What kind of shoulder problems can we treat?
by Damian Moore M.Ost

Shoulder dysfunction may be caused by problems in the shoulder itself or may be referred from the neck or other structures.  The problem in the shoulder may be because of a local dysfunction or may be the result of a problem in the back which is not allowing the shoulder to function correctly.  Often the problem is the result of a combination of factors and even if we are unable to use osteopathy to restore full pain-free function wecan increase range of motion and reduce pain.  Below is a discussion of some shoulder problems and the approach I would take to treatment.  To discuss your shoulder problem call us, there's no obligation!

Painful arc, subacromial impingement

This problem, also known as thrower's or swimmer's shoulder is relatively common.  Patients often complain of pain when they raise their arm out to the side, usually between about 70 and 120 degrees, hence the painful arc.  The pain is generated by structures becoming compressed irritated and inflamed in the 'subacromial' space, hence subacromial impingement.  There are a number of reasons this can occur but they fall into two categories.  The first is that something has taken up the sub-acromial space; degenerative joints can generate calcific spurs, ligaments can thicken, the tendon of supraspinatus or subacromial bursa may inflame and then thicken.  The second reason is that something is disrupting the normal functioning of the muscles which hold the arm against the shoulder.  In order to gain a wide range of movement the arm performs a neat trick, as you raise it out to the side, the top end is pulled slightly downward so that your arm clears the bony point you can feel at the tip of your shoulder (the acromion) this process can become disrupted, often by injury to supraspinatus, but also by biceps problems.  As  osteopaths we want to understand why these have happened now, and how your posture, and the way you use your body, contribute to that.  We can then formulate treatment and advice to start to alleviate or reverse the process, working where we can to correct imbalances and regain normal function.  Often there are underlying reasons why the shoulder is having to work in a compromised fashion and attention  to those reasons can allow the shoulder to return to normal function.

Frozen shoulder - adhesive capsulitis

A common shoulder condition, disproportionately affecting the elderly, women and diabetics but it can occur in anyone especially after a previous shoulder injury.  Following inflammation sticky proteins gum together free edges in the capsule that surrounds the main shoulder joint.  This capsule needs to be loose as the shoulder has to move through a wide range of movement.  The first symptoms are usually pain, which is often felt on the outside of the arm and is usually worst at night, the patient then gradually loses the ability to move their arm out fully to the side and most particularly the movement known as external rotation.  Brushing hair becomes especially tricky.  After some time the pain will go but the movement will remain impaired and then after a further period the function should return.  As an osteopath I can't stop the condition running its course but there is some evidence that the correct manipulative therapy at the right point in the condition can help minimise the loss of mobility in the joint.  What is more people with this condition tend to learn 'cheat' by side- bending their upper back, to compensate for the lack of shoulder movement. Osteopathic treatment can be useful to keep the upper back moving, both to help facilitate this cheat and also to help reduce any problems caused by using the back in this way.

Shoulder instability

Instability may lead a shoulder to repeatedly dislocate, to partially dislocate (sublux) or just to feel as though it will give way.  A shoulder may be unstable for one of three reasons:  Firstly injury, previous dislocation may lead to weakness or tears in the supportive soft-tissue structures around the shoulder; secondly, repetitive overuse, people who repeatedly stretch structures in the shoulder may weaken them causing the shoulder to become loose in that direction, this may happen with competitive swimmers for example; the final reason is that the patient has generally loose soft-tissues, hypermobility, in this case the shoulder may be unstable in all directions.   These conditions are not something I would look to treat directly.  Strengthening shoulder muscles can help counteract soft-tissue laxity but in the event of repeated problems surgical repair may be required.  This doesn't mean there is no role for osteopathy, the problem may have arisen as a result of poor function of the other structures that contribute to shoulder movement.  Full movement of the arm at the shoulder requires movement at the main shoulder joint (glenohumeral joint), the acromioclavicular and sternoclavicular joints, the passage of the shoulder blade over the ribcage, which can be affected by how evenly the ribs are sitting and the ability of the upper back and low neck to bend to accommodate movement. If any of these structures are compromised, or if poor posture has altered the orientation of the shoulder then the stresses on damaged or weak soft-tissues around the shoulder will be increased.  As such, my approach, in conjunction with appropriate medical care would be to work to reduce the stresses placed on the affected tissues by improving the portion of shoulder function derived from other structures.  
 

Rotator cuff dysfunction

The rotator cuff is made up of the tendons of four muscles.  These muscles are situated on your trunk and the tendons join to the top part of the humerus (bone in the top of the arm).  As well as providing movement these muscles also act to stabilise the glenohumeral joint whilst bigger muscles provide most of the power to move it.  The tendon of supraspinatus is particularly prone to injury as it has a blood supply from both ends which often doesn't supply the part where the two supplies meet very well.  Inflammation can occur causing thickening and sometimes calcium deposits within the tendon, all of these may cause painful arc symptoms (see above).   Pain often occurs at night, as when the shoulder is relaxed and the tendon is no longer under tension from gravity blood flow is less impeded and the blood returns, causing fresh inflammation.  The tendons are also prone to degradation in older age, as well as traumatic injuries.  Partial tears may resolve to a satisfactory level without surgery, full tears may be referred for intervention.  Osteopathic treatment will aim to improve postural mechanics and reduce load on the area as well as any biomechanical restrictions on function and blood flow. 


Referred pain

The nerve supply to the arm passes from the neck through the shoulder.  Irritation of the nerve root in the neck or the brachial plexus can also generate pain in  the shoulder and my questioning and examination will help me to identify if this is the case and, if necessary, treat your neck problem.  Shoulder pain can also be as a result of the body confusing pain generated by organs and structures, such as the diaphragm, which are supplied by the same nerves, in which case you will need to be referred for further investigation, see below.  


Other causes of shoulder pain

Shoulder pain can be caused by a variety of problems and many of the questions we will ask you about your general health are to exclude any serious (but rare) conditions.  We will always refer you if I believe the cause of your problem is something we don't believe we can treat using osteopathy.  If you are experiencing severe shoulder pain as the result of an injury you should visit your emergency clinic to be assessed for a fracture