Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions (Fragment)

Ana Isabel de-la-Llave-Rincón,1,2 Emilio J Puentedura,3 and César Fernández-de-las-Peñas1,2


In recent years, increased knowledge of the pathogenesis of upper quadrant pain syndromes has translated to better management strategies. Recent studies have demonstrated evidence of peripheral and central sensitization mechanisms in different local pain syndromes of the upper quadrant such as idiopathic neck pain, lateral epicondylalgia, whiplash-associated disorders, shoulder impingement, and carpal tunnel syndrome. Therefore, a treatment-based classification approach where subjects receive matched interventions has been developed and, it has been found that these patients experience better outcomes than those receiving non-matched interventions. There is evidence suggesting that the cervical and thoracic spine is involved in upper quadrant pain. Spinal manipulation has been found to be effective for patients with elbow pain, neck pain, or cervicobrachial pain. Additionally, it is known that spinal manipulative therapy exerts neurophysiological effects that can activate pain modulation mechanisms. This paper exposes some manual therapies for upper quadrant pain syndromes, based on a nociceptive pain rationale for modulating central nervous system including trigger point therapy, dry needling, mobilization or manipulation, and cognitive pain approaches.

Keywords: Upper quadrant, Pain, Sensitization, Neck, Thoracic, Manual therapy



In the twenty-first century, upper quadrant syndromes are common and cause substantial pain and disability. It has been estimated that 70% of the population experience neck or arm pain at some time during their life.1,2 In fact, musculoskeletal disorders represent the majority of occupational ill-health and upper quadrant pain is second only to back pain as a cause of work-related illness.3,4 In addition, upper quadrant pain represents high costs for health care systems as up to 58% of patients will make use of healthcare within the next 12 months.5

Walker-Bone et al. found that pain experienced in the upper quadrant region is frequently perceived in the dominant arm and the neck.6 Upper quadrant pain can arise from several widely different conditions. In fact, different terms, i.e. cumulative trauma disorders, cervicobrachial disorders, repetitive strain injury, and work-related upper limb disorders, have been used to describe pain at different sites in the neck and upper limb with no confirmed pathoanatomical abnormalities.7 Pain symptoms in the neck, shoulder, or arm, which are not based on acute trauma or underlying systemic diseases, have been defined as ‘complaints of the arm, neck and/or shoulder region’. This term suggests that symptoms in the upper quadrant may have different causes.

In this paper, we will discuss: (1) the relevance of the cervical and thoracic spine in upper quadrant pain syndromes and their management with manual therapy; (2) the presence of common sensitization mechanisms in different local pain syndromes of the upper quadrant; and (3) manual therapies proposed for upper quadrant pain syndromes based on nociceptive pain rationale.