make you a better physical therapist, if you listen to them. Be curious and let it lead you towards mastery.   A glance at this episode: [2:27] Courses and Continuous Learning [12:11] Starting the Podcast and Building a Community [13:17] Mentorship and Clinical Reasoning [19:10] Treatment Sessions and Client Engagement [22:56] The Role of Patients in Clinical Learning [26:41] Reflecting on the Year and Planning for the Future   Related links: Tough To Treat Website Erica’s Course: Decoding the Complex Patient Susan’s Pelvic Health Education Subscription Access the Transcript  

Clients self-refer for many reasons and we find ourselves on the front line of health care screening. Join Susan and Erica as they uncover key elements in a client's history and narrative around long-standing shoulder pain. Simplistic presentations usually mask true underlying considerations including the client's beliefs and red flags.   A glance at this episode: [1:41] Client's Initial Presentation and History [4:07] Exploring Past Injuries and Chronic Bike Riding [6:56] Impact of Corporate Life and Breast Cancer on Health [13:08] Concerns About Bone Health and DEXA Scan [15:21] Addressing Left Shoulder Pain and Movement Dysfunction [17:51] Implementing Modified Exercises and Pilates [39:28] Discussing the Power of the Narrative and Patient Advocacy [40:13] Connecting Patient Goals to Treatment Outcomes [45:17] Final Thoughts and Episode Closing   Related links: Tough To Treat Website Erica’s Course: Decoding the Complex Patient Susan’s Pelvic Health Education Subscription Access the Transcript  

In this episode, we explore the surprising journey of a boxer battling chronic shoulder pain that left him struggling to do even the most basic workout. Despite focusing on his shoulder, it turns out the root of his problem lay elsewhere—his elbow. Is that surprising? It was in his injury history. Do not discount the power of an old injury that could come back and haunt you. And think about the load on the elbow when you're doing a push or pull-up. Join us as we clinically reason through this interesting case from start to finish.   A glance at this episode: [0:01] Introduction and Patient Background [7:03] Initial Assessment and Observations [11:56] Exploring the Root Causes [14:12] Addressing the Pull-Up Challenge [32:06] Implementing Exercise Program [36:32] Final Thoughts and Key Takeaways   Related links: Tough To Treat Website Erica’s Course: Decoding the Complex Patient Susan’s Pelvic Health Education Subscription Access the Transcript  

Susan and Erica are back together for the Fall season! Chronic knee pain can be much more than a regional event. Susan presents a client with an extensive timeline and clinical reasoning as to why it is important to consider the entire system in this integrated approach. The key here is also maintaining relevance and sustainability for the client.   A glance at this episode: [1:18] Explanation of Episode Structure and Content [2:59] Introduction to the Client Case Study [5:30] Client's Medical History and Injuries [12:47] Initial Assessment and Observations [13:33] Treatment Plan and Initial Intervention [31:02] Follow-Up and Client Feedback [31:17] Advanced Treatment and Future Plans [31:31] Conclusion and Encouragement for Listeners   Related links: Tough To Treat Website Erica’s Course: Decoding the Complex Patient Susan’s Pelvic Health Education Subscription Access the Transcript  

In this episode, Erica explores the often-overlooked relationship between hip pain and knee function during walking when the patient does NOT have knee pain. Join in as she dives into the role of the knee in compensating for hip dysfunction, and how a thorough knee assessment can uncover hidden contributors to hip discomfort. Remember: old injuries have a way of sneaking up on us and becoming one of the drivers of our current problem. An old hamstring tear 5 years ago as a contributor to this patient's problem? Think again.   A glance at this episode: [2:23] Patient Background and Injury History [3:46] Assessment and Initial Findings [6:33] Knee and Hip Mechanics [10:11] Terminal Knee Extension and Treatment Approach [20:43] Clinical Reasoning and Patient Outcome [20:58] Conclusion and Call to Action   Related links: Tough To Treat Website Erica’s Course: Decoding the Complex Patient Susan’s Pelvic Health Education Subscription Access the Transcript  

Shoulder pain, like any other joint can present as primary pain and can be the #1 reason a client may be seeking help! In many cases, treating the obvious joint dysfunction (because it checks all of the boxes) may not result in optimal outcomes. Join the conversation as Susan and Erica explore the various reasons and important timelines in the client's history that has led to her shoulder pain. Most importantly follow the clinical reasoning that led to the real driver of this issue. Bonus - we also offer a great discussion of a good exercise progression!   A glance at this episode: [1:39] Shoulder pain and internal rotation [7:52] Which side of the table should you work from [12:40] Learning to tape the wrist [20:00] Opening the hands [22:46] Using the blocks for yoga blocks [27:58] Grip strength as a sign of health   Related links: Tough To Treat Website Erica’s Course: Decoding the Complex Patient Susan’s Pelvic Health Education Subscription Access the Transcript  

In this episode, Erica discusses the why behind shoulder problems, comparing the unique challenges faced by tennis players and non-tennis players alike. She explains why traditional shoulder treatment often fails these types of patients. A significant relationship between the shoulder and another region of the body is often missed. Erica also tells the story of one of her patients who does play tennis and the reason why he can do a full pushup but can't lift his arm over his head. For our physio listeners, oftentimes you can progress patients through a full range of CKC exercises but the OKC piece does not progress as quickly.   A glance at this episode: [0:01] Erica's Summer Vacation and Introduction to the Episode [2:30] Clinical Pearls for Tennis Players [6:15] Assessing Upper Thorax and Glenohumeral Joint Compression [12:53] Treatment Approach for Upper Thorax and Glenohumeral Joint Issues [15:54] Progressing Patients with Glenohumeral Issues [16:14] Clinical Pearls for Closed Chain Exercises [20:37] Conclusion and Encouragement for Practitioners Related links: Tough To Treat Website Erica’s Course: Decoding the Complex Patient Susan’s Pelvic Health Education Subscription Access the Transcript