Timmy The Phenom™ 🚀

I'm not sure how physical therapy got watered down to "massage and exercises". Here's what actually goes on in my head during a consultation as a physiotherapist. 🧵 (Details changed to protect the patient.) 💭 means thoughts. 2/ Patient: "My right shoulder has been getting worse for 4 weeks." 💭 54, male, worsening pain. "Progressively worse" is the phrase I listen for. Mechanical shoulder pain usually goes up and down. Steady worsening makes me curious. 3/ Me: "Did anything happen before it started?"
Patient: "I saw a chiropractor for my back. He cracked my neck, and the pain started after that." 💭 Neck manipulation, then new pain. Alarm bell. Now I'm thinking about the neck and its blood vessels, not just the shoulder. 4/ Me: "Where exactly do you feel it?"
Patient: "Down my right arm, behind my shoulder blade, and tingling on the inside of my arm." 💭 Inner arm tingling points to C8/T1 nerve territory. Pain behind the scapula. Not a typical shoulder pattern. 5/ Me: "What makes it better or worse?"
Patient: "Better when I move. Worse when I rest." 💭 That's the opposite of most mechanical shoulder problems. Non-mechanical pain means I keep digging. 6/ Me: "Anything else unusual, even if it seems unrelated?"
Patient: "At the gym, only the left side of my face was sweating." 💭 No sweating on the right side of the face is anhidrosis. 7/ Me: "Any problems with your eyes?"
Patient: "My right eye is blurry." On examination: right pupil smaller, right eyelid drooping, reduced sensation in the T1 area. 💭 Ptosis + miosis + anhidrosis on the same side = Horner's syndrome. 8/ 💭 Then I check the shoulder itself: full, pain-free movement. So the shoulder isn't the problem. The pain is coming from somewhere else. 9/ 💭 What causes Horner's + scapular pain + T1 symptoms? Top of my list:
• Pancoast tumour (lung apex tumour pressing on T1 and the sympathetic chain)
• Carotid or vertebral artery dissection after neck manipulation
• Nerve root compression or cervical fracture 10/ 💭 Also on the list:
Central: brainstem stroke, syringomyelia, brain tumour
Peripheral: neck lymph nodes, aortic aneurysm, neck trauma Droopy eyelids can also come from age, opioids, anticonvulsants, eye injury, cranial nerve problems or myasthenia gravis. 11/ Next questions:
"Do you smoke?" "Any cough or coughing up blood?" "Weight loss?" "When was your last chest X-ray?" 
Then: neck red-flag questions and a full cranial nerve assessment. 💭 Each answer moves a diagnosis up or down my list. 12/ 💭 My plan:
• No shoulder treatment. This needs a doctor.
• Urgent medical review today, to rule out artery dissection
• Chest X-ray for a possible Pancoast tumour
• Safety-netting: new headache, dizziness, speech or vision change means emergency care now 13/ And if this HAD been a simple injury? I'd still think beyond the tissue:
• Biomechanics: how you move, lift and load
• Psychosocial: sleep, stress, fear-avoidance, pain beliefs
• Social : work, family, what you need to get back to 14/ Every "just a few questions" is clinical reasoning: screening red flags, building a differential diagnosis, and knowing when to refer. Physios don't just treat a body part. We treat the whole person. @Rehabify_health launches in 3 days. Are you a physiotherapist in Nigeria? Start here: physioaroundme.com/platform/… If you run a physio clinic, start here: physioaroundme.com/platform/… Are you a Nigerian doctor/hospital manager who wants to refer your patient for physical rehabilitation ? start here: physioaroundme.com/platform/… Are you in any joint or body pain ? or recovering from stroke ? Start here: physioaroundme.com/