A very very common presentation for a lot of Chiropractic and physio complaints. Shoulder issues are a fun and interesting thing to treat as no one shoulder problem is the same. They can be complex and sometimes difficult to treat as it is the most mobile joint in the body and is multidirectional. It has many different pain generators from the muscles, to the ligaments, to the joint and the tendons.
The interesting thing with shoulders is that 9/10 there will always be a postural component causing the muscle imbalance. But due to where it is in the body and the muscular attachments the shoulder is directly linked with neck issues and the thoracic spine, thorax in general and the anterior chest wall. So some patients find it odd if they present with a shoulder problem and the Chiropractor is also working on the chest, thorax and or neck.
In my experience with any shoulder complaint there is always “subscapularis” muscular involvement the muscle that sits anterior to your shoulder blade right into your armpit region. This is an uncomfortable muscle to have worked on but with huge relief.
The most common typical shoulder presentation patient: is someone who is rounding their shoulders so straight away the glenohumeral joint is not stable in the joint but rounded (anterior). The rotator cuff muscles sit in the back of the shoulder blade i.e supraspinatus, infraspinatus and teres minor and major. So a lot of the shoulder pain will be at the front of the shoulder where the tendon attaches where it gets pinched or “impinged” but the tension and restriction is all at the back where shoulder blade or scapula is. So typically a patient will have pain doing up their bra strap or putting on their coat, or doing up their car seat belt- sound familiar? Once the tendon becomes inflamed and “impinged” even holding a cup of tea can be painful.
So what do we do about it?
We will release all the rotator cuff muscles, there are many ways to do that, stretching, massage, active release techniques, using instrument assisted work, physiotherapy modalities, dry needling to name a few. But it will be movement based soft tissue release and usually uncomfortable to release these muscles. The second thing is to decrease inflammation of the actually tendon itself where it is getting pinched. Usually ice packs will be prescribed or ultrasound therapy applied to the rotator cuff tendon where it attaches on the upper arm.
Why does it happen?
These strains to the rotator cuff muscles happen a lot- probably with out us usually noticing. These are called little micro strains or repetitive injury and when we are younger such as a child, teenager, and a young adult they repair so quickly we probably don’t even know you have it.
When your older there is usually adhesions within the muscles, calcification, even joint arthritis so the muscles aren’t as stretchy and glide as well as they used to. The “subacromial space” which is where the rotator cuff tendon passes through in a healthy individual has about 8mm of room to pass through. If there is tension, inflammation and irritation here then of course the tendon starts to catch and you will start getting pain.
It can take a few sessions to loosen the rotator cuffs and you will need to make changes to your posture and strengthen the muscles to stabilise the shoulder complex to stop you straining it so much pulling the shoulder joint back into a more closed packed position.
It won’t make a full recovery if there are any bony spurs in the way or a significant tear of the tendon and you will need to be referred to see an orthopaedic specialist with a view of having an ultrasound scan.
Bursas are fluid filled sacs that surround certain joints of the body and act to prevent excess friction between tissues and/or bony surfaces. In the shoulder, you will find the sub-deltoid bursa that lies underneath the deltoid muscles. (These muscles make the rounded shape of the shoulder/arm). The bursa can become inflamed (bursitis) or pinched which in turn will produce pain and some limited movement of the shoulder. Slight swelling and heat production may be felt. Ultrasound therapy can work well the flush out the swelling and promote faster healing of the bursa. Allowing the muscles and tendons to glide again pain free.
Between “Shoulder blade pain” rhomboid strain
Another common complaint the muscle that attaches from the shoulder blade or scapula to the spine. In someone with a very rounded posture naturally these muscles are strained and become weak and tight. Some specific work to the muscles and the mid spine usually releases the tension and then strengthen the middle spine or “scapula stabilisers”.
Rotator cuff issues: in all their forms. As discussed there are many forms of rotator cuff issues which can be addressed.
Strains, impingements, chronic tendinosis, tendonitis. Adhesion formation of the rotator cuff, acromial impingements. Rotator cuff tendon tears. Muscle imbalances and weaknesses.
This muscle is always involved in 99% of all shoulder complaints. A largely forgotten about muscle that sits on the front of the shoulder blade deep into the armpit area. Some release of this muscles helps the whole shoulder complex work in harmony together with nice normal fluid movement returning.
Trauma or injury
From grade I to grade III tears of the tendons, muscular tears or contusions. There are a lot of pain generators and areas to injury. We can target what the issue is and treat accordingly. Usually strapping or dynamic taping helps to stabilise the shoulder during the acute phase of an injury. Then manual therapy work and then rehabilitation to prevent injury.
AC, SC joint injuries: We have to think of the injury sustained to the joints that attach on to the shoulder joint itself which is very common particularly in rugby players.
An x ray normally will give a firm diagnosis alongside your clinical examination. We give realistic expectations and outcomes when there is degeneration of the should glenohumeral joint and its surrounding structures. It is normally a case of relaxing all the soft tissue structures around the stiffened joint to help it move better and decrease pain and inflammation.
• Shoulder capsulitis “frozen shoulder”
What is a Frozen shoulder?
Frozen shoulder, or “adhesive capsulitis” refers to loss of arm movement at the shoulder joint combined with inflammation of the tissues within the joint capsule that surrounds the shoulder and is often accompanied by a great degree of pain during even the slightest movements.
These tissues become thickened and shortened and eventually ‘stick’ together, hence the medical term – adhesive capsulitis.
What are the symptoms?
There are three main stages:
1 – “Freezing Phase” Initially, there is progressive limitation of all movements of the shoulder. This may follow a recent minor trauma, dislocation, prolonged immobilisation, heart attack (myocardial infarction) and sometimes neck problems. Pain may or may not accompany this, although pain will be felt if you try to exceed the limited movement. This phase can last anywhere between 2 and 9 months. Which is why a lot of doctors will just diagnosis this issue and say it will get better after a year. However all is not lost treatment in the early phases can significantly helo.
2 – “Frozen Phase” As the fluid in the joint becomes thickened there may be more pain and eventually, the condition progresses until all movement is greatly restricted. This phase can last from 4 to 12 months.
3 – “Thawing Phase” As the inflammation begins to subside so does any pain experienced. During this phase movement in the shoulder begins to gradually return but may or may not recover 100% if left untreated. This phase characteristically lasts between 6 to 9 months.
*Early diagnosis is vital because the condition is reversible. Once it has progressed into the adhesive/frozen stage, some persistent restriction may remain.
The recovery period varies depending on how long the problem has been there and the severity of it. It is not uncommon for it to take up to 6 months to recover with treatment and up to 12-24 months without treatment.
But it can be misdiagnosed as ‘frozen shoulder’, so it is important to have your shoulder examined for an accurate diagnosis and treatment by your Chiropractor.
Shoulder Ligamentous injuries
Unfortunately you can’t strengthen a ligament so if you have “subluxed” the shoulder and stretched the capsule and ligaments or even dislocated the shoulder from a fall or injury. You have to be careful you have not sustained a “bankhart lesion” at the top of the humeral head from the dislocation. After a full examination and or x ray you will need to have some manual therapy to the damaged structures and then stabilise the shoulder. As the muscles attach to the ligaments by strengthening the muscles you will strengthen the shoulder itself.
• Shoulder peripheral nerve entrapments
Referred pain from the Neck
It is one of the most common co-existing causes of shoulder pain seen in the chiropractic practice. When the spinal joints are sprained and become inflamed and irritated in the neck, it automatically triggers muscle spasm. The muscles spasm can cause nerve irritation that innervates the shoulder muscles causing the muscle to be weak and painful affecting the movement. Even low-grade neck muscle tensions make you more likely to develop shoulder pain and problems. Chiropractic treatment can help will all of this and prevent it from happening.
Shoulder muscle strain
Simple muscle strains are easy to treat most commonly, levator scap strain or upper trapezius muscle strain. Any combination of dry needling, massage, stretching techniques can relax this down. Usually ice therapy works better for acute injuries such as these.
THE SYKES VERWEY CENTRE IS THE LEADING CHIROPRACTIC AND SPORTS INJURY CLINIC IN DEVON.
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