Clinical View on Chronic Muscle Pain: From Overload to Chronicity

Patient Profile:

Age and gender: 28-year-old Male
Occupation: IT employee
Complaint: Right-sided posterior shoulder pain, mid scapular pain for the past 6 years.

History:

During his college years in 2019, he played cricket regularly while he was also working night shifts at a part-time job.  He had no proper, programmed strength training history. This led to inadequate recovery, poor sleep, and over a period of time, he developed pain in the mid-scapular region. Although he underwent many treatments for the pain, none provided long-term relief, and the pain persisted intermittently. 

By 2021, when he started going to the gym regularly, he began to experience pain in his upper back and shoulder as well. At times, he also reported feeling a tingling sensation radiating to the right side of his neck, arm, and hand. 

No past medical history or injury.

Physical activity status:

Currently, he goes to the gym five days a week, focusing solely on resistance training but not following a structured program. He plays cricket on weekends, and he averages only 3,000–4,000 steps per day during weekdays.

Stress :

He has stress due to his pain, because even after so much effort, he was not seeing any results. It reduced productivity in his work and also in daily life. 

Sleep:

Disturbed due to professional work and pain. Sleeping only 5-6 hours every day. Might reduce to 3-5 hrs somedays due to work.  

Reason for consultation:

• He wants to know the reasons why the pain is persistent and wants to get rid of this. 
• He also wants to work on overall fitness and to play without pain.

Pain Analysis:

Intensity: 5.5/10

Onset:

Gradual; began in 2019 and has progressively worsened over 6 years.

Duration:

Chronic (approximately 6 years).

Location:

Primarily neck and upper back (mid-scapular region), with radiation to the arm and forearm, and mild pain in the mid-back region.

Aggravating Factors: 

• Playing cricket (throwing, batting, bowling); 
• Upper-body exercises (overhead press, barbell bench press, shoulder shrugs, lateral raises, face pulls); 
• Stress and inadequate sleep.
• Sometimes, daily activities such as washing clothes

Relieving Factors:

Rest, application of a hot pack, and occasional use of painkillers when pain intensity increases.

Character of Pain:

Mechanical (load-induced), intermittent; persistent discomfort in the right mid-scapular area.

Irritability:

Moderate (pain increases with bowling, upper-body exercise, or daily chores).

Sensitivity:

Moderate (symptoms take a few hours to settle).

Lifestyle Impact:

High; pain significantly interferes with daily chores and occupational tasks.

Fear of Movement Analysis:

Pain & movement-related fear are present significantly. 

Psychosocial factor analysis: 

Cognitive:

Slightly affected. After having multiple treatments without achieving lasting relief, he doubts whether he will get long-term relief.

Affective:

He is worried about his pain and its impact on his personal growth.

Social:

Being the sole earning member of his family, he experiences significant stress when his work is affected due to pain. 

Our understanding of the patient’s problem from history and pain analysis: 

He has been pushing himself every day physically, with inadequate recovery, stressed work life, and poor sleep. This might be demanding beyond his capacity, leading to overloading. Additionally, he has no programmed strength training and no proper rehab and guidance for his pain.

Further, we need to assess his strength, mobility, and other appropriate assessments as required to confirm the reason for his pain and design an individualized rehab program for him. 

PHYSICAL EXAMINATION:

Observational findings:

Weight – (92.2kg) 

Height – 176cm 

BMI – 29.8 (overweight)

ROM analysis

Shoulder: 

Lt side – 80°

Rt side – 65°

The right side IR was restricted

Other Shoulder range of motion -Good;  No side-to-side difference. 

Neck: 

Rotation and lateral flexion on the right side were painful, but no significant reduction in range.

Thoracic spine: 

Thoracic rotation – mild restriction on the left side. 

Strengthening screening:

Palpation: 

Pain over the right upper trapezius, rhomboids, and erector spinae.

Mildly painful Biceps, Brachioradialis

Special tests:

Upper limb tension test – Negative. 

Cervical distraction test – Negative.
Spurling test – Negative. 

INVESTIGATION: 

Blood investigations- ESR, CRP,  anti-CCP- nil significant.

Normal X-ray

DIFFERENTIAL DIAGNOSIS:

Cervical radiculopathy:  

No neurological symptoms such as numbness/tingling
Upper limb tension test, Spurling, and distraction tests are also negative. 

So cervical radiculopathy was ruled out. 

Acromio-clavicular joint pathology  

There is no localized pain over the AC joint. No pain in Horizontal adduction.

No history of injury. So, AC joint pathology- ruled out

Polymyalgia Rheumatica

(PMR) –Normal ESR, CRP, and there is no multijoint pain. 

Rotator cuff tear/Labral tear – 

 All the AROM of the shoulders is normal
No pain in the shoulder joint
No history of swelling.
No history of injury
So, ruled out.

Peripheral Neuropathy 

No sign of distal sensory loss, burning. 

Fibromyalgia  

No Widespread, bilateral pain

Not disturbances of sleep due to pain. No sign of anxiety and distress

No sign of fatigue, no systemic involvement

DIAGNOSIS:

Overload/Overuse-induced muscular pain 

Validation: 

The clinical presentation such as load induced load-induced muscle pain, muscular strength asymmetries (LSI 72–89%) and restricted shoulder/thoracic mobility indicate a regional overload. 

Key perpetuating factors include unstructured training, repetitive cricket and gym activity, inadequate sleep, and occupational stress. 

Psychosocial elements like stress, disturbed sleep, and fear of movement play a significant role in maintaining chronicity.

Localized pain with tenderness in the trapezius, rhomboids, and erector spinae may presents like a myofascial pain syndrome, but currently there is no standardized diagnostic criteria for MPS. So, it is not the actual problem in this case.  

Needs & goals: 

To be pain-free & to improve his strength & fitness

Totally, 30 sessions planned 

• 1st month – 12 days
• 2nd month – 8 days 
• 3rd month – 8 days 

Detailed treatment plan strategy:

1st month:

• Patient education provided regarding how stress, sleep, and fluctuations in work-life balance are provoking his pain, gave an idea about how to select the right exercise variation according to his capacity with proper load management, progression, and also provided the psychological support, positive reinforcement to do the exercises regularly. 
• Set positive belief in what he is doing, start exercising with full body mobility and flexibility movements, and include mild to moderate strengthening. Mainly unilateral exercises for the upper and lower body with adequate resistance to avoid overloading. 
• Focused initially on Eccentric load for back arm functional chain muscles, including other push and pull movements. 
• Guide to start meditating and breathing exercises
• Low-intensity aerobic exercise should be included

2nd month plan:

• Dynamic stretching and mobility drills are progressed. 
• Progressively overload the unilateral strengthening and start compound movements. 
• Overall body strengthening to achieve his goal.
• Zone 2 training is focused.  

3rd month plan:

• Functional movement patterns trained 
• Plyometric drills initiated 

Notes – 

In the early stages of rehabilitation for overuse-related muscular pain, overstretching or aggressive strengthening should be avoided because the affected muscles are already overloaded, fatigued, and sensitized.

At the same time, breathing, sleep, and stress management are crucial because they directly influence muscle recovery and pain perception. Poor sleep and high stress increase cortisol levels, reduce tissue healing, and heighten pain sensitivity, while dysfunctional breathing patterns can add tension to neck and scapular muscles.