Neck and Shoulder Pain: What Could Be Causing It and What Actually Helps?

Part 4 of our Move Better, Feel Better: Pain & Movement Explained series

Written by Jessica Brown, Osteopath and Owner of One Health Osteopathy Clinic, Tunbridge Wells

Neck and shoulder pain are incredibly common, but working out exactly where the pain is coming from is not always straightforward.

You may feel an ache across the top of your shoulder, stiffness when turning your head, pain around your shoulder blade, discomfort when lifting your arm or symptoms travelling into your arm or hand.

Is it your neck? Your shoulder? A muscle? A joint? A nerve?

Sometimes the answer is clear. Quite often, several structures and factors are contributing at the same time.

The neck, upper back, ribs, shoulder blades and shoulders all work closely together. Pain felt in one area can also originate somewhere else, which is why treating only the spot that hurts does not always tell us the whole story.

At One Health Osteopathy Clinic in Tunbridge Wells, we regularly assess people with neck pain, shoulder pain, upper back discomfort, headaches and nerve-related arm symptoms from Tunbridge Wells, Tonbridge, Sevenoaks and surrounding areas of Kent.

In this guide, I explain some of the most common causes of neck and shoulder pain, how we distinguish between them and what can help.

Neck and shoulder pain at a glance

Neck and shoulder pain can come from several different structures. Muscles, joints, ligaments, tendons, nerves, discs and fascia may all contribute.

Where you feel the pain does not always tell us where it originates. A problem in the neck can sometimes be felt around the shoulder or shoulder blade, while a shoulder problem may cause pain into the upper arm.

Movement is usually important. Gentle movement, stretching and gradually returning to normal activity can be helpful for many musculoskeletal neck and shoulder problems.

Strength matters too. Depending on the problem, building the strength and endurance of the neck, upper back, shoulder blade and shoulder muscles may form an important part of rehabilitation. Research in people with persistent neck pain supports strengthening as one potentially helpful component of care, although no single type of exercise is right for everyone.

Pins and needles, numbness or weakness need more careful assessment. These symptoms may suggest involvement of a nerve.

Most neck and shoulder pain is not caused by anything serious, but certain symptoms do require prompt medical attention.

The key is understanding what appears to be contributing in your particular case rather than assuming that all neck or shoulder pain needs the same treatment.

What can cause neck pain?

Your neck, or cervical spine, contains seven vertebrae together with joints, discs, ligaments, muscles, fascia, nerves and the spinal cord. It is a highly mobile area that needs to provide both movement and stability while supporting your head. Neck pain can arise from several different tissues.

Muscles and soft tissues

Muscular neck pain is very common. The muscles around your neck, upper back and shoulders can become sore or sensitive following:

• prolonged periods in one position;
• unfamiliar activity;
• increased exercise or training;
• repetitive work;
• lifting;
• poor sleep;
• illness;
• increased workload or stress;
• an injury such as whiplash.

Muscle pain may feel aching, tight, tired or tender to touch. You may also notice that your neck feels less comfortable at the end of its normal range of movement.

Massage, soft-tissue treatment, stretching and movement can often feel particularly helpful when muscle tension is contributing.

However, if the problem keeps returning, it is worth looking at why those tissues may repeatedly be becoming overloaded or sensitive.

Joints of the neck and upper back

The small joints of the neck can also become stiff, irritated or sensitive. You may notice pain when turning your head to one side, looking upwards or checking over your shoulder when driving. Sometimes stiffness in the upper back or rib cage may also influence how comfortably the neck and shoulders move. This is one reason an osteopathic assessment usually considers more than the exact spot where the pain is felt.

Age-related changes

The joints and discs of the neck naturally change as we get older. These changes are sometimes described as cervical spondylosis. Importantly, age-related changes are extremely common and do not necessarily cause symptoms. Many people have them without experiencing neck pain at all.

When symptoms are present, they may include neck or shoulder pain, stiffness and sometimes headaches originating from the neck. A scan finding therefore needs to be considered alongside your symptoms and clinical examination rather than viewed in isolation.

Can neck pain travel into the shoulder or arm?

Yes.

Pain originating from the neck can sometimes be felt around the shoulder, shoulder blade or upper arm. This is known as referred pain. It does not necessarily mean a nerve is involved.

Joints, discs, muscles and other structures in the neck can all produce pain that is experienced away from the exact source.

This is why someone who thinks they have a shoulder problem occasionally discovers during assessment that their shoulder itself moves normally and the symptoms are actually being influenced by the neck.

What does a trapped nerve in the neck feel like?

The nerves that supply sensation and muscle function to your arms leave the spinal cord through openings between the vertebrae in your neck.

If one of these nerve roots becomes irritated, it can cause cervical radiculopathy, sometimes described as a trapped nerve.

Symptoms may include:

• neck pain;
• pain around the shoulder blade;
• pain travelling down the arm;
• pins and needles;
• tingling;
• numbness;
• altered sensation;
• weakness in the arm or hand.

You can also have nerve-related arm symptoms without much neck pain.

Although the phrase “trapped nerve” is commonly used, the nerve does not always have to be severely physically trapped. Inflammation and irritation around a nerve root can also produce symptoms.

If you have persistent numbness, tingling or weakness in your arm or hand, it is important to have this assessed.

What can cause shoulder pain?

Shoulder pain has its own range of possible causes. The shoulder is a remarkably mobile joint. Its movement relies on the coordinated function of the shoulder joint itself, shoulder blade, collarbone, upper back and a group of muscles and tendons called the rotator cuff.

Understanding which movements provoke your symptoms can give us useful information.

Rotator cuff-related shoulder pain

The rotator cuff is a group of four muscles and their tendons that help control and stabilise your shoulder as you move your arm.

Rotator cuff-related pain is a common reason people develop discomfort when reaching, lifting or using their arm.

You may notice pain:

• when lifting your arm overhead;
• when reaching behind you;
• putting on a coat or bra;
• lifting something away from your body;
• exercising;
• or lying on the affected shoulder.

Shoulder tendon pain is not simply a case of having an inflamed or damaged tendon that needs complete rest. Tendons respond to load. Rehabilitation will often involve finding a manageable level of activity and then progressively building the strength and capacity of the shoulder.

What is frozen shoulder?

Frozen shoulder, also known as adhesive capsulitis, causes increasing pain and stiffness in the shoulder. Unlike many other shoulder conditions, the most noticeable feature is often a significant loss of movement. You may find it increasingly difficult to reach overhead, behind your back or out to the side.

Frozen shoulder can take a considerable amount of time to resolve and may progress through different stages. It is most common between around 40 and 60, and is seen more often in people with diabetes and thyroid disorders, particularly hypothyroidism and subclinical hypothyroidism.

There is also growing interest in the relationship between perimenopause, menopause and frozen shoulder. Frozen shoulder disproportionately affects women in midlife, at a time when oestrogen levels are changing, and researchers are investigating whether hormonal changes may influence inflammation, collagen turnover and fibrosis within the shoulder capsule. Early observational research has suggested a possible association between hormone therapy and lower rates of frozen shoulder, but this is not yet conclusive, so it would be premature to say that menopause directly causes frozen shoulder or that HRT prevents it.

This is also an area where the evidence base is still developing. Women’s health has historically been under-researched, and women have been under-represented in some areas of clinical research, which has contributed to gaps in our understanding of how conditions that affect both sexes may present or behave differently in women. The UK Women’s Health Strategy specifically identified menopause, sex differences and musculoskeletal health as areas where stronger research and better data are needed.

Other recognised associations with frozen shoulder include previous shoulder injury or surgery and prolonged immobilisation. If shoulder pain and stiffness develop during midlife, particularly alongside diabetes, thyroid disease or menopausal changes, these factors are therefore useful to consider as part of the wider clinical picture.

If your shoulder is becoming progressively stiff as well as painful, it is worth having it assessed rather than assuming it is simply muscular tension.

What about bursitis and shoulder impingement?

These are terms you may have heard if you have searched online for shoulder pain.

A bursa is a small fluid-filled structure that helps reduce friction around the shoulder. The tissues around the shoulder, including the bursa and rotator cuff tendons, can become sensitive and painful. The term “shoulder impingement” has traditionally been used when pain occurs as tissues beneath the top of the shoulder become irritated during movement.

We now understand that shoulder pain is usually more complex than one structure simply being mechanically pinched every time you lift your arm. Strength, tendon capacity, activity levels, movement, sleep, general health and how much load has recently been placed on the shoulder may all be relevant.

Can arthritis cause shoulder or neck pain?

Yes, although the presence of arthritis on an X-ray does not necessarily mean it is responsible for all of your pain. Osteoarthritis can affect the joints of the neck and shoulder. The small acromioclavicular joint, or AC joint, at the top of the shoulder can also become painful.

Symptoms may include stiffness, discomfort with particular movements and sometimes pain when lying on the affected side. As with spinal changes, imaging findings are most useful when they fit with the pattern of your symptoms and clinical assessment.

Why does my shoulder blade hurt?

Pain around or between the shoulder blades is extremely common.

It may come from:

• muscles surrounding the shoulder blade;
• joints of the upper back;
• the neck;
• the rib cage;
• prolonged or unfamiliar activity;
• strength or endurance demands;
• nerve irritation.

People often describe a knot or persistent ache along the inside edge of the shoulder blade.

Hands-on treatment and stretching may help relieve symptoms, but recurring pain in this region can also respond well to improving upper-body movement, shoulder-blade control and strength.

Importantly, pain between the shoulder blades is not always musculoskeletal. New or unexplained pain accompanied by chest symptoms, breathlessness, sweating or feeling acutely unwell needs appropriate medical assessment.

Can neck problems cause headaches?

Yes, some headaches can arise from structures in the neck. These are called cervicogenic headaches. They may be associated with neck pain or stiffness and can sometimes be aggravated by particular neck movements or sustained positions.

However, headaches have many different causes. Migraine, tension-type headache and numerous medical conditions can all produce head pain, so we should not automatically assume that every headache comes from the neck.

If a headache is new, unusually severe, changing significantly in character or associated with neurological symptoms or feeling very unwell, appropriate medical assessment is important.

Can stress contribute to neck and shoulder pain?

Yes, and this does not mean the pain is imaginary. Stress affects us physically as well as emotionally. During demanding periods you may notice that you hold more tension in your shoulders, clench your jaw or move less throughout the day.

Stress can also affect sleep and recovery and may influence how sensitive the nervous system is to pain. Often there is not a choice between saying pain is either “physical” or “stress-related”. It can be both.

A painful joint, muscle or tendon may be contributing while stress, sleep, workload and reduced recovery influence how sensitive those tissues feel. This is why understanding the whole picture can be valuable.

Are stretching and mobility exercises helpful for neck and shoulder pain?

Yes. Stretching and mobility exercises can both be very helpful, particularly if your neck, shoulders, chest or upper back feel stiff after spending time in one position.

Gentle movement helps the joints and soft tissues move through a more comfortable range, while also encouraging normal blood flow and circulation to working muscles and surrounding tissues. This can be particularly useful after prolonged sitting or computer work, when some muscles have been working in relatively sustained positions and may start to feel tired, tight or uncomfortable.

Regular mobility work also changes the load going through the neck, shoulders and upper back. Rather than asking the same muscles and joints to remain in one position for long periods, it gives them variety and can help reduce the build-up of stiffness and fatigue.

Depending on your symptoms, useful movements may include gentle:

• neck rotations;
• side bending;
• upper-back rotations;
• chest stretches;
• shoulder stretches;
• shoulder rolls;
• arm movements overhead;
• upper-back extension;
• shoulder-blade movements;
• gentle spinal and rib-cage mobility.

Stretching should generally feel comfortable rather than aggressive. You do not need to force through significant pain to make a stretch effective.

Mobility exercises are often most useful when they are done little and often, rather than waiting until your neck or shoulders feel very stiff. Even a minute or two of movement during the working day can help restore circulation, vary the load on the tissues and make movement feel easier.

For recurring neck or shoulder problems, stretching and mobility usually work best alongside strengthening, regular physical activity and gradually increasing the capacity of the muscles and joints to cope with the demands placed on them.

Is strengthening important for neck and shoulder pain?

Often, yes. A painful area does not always need to be protected indefinitely. Sometimes it needs to become stronger.

Your neck, shoulders and upper back need sufficient strength and endurance to cope with everything you ask them to do, whether that is working, carrying children, gardening, lifting weights, swimming, playing tennis or simply getting through a busy day.

A systematic review of office workers with persistent neck pain found that strengthening the muscles of the neck, shoulder and shoulder blade was associated with reductions in pain and disability, although the researchers rated the certainty of the evidence as low.

Depending on your individual presentation, rehabilitation might include:

• shoulder-blade strengthening;
• rotator cuff exercises;
• rowing and pulling movements;
• neck muscle endurance work;
• shoulder strengthening;
• upper-back exercises;
• resistance bands;
• weights;
• progressive whole-body strength work.

The aim is not to prescribe the same three exercises to everyone. It is to identify what your body needs to be able to do and gradually build towards it.

Should you rest a painful neck or shoulder?

A short period of relative rest can be helpful if certain activities are clearly aggravating symptoms. This might mean temporarily reducing overhead lifting, changing a gym exercise, carrying less weight or adjusting another activity that repeatedly produces significant pain.

But relative rest is different from stopping all movement. For many musculoskeletal neck and shoulder problems, continuing comfortable movement is useful. The balance will depend on what is causing your symptoms and how irritable they currently are.

When should neck or shoulder pain be assessed?

Consider seeking an assessment if:

• pain or discomfort is affecting your sleep or everyday activities;
• the problem has persisted for several weeks;
• symptoms keep returning;
• your neck or shoulder movement is becoming increasingly restricted;
• you cannot comfortably lift or use your arm;
• pain travels down your arm;
• you have persistent pins and needles, tingling or numbness;
• you notice weakness in the arm or hand;
• you are experiencing recurring headaches alongside neck pain;
• an injury is not recovering as expected;
• or you are unsure what activities or exercises are appropriate.

A good assessment can help distinguish between a problem arising primarily from the neck, the shoulder, a nerve or a combination of factors. Having symptoms assessed earlier can also be helpful, particularly if they are not settling as expected, as this can allow contributing factors to be identified and addressed before the problem becomes more persistent. In some cases, earlier advice, treatment and appropriate rehabilitation may also mean that a simpler course of care is needed than when symptoms have been present for a long time.

When is neck or shoulder pain more urgent?

Most neck and shoulder pain is musculoskeletal and is not dangerous. However, seek urgent medical advice if you develop significant or worsening neurological symptoms, particularly increasing weakness or numbness.

Urgent assessment is also important if neck symptoms are accompanied by new problems with walking, coordination or bladder or bowel function. These can, rarely, indicate pressure affecting the spinal cord. Following a significant injury, severe pain, visible deformity or an inability to move your arm also warrants prompt assessment.

Neck, shoulder, arm or upper-back pain accompanied by chest pain, severe shortness of breath, sweating, nausea or feeling acutely unwell should not automatically be assumed to be musculoskeletal and requires urgent medical attention.

Can an osteopath help with neck and shoulder pain?

Osteopaths are regulated healthcare professionals trained to assess, diagnose and manage musculoskeletal conditions, including neck, shoulder and upper-back pain.

At One Health, the first step is understanding where your symptoms are likely to be coming from and what may be contributing to them.

Depending on your presentation, we may assess:

• movement of your neck and upper back;
• shoulder movement;
• the rotator cuff;
• shoulder-blade function;
• muscles and fascia;
• joints and surrounding tissues;
• strength;
• sensation and reflexes;
• nerve function;
• relevant movements or activities that reproduce your symptoms.

We also take into account your medical history, exercise, work, sleep, previous injuries and what you want to get back to doing. If your presentation suggests that further investigation or assessment by another healthcare professional would be more appropriate, we will discuss this with you.

Our osteopathic approach to neck and shoulder pain

Osteopathy considers how different parts of the body work together. The neck, upper back, rib cage, shoulder blades and shoulders form an interconnected region. Good movement relies on joints, muscles, tendons, fascia and nerves all working together.

This does not mean that every painful shoulder needs the whole body treated. It means we look at the areas that appear relevant to your presentation rather than focusing automatically on the exact spot where you feel the pain.

Where appropriate, osteopathic care may include:

• joint mobilisation and articulation;
• soft-tissue treatment and massage techniques;
• myofascial techniques;
• stretching and mobility work;
• muscle energy techniques;
• manipulation where clinically appropriate and with your consent;
• neuromuscular and movement retraining;
• rotator cuff and shoulder rehabilitation;
• shoulder-blade strengthening;
• neck and upper-back strengthening;
• progressive resistance exercises;
• advice about returning to exercise, work or sport.

Hands-on treatment may help improve comfortable movement and reduce muscle tension, while rehabilitation aims to improve the strength, control and physical capacity you need for everyday life.

Treatment is always adapted to the individual. Someone with an acutely stiff neck may initially benefit from gentle hands-on treatment, movement and stretching. Someone with recurring rotator cuff-related shoulder pain may need a much greater emphasis on progressive strengthening. A person experiencing nerve-related symptoms will require careful neurological assessment and an approach appropriate to how sensitive the nerve currently is. The aim is to help you understand the problem, improve comfortable movement and build confidence in what your body can do.

What actually helps recurring neck and shoulder pain?

There is rarely one magic technique. For many people, the most effective approach involves combining several strategies.

Keep moving. Regular, comfortable movement prevents your neck and shoulders spending too much time in the same position.

Stretch when you feel stiff. Stretching can be a useful way to restore comfortable movement and reduce feelings of tension.

Build strength. Improving the capacity of the neck, shoulders, shoulder blades and upper body may help you tolerate work, exercise and everyday demands more comfortably.

Manage activity rather than avoiding it completely. If something repeatedly aggravates your symptoms, temporarily modify it and then gradually build back up.

Look at the whole picture. Sleep, stress, workload, general physical activity and recovery can all influence symptoms.

Understand what you are dealing with. Knowing whether pain is coming primarily from the neck, shoulder, a tendon or a nerve can make decisions about treatment and exercise considerably easier.

The aim is not simply to get rid of pain for a few hours. It is to help you move comfortably, become stronger and return confidently to the things you want to do.

Can shockwave therapy help shoulder pain?

For some persistent shoulder problems, shockwave therapy may be considered as part of a wider treatment and rehabilitation plan, depending on the diagnosis and how symptoms have responded to other approaches.

One condition where shockwave has been studied extensively is calcific rotator cuff tendinopathy, sometimes called calcific tendonitis. This occurs when calcium deposits develop within one or more of the rotator cuff tendons and can cause significant shoulder pain, stiffness and difficulty lifting the arm. Research suggests that shockwave may help reduce pain and improve shoulder function in some people, and may also encourage changes in the calcium deposit itself.

Shockwave has also been investigated for non-calcific rotator cuff and other shoulder tendinopathies. Some studies show improvements in pain, particularly in the short term.

Importantly it should always be considered alongside progressive strengthening, appropriate load management and rehabilitation rather than as a stand-alone treatment.

There is also emerging evidence for the use of shockwave as an adjunct treatment for frozen shoulder. Some research has found improvements in pain and shoulder function when shockwave is added to usual rehabilitation, although studies are variable.

At One Health, shockwave would only be considered after an appropriate assessment, where the diagnosis, stage of the condition, symptom duration and previous treatment can all be taken into account. If appropriate, it would form part of a broader plan that may also include hands-on osteopathic treatment, mobility work, stretching and progressive shoulder rehabilitation.

Neck and shoulder pain treatment in Tunbridge Wells

If neck or shoulder pain is affecting your sleep, work, exercise or everyday activities, a thorough musculoskeletal assessment can help identify what may be contributing.

One Health Osteopathy Clinic is based in central Tunbridge Wells and welcomes patients from Tunbridge Wells, Tonbridge, Sevenoaks and surrounding areas of Kent.

Our registered osteopaths assess and manage a wide range of neck and shoulder problems, including:

• neck pain and stiffness;
• shoulder pain;
• rotator cuff-related shoulder pain;
• upper-back and shoulder-blade pain;
• muscle tension;
• recurring neck problems;
• nerve-related arm symptoms;
• sports and exercise-related problems;
• musculoskeletal headaches;
• difficulty returning to normal activity following pain or injury.

Our approach combines careful clinical assessment with hands-on osteopathic treatment where appropriate, together with movement, stretching, strengthening and tailored rehabilitation.

We want you to understand what may be contributing to your symptoms, feel confident using your body and have a clear plan for returning to the activities that matter to you.

Frequently asked questions about neck and shoulder pain

How do I know if my shoulder pain is coming from my neck?

Neck-related pain may be felt around the shoulder or shoulder blade and can sometimes travel into the arm. If symptoms change when you move your neck, or are accompanied by tingling, numbness or weakness, the neck or nerves may be involved. However, a clinical assessment is often needed to distinguish neck-related pain from a shoulder problem.

How do I know if I have a rotator cuff problem?

Rotator cuff-related pain commonly affects the outer shoulder or upper arm and may be aggravated by lifting your arm, reaching overhead, reaching behind you or lying on that shoulder. Other shoulder problems can cause similar symptoms, so assessment is useful if pain persists.

Can neck pain cause pain between the shoulder blades?

Yes. Structures in the neck can refer pain towards the shoulder blade, while the joints and muscles of the upper back can also produce pain in this area.

Can a trapped nerve in the neck cause hand tingling?

Yes. Irritation of a nerve root in the neck can cause pain, tingling, pins and needles, numbness or weakness into the arm or hand. Persistent or worsening neurological symptoms should be assessed.

Does shoulder pain always need a scan?

No. Many shoulder problems can initially be assessed clinically. Imaging may be useful when the history and examination indicate it is likely to change management or when symptoms are not progressing as expected.

Is massage good for neck and shoulder pain?

Massage and soft-tissue treatment can be very helpful for muscle tension, stiffness and discomfort. If symptoms repeatedly return, it is also important to consider strength, joint movement, activity, rehabilitation and other contributing factors.

Is stretching helpful for neck and shoulder pain?

Yes. Comfortable stretching can help reduce stiffness and tension and restore movement. It can be particularly useful when combined with regular activity and strengthening where appropriate.

Should I exercise if my shoulder hurts?

Often some form of movement and exercise can be continued, but the type and amount may need to be modified. Completely avoiding use of the shoulder for prolonged periods is not usually necessary for common musculoskeletal problems. An assessment can help determine what is appropriate for your particular condition.

Can stress make neck pain worse?

Yes. Stress may increase muscle tension, disrupt sleep, reduce recovery and influence pain sensitivity. This does not mean the pain is not physical. Musculoskeletal and wider factors often interact.

Should I see an osteopath for neck or shoulder pain?

An osteopath can assess your neck, shoulder, muscles, joints, nerves and movement to help establish what may be contributing to your symptoms. Where appropriate, treatment may include hands-on osteopathic care together with stretching, movement, strengthening and rehabilitation.

Coming next

Knee Pain: Common Causes and When Should You Get It Assessed?

Part 5 of our Move Better, Feel Better: Pain & Movement Explained series.

The Move Better, Feel Better: Pain & Movement Explained series

1. Lower Back Pain: What Causes It and When Should You Get It Checked?
2. Sciatica: What Does It Feel Like and When Should You Get Help?
3. Is Sitting Really Bad for Your Back?
4. Neck and Shoulder Pain: What Could Be Causing It and What Actually Helps? (you are here)
5. Knee Pain: Common Causes and When Should You Get It Assessed?
6. Hip Pain: Is It Coming From Your Hip, Back or Somewhere Else?

About the author

Jessica Brown is a registered osteopath and owner of One Health Osteopathy Clinic in Tunbridge Wells.

Jessica holds a Master’s degree in Osteopathy from the University College of Osteopathy, where she received awards for academic achievement and her dissertation. She also has postgraduate training in women’s health osteopathy.

Her clinical approach combines careful assessment, hands-on osteopathic treatment where appropriate, movement, rehabilitation and clear, evidence-informed advice. She is particularly interested in helping people understand their symptoms, regain confidence in their bodies and return to the activities that matter to them.

Evidence and further reading

This article is informed by current UK health information and contemporary research relating to neck and shoulder pain.

Research in people with persistent neck pain suggests that strengthening the neck, shoulder and shoulder-blade muscles can reduce pain and disability, although the certainty of current evidence is limited.

NHS information recommends maintaining movement for common neck pain and seeking assessment when symptoms persist or are accompanied by neurological symptoms such as pins and needles. NHS guidance also highlights several common causes of shoulder pain including tendon-related problems, bursitis, frozen shoulder, arthritis and AC joint problems.

The General Osteopathic Council describes osteopathic care as combining thorough clinical assessment and hands-on treatment with exercise and self-management advice where appropriate.

Clinical evidence continues to develop, and this article should be reviewed periodically as new research becomes available.

One Health Osteopathy Clinic
Oxford House, 15–17 Mount Ephraim Road
Tunbridge Wells, Kent TN1 1EN

This article provides general health information and does not replace an individual medical assessment.

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