Suffering shoulder pain?
You’re not alone. Shoulder pain and injuries are one of the most common peripheral (ie. non-spinal) complaints we see every day here at the clinic. They can affect all age groups and have the potential to have a big impact on quality of life. Shoulder pathology is known to affect approximately 15% of the population. It is commonly linked with sleeping difficulties, workplace issues, reduction in sports participation and difficulties in activities of daily living. Early diagnosis and management can help reduce the impact of these conditions and help the patient return to full pain free functioning.
Of the possible shoulder presentations, rotator cuff injury and shoulder impingement are by far the most common diagnosed conditions. Whereas conditions such as adhesive capsulitis or frozen shoulder actually continue to be over-diagnosed within shoulder pain sufferers. For the purpose of this blog we are going to go over both rotator cuff and frozen shoulder and provide some information about them and how we as chiropractors address shoulder pain.
The Rotator Cuff
The shoulder joint is a synovial ball and socket joint made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle). The ball, or head, of your humerus fits into a shallow socket in your shoulder blade. The arm is kept in your shoulder socket by your rotator cuff, consisting of four muscles that come together as tendons to form a covering around the head of the humerus. The rotator cuff attaches the humerus to the shoulder blade and helps to lift and rotate whilst providing stability to your arm.
With injury to these dynamic muscular structures strength, stability and subsequently function can be affected. Rotator cuff injuries are a common cause of shoulder pain and disability presenting in all age groups and types of people. An injury or tear to the rotator cuff will usually present with pain and weakness within the shoulder and can become debilitating in nature depending on severity and lifestyle factors of the affected individual. Shoulder range of motion is often limited and painful and commonly impacts daily life. Lifting, elevating and rotating the arm can become difficult and weak making simple tasks like brushing your teeth, combing your hair or getting dressed hard to perform.
Rotator cuff disease may be degenerative or traumatic, with either an acute or chronic onset. Rotator cuff disorders encompass a spectrum of pathology, from tendinosis, to partial-and full- thickness tears. People who do repetitive lifting or overhead activities are at heightened risk for rotator cuff injury. Painters, carpenters, and others who do overhead work also have a greater chance for tears. Athletes are especially vulnerable to overuse tears, particularly tennis and cricket players. Although overuse tears caused by sports activity or overhead work also occur in younger people, the majority in young adults are caused by traumatic injury, like a fall.
The likelihood of rotator cuff injury increases with age, with people over 40 at greater risk. Although full thickness tears are rare before the age of 60, by 70 it is estimated to be present in up to 50% of the population. As you age, the muscle and tendon tissue of the rotator cuff loses some elasticity, and due to the inherent poor blood supply to the mid part of the tendon healing is slow and degenerative changes are often found. This is the reason that rotator cuff tears are more commonly seen in older people. Literature suggests conservative management of low to medium grade rotator cuff injury is generally quite successful. Chiropractic, physiotherapy and massage have all shown to have beneficial outcomes in rotator cuff management. The small majority of large tears and severe injury have been reported to warrant orthopaedic or surgical opinion, however full resolution of these issues following surgery are poorly supported in literature.
Frozen shoulder or adhesive capsulitis is too commonly used to describe any painful limitation of shoulder movement. It is often applied as a general description for a set of symptoms, rather than as a specific diagnosis that describes a distinct pathological process. A true case of frozen shoulder involves thickening and fibrosis of several ligaments within the shoulder joint. This impacts structures particularly relevant to movement and results in motion restrictions. Surprisingly a distinct feature of frozen shoulder is normal x-ray appearance. Most diagnoses of frozen shoulder are done using a combination of clinical findings in combination with ultrasound or arthroscopic examinations.
Frozen shoulder is actually a genetically influenced contracture of the shoulder joint capsule. Surprisingly it is reported that frozen shoulder has a heritability of up to 42%. Of the 15% of people experiencing shoulder pathology, capsular contracture is reported to only affect 5% of these. It is therefore estimated that the prevalence of frozen shoulder to be at only 0.75% of presenting shoulder issues. It is frequently observed that patients commonly develop frozen shoulder after surgery to the shoulder or chest region. An abnormal healing response is thought to occur in which excessive connective tissue is produced resulting in fibrotic changes around the joint tendons/ligaments. There are well defined clinical criteria used for diagnosis and it is commonly overlooked or ignored. This 12 point checklist developed many years ago is very useful in diagnosis however common shoulder issues also share many of these features. It is with this reason that several key symptoms of frozen shoulder were observed. Painful and restricted external rotation is one of the unique features of frozen shoulder. Actions such as throwing and combing hair can be extremely difficult and painful. Limited passive external rotation will also be present in frozen shoulder. This means the practitioner will not be able to move your arm in that same range of motion you are not able to achieve. This is where many people get confused. Many people will have a movement issue within the shoulder but will not have any problem when the shoulder is passively moved. If this is the case you do NOT have frozen shoulder.
There are two aspects of this condition to be treated – the pain and the contracture. It is also important to tailor any treatment to the phase of the disease progression. For early and milder cases, a manual approach would aim to stretch the joint capsule and minimise the impact of abnormal movement patterns of the shoulder girdle and cervical spine. For longer and more severe cases surgical intervention is generally considered. Literature suggests relief and recovery from keyhole surgical debridement of contracted fibrous tissue within the shoulder results in an improvement of pain and function in approximately 88% of people.
When the shoulder joint becomes painful and symptomatic such as in cases of rotator cuff injury and frozen shoulder it is imperative that all anatomical components are considered. Shoulder pain can commonly occur as a result of thoracic or cervical spine dysfunction. The direct relationship these structures hold can result in pain referral to the shoulder from theses distant structures. An accurate and prompt diagnosis is essential in successful management shoulder pain.
As chiropractors, we perform comprehensive history, followed by extensive orthopaedic and neurological examinations. It is only once an accurate diagnosis has been reached an appropriate management plan can be applied. If the practitioner believes the issue is too serious or sinister to warrant a conservative trial of treatment immediate orthopaedic referral may be suggested. The quicker the diagnosis and implementation of an adequate treatment plan, the less likely the issue will progress and continue to be debilitating in nature. Once assessment of the symptomatic site and surrounding related structures has been completed and a diagnosis provided, a treatment plan should be implemented. Any treatment plan is most successful when modified and tailored to best suit the individual.
The stages of chiropractic care are implemented sequentially. The initial phase is aimed at reducing inflammation and consequent pain. The second phase is focused around stabilising and normalising joint function. The final stage is aimed at rehabilitating the involved structures for strengthening and prevention.
Stage 1 (reducing pain and inflammation)
To minimise complications from your shoulder injury, you should seek prompt evaluation if shoulder pain persists longer than a few days. The reduction of pain and inflammation is our first goal. The use of ice, light massage and soft tissue techniques at the shoulder usually provides quite a lot of symptomatic relief whilst addressing inflammatory changes. Advice to avoid aggravating activities may be given and implementation of supporting taping/bracing is also commonly suggested. Chiropractic adjustments and mobilisations of surrounding joints is also very helpful as the body can compensate for the injured shoulder placing increased strain on neighbouring structures. The thoracic spine and neck are commonly impacted with conditions affecting the shoulder. Ensuring neighbouring areas are functioning adequately provides a stable and sound frame for the shoulder to work from. Once pain and inflammation has been addressed simple range of motion exercises, muscle release techniques and dry needling can be implemented early aimed at reducing capsular adhesive build up and promoting blood flow and muscle stimulation.
Stage 2 (Normalising function)
It is important to keep the shoulder moving to avoid muscle and function loss. Reductions in joint proprioception and surrounding muscle weakness usually occurs either due to decreased use or pain inhibition. Joint movement restrictions are also common in injury to most sites of the body. To account for the lack in movement in affected areas, surrounding areas must accommodate for this may become hypermobile and symptomatic. It is important we address all these joints and areas to ensure normal function can be restored. Deep soft tissue work including muscle release techniques, trigger point therapy and cross friction myofascial may be applied to reduce tone and lengthen tight areas of muscle spasm and hypertonicity. Chiropractic adjustments and mobilisations to the shoulder and surrounding joints are provided to help initiate and restore movement and function. Specific muscle stretching and home exercises can be prescribed to correct any muscular imbalances between the upper back and chest. Correcting these imbalances helps to ensure smooth shoulder motion and allow for further healing to occur.
Stage 3 (Rehabilitation)
Once the shoulder is back to optimal functioning, it is important these improvements are maintained. Strengthening and proprioceptive exercises should be implemented or continued aimed at increasing and maintaining co-ordination that may have been affected in the injury process. These exercises will not only help condition certain tissues but also help in reducing the likelihood of re-injury. With the application of these exercises it is common to get changes in joint motion and functioning. Chiropractic adjustments and mobilisations to the shoulder and surrounding areas are continued to ensure adequate range of motion and joint functioning are maintained. It is important for the individual to understand the changes that have taken place and that it is vital to maintain them.
Most shoulder conditions do not require surgery. However, if your pain does not resolve with a trial of conservative care, further testing, such as an MRI, may be required to determine exactly how much shoulder damage/dysfunction is present. Literature suggests the large majority of shoulder injuries respond adequately to conservative management however in cases that do not improve orthopaedic or surgical consultation may be necessary.
By Dr Grant Colombo (chiropractor), March 2017
Suffering from shoulder pain?
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