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Shoulder Pain

Shoulder pain is one of the more common problems seen at the clinic. It can stem from the neck or it may be a problem on its own. An exam and occasionally imaging are needed to determine which structures are producing pain and what will be the best treatment for the problem at hand. 

Man with shoulder pain

Anatomy of the Shoulder

The shoulder is a complex joint encompassing a wide variety of tissues and structures. The shoulder has a remarkable range of motion. When healthy, the shoulder allows us to reach behind our backs, across the body, above the head and more which is really impressive to say the least. However, the freedom of movement is precisely what makes the shoulder such a common source of pain and dysfunction.

The Glenohumeral Joint:

The glenohumberal (shoulder) joint is a ball and socket type. It is shallow compared to the femoroacetabular (hip) joint which grants us more freedom of movement in the shoulders compared to the hips. The joint is formed between the scapula (shoulder blade) and the humerus (upper arm). It is precisely this which leaves the shoulders susceptible to dysfunction and injury. The joint itself is lined circumferentially by a labrum that is attached around the rim of the joint which gives some stability to the joint given how shallow it is. This is the main cartilage of the shoulder joint and the part of the joint that is often injured. Fractures do occur at the shoulder and require orthopedic intervention often damaging the soft tissues of the shoulder in the process. While bones are remarkable for their ability to heal when correctly aligned cartilage if not since it typically has such a poor blood supply. Just outside of the shoulder joint a collection of ligaments encapsulate the shoulder, both front and back. These may be injured as well or become chronically inflamed as is commonly seen in frozen shoulder (adhesive capsulitis).

 

The Rotator Cuff:

The rotator cuff comprises four muscles that (you guessed it) assist the shoulder in rotation. Rotation of the shoulder is an integral part of nearly every movement we do with out shoulders. When the rotator cuff is injured you are certain to feel it with varied movements of the arm and it's particularly sensitive to laying on the affective shoulder when trying to sleep at night. First and foremost we have the supraspinatus which primarily acts to stabilize the shoulder through its varied movements. The supraspinatus is by far the most common rotator cuff muscle to be dysfunctional or injured. It has a small space to live and is surrounded by bones which puts it at risk for impingement and tear. In addition to its precarious home in our shoulders there is a bursa that helps it glide along in there that is prone to injury (falls, overuse, etc) and can be very painful. When the bursa becomes inflamed we call it bursitis. Good news is that bursitis generally resolves itself with little intervention needed. The remaining 3 rotator cuff muscles are rarely a primary shoulder problem. All 4 rotator cuff muscles take their innervation from the lower neck (big trouble area I see in the clinic) and are often involved in arthritic / disc problems in the neck which are quite common. The infraspinatus and teres minor both act to rotate the shoulder externally (or outwards) and the subscapularis is a very strong internal rotator of the arm. While I see a lot of tendinopathy (tendonitis) in the supraspinatus, I rarely find that the remaining rotator cuff muscles involved in a tendonitis. Most of the time when they are painful is comes from the neck or the shoulder capsule / labrum.

The Labrum:

You may have heard of the labrum before. Probably in the light of labral tears which are common. The shoulder joint, when injured nearly always involves the labrum. It is the cartilaginous part and consequently prone to injury or wear and tear. People often get a painful grinding or catching in the shoulder joint with labral injuries. When injured they swell and involve the adjacent or surrounded tissues making it seem like maybe its just a rotator cuff or muscle problem. It is difficult to diagnose labral tears without imaging. Generally, an MRI will do the trick but the gold standard remains arthroscopy (literally using a camera inside the shoulder joint in the operating room). Fortunately, most labral injuries can heal without surgical intervention. I strongly recommend specific shoulder exercise for these patients or more specialized treatment with a physical therapist before considering surgery. Being hurt for the first time can be overwhelming but it is important to give your body ample time to heal (6-12 weeks for labral injuries) before considering surgery. Like I always say, surgery is always an option so its best to exhaust conservative and natural options first. 

The scapulothoracic / shoulder complex:

Recall from above that the shoulder joint is between the scapula and the humerus. The scapulothoracic complex constitutes the articulation between the upper body and the shoulder complex (scapula, clavicle and humerus). This is a very complex set of bones and joints made mobile by 16 different muscles (arguably more). There is a rhythm or coordinated movement between the scapula, clavicle and humerus that must occur to provide full range of motion of the shoulder. As the shoulder abducts (moves away from the body) the scapula must follow with an external type of rotation and the clavicle must allow such a pivot. The term for this is scapulothoracic rhythm. The text books say it should be 2:1 humerus to scapula. Biomechanical imbalances, injuries, and pinched nerves can really disturb this rhythm and cause problems all around the shoulder and even up the neck (recall those 16 muscle groups). Often, a single problem leads to multiple painful structures about the shoulder, upper back and neck which can make it difficult to diagnose and treat. As a chiropractor, it is my job to evaluate and treat such things and, for me, the more complex the better.

shoulder joint anatomy and chiropractic care
shoulder joint anatomy and chiropractic care

Treatments for shoulder pain

There are a lot of treatments for shoulder pain. I guess that should be expected given how complicated the shoulder can be. At the end of the day, the treatment that is most effective is the one that addresses the root problem and elicits the best healing response. You might think that given a specific problem, a specific treatment is always best. A millennia of clinical experience from practitioners worldwide would say otherwise. In fact, studies have shown this time and time again. 

Chiropractic care:

People think of cracks and pops when they think of chiropractic care. The shoulder joint, however, is loosely packed and doesn't cavitate like our knuckles or the facet joints in the spine. In fact, the shoulder rarely responds to joint manipulation in the long term. Joint manipulation of the shoulder may provide some temporary relief but, generally, a more comprehensive approach is needed. 

Soft-Tissue:

Addressing the soft-tissues (muscles, tendons) of the shoulder with manual techniques like myofascial release is generally effective in treating many shoulder conditions and imbalances. Exactly how is kind of a mystery, but we know that soft-tissue work generally stimulates a healing response in and round the tissues worked on. I have to say, my first approach to most shoulder patients presenting at the clinic is soft tissue work. It can be uncomfortable to have deep tissue work done around the shoulder but it is often really effective and the side-effects are minimal.

Electrical muscle stimulation:

EMS or TENS is an effective way to reduce muscle spasm and inflammation. It is not going to cure you but it often makes a huge difference in peoples pain levels and improved function. The latter is a quality that helps people to use and exercise the shoulder which is vitally important to healing

Acupuncture:

Acupuncture has been around forever. Well not forever, but a really long time (3000 + years) as best we can tell. There are many forms of acupuncture and some have been shown to be more effective for different conditions. In the shoulder, modern acupuncture (needling the structures involved) and dry needling for the rotator cuff have been shown to be very effective for many shoulder conditions. Again, it is important to identify the root of the problem as to not chase symptoms and neglect that actual cause of the shoulder problem. Acupuncture at the clinic always follows a detailed exam and diagnosis so you can rest assured we are delivering the best possible care for your specific problem.

Physical therapy:

There is abundant evidence that physical therapy is an effective treatment for many (if not all) shoulder conditions. We strongly recommend PT for the shoulder. PT is best delivered by a professional. We often make referrals to PT for shoulder conditions. While the Chiropractor cannot, strictly speaking, deliver physical therapy, therapeutic exercise is often prescribed to help our patients recover from shoulder problems.

Other treatments:

As above, surgery, injections, medications are valid treatments for shoulder pain. While not natural or conservative, they have become the norm in a modern society. There is a time and place for invasive measures. Two factors go into that decision: 1) How bad in the injury? and 2) Will the injury heal appropriately without it. Often times the determining factor is who patients choose as their first provider. For example, people that go to a chiropractor or physical therapist are significantly less likely to have surgery. My advice is be patient and follow that proper channels before receiving invasive care.

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