160. Cloward’s Sign: When Scapular Pain Is Coming From the Neck

Hey guys, welcome to PT Snacks podcast with Kasey as your host. In today's episode, we dive into Cloward's Sign, its origins, and its significance for physical therapists. We explore how Ralph Cloward's 1959 paper highlighted the connection between cervical discs and scapular pain, providing a map for diagnosing neck-related shoulder and thoracic discomfort. If your patients struggle with persistent scapular pain, tune in to learn how to distinguish between different types of pain, effective screening methods, and treatment plans. =

00:00 Introduction to PT Snacks Podcast
00:19 Understanding Cloward's Sign
01:09 Historical Background of Cloward's Sign
02:27 Clinical Implications and Symptom Mapping
03:31 Diagnosis and Treatment Strategies
05:31 Patient Communication and Management
07:26 Conclusion and Additional Resources

Transcript

0:30

Hey guys. Welcome to PT Snacks podcast. This is Case your host, and if you're tuning in for the very first time, first of all, welcome. What you need to know is that this podcast has been for physical therapists and physical therapist students who are looking for fundamentals to grow in bite-size segments of time. Now, today we are gonna talk about something called Cloward's Sign. So if you've had patients that have complained about pain that's around their scapula, they just can't get rid of it. It's always there. They've tried to roll on the lacrosse ball in their rhomboids and no such luck. This episode is for you. And for them, but also for you. Now, before we move on, if you've listened to at least three shows and you found them to be helpful, if you wouldn't mind leaving a review wherever you listen, that would be so helpful. I really appreciate those who take the time to do that. But with that being said, today, let's talk about what Cloward's Sign is, where it even came from, and why it's important for us to keep in mind when we are trading, treating people who are complaining of neck, thoracic, and or shoulder pain. So cloud sign came from a classic 1959 paper by Ralph Cloud. Lo and behold, it was named after someone and he wrote this paper in the Annals of Surgery, so he actually used cervical discography during surgery. Basically, it involved simulating different parts of cervical disc in awake patients and then mapping where they felt pain, which sounds wild to me. What he found was wild too. So what he found was that by stimulating the anterior surface of certain cervical discs, it reproduced sharp pain along the medial border of the scapula without arm symptoms stimulating more posterior lateral portions produce pain that could spread into the scapula shoulder and sometimes down into the elbow. So these consistent patterns gave us what we now call as clouded sign. Essentially, you might've seen this even if you aren't familiar with cloud sign as basically facet referral graphs down into people's shoulder blade from the cervical region. We're talking about the same thing here. So scapular, parascapular pain referred from a cervical disc or sometimes facet, often along the medial border of the scapula with or without arm symptoms is what we call clouded sign. So typical anterior disc referral patterns that come from that work and later mapping are as follows. Get a visual image of this in your mind so C3 through four. We're talking about our upper trapezius and top of the shoulder region C four through five, superior angle of the scapula, C five through six, along the mid medial border of the scapula, and C six through seven towards the inferior angle of the scapula. Modern symptom mapping studies and cervical discography work have basically confirmed that cervical disc can refer pain into the neck, interscapular region, trapezius and shoulder without always giving classic radicular arm pain. More recent work on scapular pain in cervical radiculopathy also shows that scapular and parascapular pain can actually proceed arm pain by weeks and radicular pain. Can be confined to the neck and the scapular region without distal symptoms. Now here's the thing. If the pain is disc or facet driven,'cause remember it can be from both. The scapular muscle spasm is often secondary. Hyperalgesia or guarding, not necessarily the root cause. Massage might have been helpful for these patients temporarily, but the problem usually comes back. And why is that? Because it's not the root of the problem. And I'm not saying that every single issue in this region is coming from the neck, but you better make sure that you're screening it out right now in the clinic. I think an easy way to avoid this mistake is to make sure wherever the problem is, you're screening out the joints that are above and below, or really the surrounding region. So if it's in the shoulder blade region, we're checking the thoracic, the cervical, and the shoulder regions. So we wanna ask our patient, obviously, where is the pain? What does it act like? Does it change? Does it switch sides? Is it constant? Is it intermittent? What hurts it? All? The typical questions, right? Does anything that we do with the neck, aggravated, they have neck involvement, stiffness, vague neck ache, pain with prolonged sitting, et cetera. That doesn't necessarily rule out the things as well, but something to keep in mind. We wanna make sure that we're testing for range of motion, strength, resisted testing, palpation. Essentially if we're really trying to make sure we're in the right region, we have to make sure that we're taking the other regions out of the equation. Are we able to load? Are we checking quadrants, are we checking with over pressure, et cetera. Flexion, extension, side, bending, rotation, all that good stuff. Are we checking active range of motion and passive range of motion, right? Because that's pretty important to differentiate between if it's an active tissue or passive tissue. This goes for everything, right? Now, let's say with this patient, you are reproducing it with cervical motion and nothing with shoulder, thoracic, et cetera. When we're talking with our patients. We don't wanna freak'em out and be like, your neck is broken. But essentially, oh, I think I understand why massage isn't helping you. It's just reacting to problem that's coming from somewhere else. You see how when you bent your neck, like this, it caused it to go here? The body is pretty crazy in that sometimes it sends pain signals elsewhere, so it we don't always realize it, but the good thing is there's a lot of research that has been able to give us an exact map on where these things are. Now that we've found the issue, we can actually put together a plan to help you fix the root of the problem, and hopefully not need a massage unless you want one. So essentially as we're treating them, we're trying to help this region build resilience. Depending on, again, is it discogenic, is it facet? Do they have any mobility deficits that we need to address? Are they sensitive in particular ranges of motion or with specific amounts of load? We're probably gonna build a plan to ease them into that and not just force it. And strengthening that area to basically offload our passive structures. If your patient is showing signs of progressive neuro deficits, myelopathy signs if we're suspicious of serious pathology or they're failing PT after a good four to six weeks of evidence-based conservative care, then it might be a good time to refer. But often these patients in general will respond well to helping to improve pain-free mobility and strengthening the area around it. Now what you should have gotten from this episode is essentially something to keep on your differentials if you're treating patients that have that pesky pain in the upper back or shoulder blade region which is good because. If you are stuck with some patients, hopefully this helps you to get unstuck.'cause now you know where the problem is and you can help your patient to fix it. So if you have any questions, feel free to reach out to PTs next podcast@gmail.com. Or you can reach out through our newsletter on Instagram, all sorts of ways that we can talk. Lemme know if there's also any additional questions or other diagnoses that you'd like me to cover.'Cause at this point there's a pretty good volume of episodes, and if you're trying to look for a specific topic, I would recommend that you type in PT snacks and then your keyword, and then that will show up, if you're on Apple or Spotify, the entire library to help you find that. Also if you guys are needing to get some CCUs or you wanna take deeper dives into these particular topics, med Bridge is actually offering listeners over a hundred dollars off, which is pretty good. And if you're not familiar with Med Bridge, they have over 2000 CE courses, webinars, they've got specialty exam prep and some of their. And they even have a subscription level where you can have a home exercise program builder if you need something to use with your patients. So they've got a ton of exercises in there. You can basically, combine them into an exercise program, type in reps, sets, print it off for your patient, or give them a QR code depending on what your patient wants, and they're able to go and watch videos of these exercises. So it's pretty cool, but definitely just check that out. Use the promo code, PT snacks podcast, and you should be all set from there, but you'll find it all in the show notes there. Other than that, I hope you have a great rest of your day, and until next time.