Shoulder Pain
Overview
Compromised shoulder movement can carry significant disability for a person to carry out their daily activities.
3rd most common cause of musculoskeletal consult in doctor's offices.
1/4 individuals have shoulder pain at any point in time.
There are several different diagnoses that can be found in the shoulder. Luckily, in the majority of cases, they are normally treatable conditions, if approached from a researched, conservative approach. This article covers what it is as well as what it is not.
What It Is
The shoulder is a ball-and-socket joint that needs to be able to move while maintaining stability.
If you would, imagine a golf ball on a tee. The golf ball (arm) sits on the tee (shoulder blade). It is imperative the tee is stable in the ground. If the tee isn't stable, the complex will tip, causing the golf ball to gravitate to one side of the tee.
Luckily for your shoulder, there are 17 different muscles that attach to the shoulder blade to keep it stable. Each of these muscles carry an important function to provide stability as the arm rotates within the joint.
Each of these muscles are controlled by nerves coming from the neck. If the joints in your neck cannot properly move, signals from the brain and shoulder are altered, leading to improper stability within the scapula. In chiropractic, we call this subluxation.
When this happens, our body will adapt and will utilize different muscles to (if you will) tighten the tee to the earth. Commonly, the tissues adapting for the increased force are the rotator cuff (muscles around shoulder), glenohumeral joint (bones of the shoulder), and the acromioclavicular joint (clavicle meets breastbone).
In common medicine, we label and diagnose the tissue that is being strained. The diagnosis describes where the pain is coming from (what it is), but the diagnosis does not necessarily describe WHY it occurred. Without knowing WHY something happens, how can we begin to know HOW to correct it?
Shoulder pain is most commonly mechanical in nature. It can be determined to be mechanical if it is affected, in any way, by position or movement. This is because when we move, force is transferred onto various structures.
Consider: If tee was crooked, and the golf ball repeatedly hung on the edge of the tee and spun all day long, the part of the tee that the ball was in contact with will wear down (compared to the other side).
Treatment first begins with sparing the affected tissue and figuring out why that tissue was affected to begin with.
Are there ways, at home, that I can tell if my tee is loose?
A great amount of information can be obtained from examining your posture. Posture tells us how our bodies are adapting to our lifestyle. Most frequently, chronic poor positioning and movement mechanics restrict our spines and nerves, and our body's attempt to improperly stabilize will be reflected in posture.
If you look in the mirror:
Is one shoulder higher than the other?
Is one more rolled forward than the other?
Is the head tilted to one side? Rotated to a side?
When you breathe in deeply, do your shoulders rise?
If you notice your body adapting to the forces it's exposed to, you have an early idea of what kind of wear they will face in the future. These are mechanical forces at work.
If a mechanical force caused the problem, then logic would have it that mechanical force can cause the solution. However, a doctor must examine WHY the tissue is being overloaded.
We do this by addressing mechanical positioning and movement in the neck, mid-back, scapula, AC joint (see above), shoulder, and also the elbow and hand. By asking your body to move, we have a clear understanding of WHY your tissues are overloaded, and HOW to best treat it.
In rare cases, shoulder pain can indicate a serious medical problem. If you are experiencing any dizziness, blurred vision, direct trauma, unexplained weight loss, difficulty speaking/swallowing, or jaw pain, seek immediate medical attention.
What It Is Not
Our body exhibits pain in an attempt to warrant a change. Narrowly viewing and treating the pain generator is linked with poor clinical outcomes. As described above, only focusing on what structure is overloaded (while ignoring why) is linked to poor outcomes.
Consider the following from the Journal of Orthopedics in March of 2013:
664 people were given an MRI of the shoulder.
147/664 had fully torn rotator cuffs. Only 35% of those individuals had any pain.
Tears without pain were twice as common as tears with pain.
From the Journal of Orthopedic Sports Medicine, January of 2016:
53 individuals aged 45-60 years old with no pain, injury, or history of surgery were given an MRI of the shoulder.
72% of them were found to have tears in their labrum.
They found no difference amongst sex, age, dominant shoulder, or occupation (physical job).
The authors conclude that superior labral tears diagnosed by MRI between the ages of 45-60 may be normal age-related findings.
In a Journal of Joint Disorders and Orthopedic Sports Medicine (ISAKOS):
Failure of tendon healing after surgical rotator cuff repair is common and reported in 1/5 cases.
Current review indicates that surgical repair of rotator cuff can lead to improvements despite a high re-tear rate.
Lastly, the South African Journal of Physiotherapy, 2016, examined corticosteroid injections vs. physiotherapy on shoulder function in a full review of several other studies. They concluded:
There is a significant improvement in shoulder function in short term measurements for physiotherapy and corticosteroid injections.
In medium to long-term measurements, range of motion and shoulder function improvements do not favor the use of corticosteroid injections.
Let's review what the above studies reported:
Tears in the labrum and rotator cuff are so common that they're considered a normal part of aging. These tears are even more likely to be found in people without pain. Simply injecting anti-inflammatories into the inflamed tendon doesn't provide long term relief. Surgically repairing the tissue often leads to a high re-tear rate.
Ask yourself:
Why would a rotator cuff muscle or labrum tear?
Most likely: The muscle is overworking.
WHY is the muscle overworking?
Figuring that question out is the key to effective treatment.
Otherwise, it's like pounding on screws with a hammer.
Zeroing in and focusing on just the overloaded tissue/pain generator has low evidence for long term solutions. Identifying degeneration (overloaded tissue) is not backed by evidence. By identifying pain as mechanical and finding dysfunctions that fuel the mechanical overload, both structural and functional, a chiropractor can best equip you with the care needed to not just live pain free, long term, but to get your life back, doing the things you love.
Remember that you were made to have life and have it more abundantly; You were made to thrive.
Sources
Burger, Marlette et al. “Effect of corticosteroid injections versus physiotherapy on pain, shoulder range of motion and shoulder function in patients with subacromial impingement syndrome: A systematic review and meta-analysis.” The South African journal of physiotherapy vol. 72,1 318. 27 Sep. 2016, doi:10.4102/sajp.v72i1.318
Lädermann, Alexandre, et al. “Management of Failed Rotator Cuff Repair: a Systematic Review.” Journal of ISAKOS: Joint Disorders & Orthopaedic Sports Medicine, BMJ Publishing Group Limited, 1 Jan. 2016, jisakos.bmj.com/content/1/1/32.
Minagawa, Hiroshi et al. “Prevalence of symptomatic and asymptomatic rotator cuff tears in the general population: From mass-screening in one village.” Journal of orthopaedics vol. 10,1 8-12. 26 Feb. 2013, doi:10.1016/j.jor.2013.01.008
Mitchell, Caroline et al. “Shoulder pain: diagnosis and management in primary care.” BMJ (Clinical research ed.) vol. 331,7525 (2005): 1124-8. doi:10.1136/bmj.331.7525.1124
Schwartzberg, Randy et al. “High Prevalence of Superior Labral Tears Diagnosed by MRI in Middle-Aged Patients With Asymptomatic Shoulders.” Orthopaedic journal of sports medicine vol. 4,1 2325967115623212. 5 Jan. 2016, doi:10.1177/2325967115623212