Shoulder Pain

Intervertebral Disk (IVD)

The Shoulder Complex: a disclaimer

The shoulder complex is made up of the glenohumeral, scapulothoracic, sternoclavicular and acromioclavicular joints with 18 associated muscles and a multitude of ligaments. The following article tries to break down some of the more common problems that affect with the shoulder complex. However, appreciate that problems can overlap and often there are simultaneous disorders that can affect the shoulder.

The glenohumeral (ball and socket) joint is the most mobile joint in our body but as a trade-off is an unstable joint to allow for this motion. The rotator cuff is a dynamic stabiliser mechanism created by the four muscles depicted in the graphic.
The rotator cuff muscles maintain congruency of the joint surfaces allowing for smooth and seamless motion.
Unfortunately, problems can occur with the rotator cuff, especially the supraspinatus which can get externally impinged beneath the bony prominence (acromion) of the shoulder blade. This is known as subacromial impingement (SAI) and is often associated with tendinopathy, calcification, muscle tears and even complete tendon rupture¹.

Typical Symptoms may include:

Pain/clicking on shoulder movement
Painless weakness/ weakness
‘Catching’ sensation/pain
Worse with overhead movement/ work
Reduced shoulder mobility
Reduced confidence in movement

Treatment plan: Every patient is unique and the approach will reflect this.

Together, you and your osteopath will discuss a course of action and treatment which best suits you.

Common key areas to be addressed may include:

Shoulder muscles function appropriately for smooth and efficient motion
Mobility of shoulder complex and its related joints
Cervical spine, thoracic spine and rib mobility
Exercises for mobility, strengthening and pain management
Effects of ergonomics (desk, sleeping, driving), posture and work-related activity on pain and shoulder function
Other risk factors of SAI explored and addressed

1.Shoulder Doc. Subacromial Impingement. Available at: https://www.shoulderdoc.co.uk/section/9 [Accessed 20/06/2017]

Labral Tears

The labrum is the fibrocartilaginous structure that deepens the socket of the glenohumeral (ball and socket) joint. This provides extra support to the shoulder to help compensate for its instability. Tears of the labrum can occur with trauma and/or repetitive over arm use e.g. throwing, with the location of the tear dependent on the mechanism of injury:

SLAP – top area of the labrum, can be associated with bicep tendon tear/tendinopathy
Bankart – front of the labrum, associated with anterior dislocations and common in rugby players
Kim – back/bottom of the labrum, associated with posterior dislocations (less common)

Typical Symptoms may include:

Shoulder pain with overhead/cross the body movement
Pain that radiates down the arm
Weakness/ stiffness
Feeling of instability
Popping, clicking and/or catching sensation

Treatment plan: Every patient is unique and the approach will reflect this. Together, you and your osteopath will discuss a course of action and treatment which best suits you. Common key areas to be addressed may include:

Local musculature – identification and treatment of myofascial trigger points (MFTP) of the head, neck and shoulders
Cervical spine, thoracic spine and rib mobility
Manage return to activity
Progressive rehabilitation program
Exercises for mobility, strengthening and pain management
Effects of ergonomics (desk, sleeping, driving), posture and work-related activity on pain and shoulder function
Refer for further investigations if necessary

Frozen Shoulder (Adhesive Capsulitis)

Frozen shoulder or Adhesive Capsulitis has been described as a ‘condition of uncertain aetiology characterised by significant restriction of both active and passive shoulder motion that occurs in the absence of a known intrinsic shoulder disorder¹. This basically translates into: a stiff/painful shoulder for no apparent reason.

The main structure in the shoulder that is affected is the glenohumeral (ball and socket) capsule or the connective tissue around the joint. We do not fully understand why this happens but is more common with

Diabetes
Thyroid conditions (hypothyroidism)
Ischaemic Heart Disease
Shoulder Trauma/ Surgery
Period of immobilisation/ inactivity

The clinical progression of Frozen Shoulder tends to go through three phases²:

Freezing or Painful stage = lasts 2-9 months; increasingly painful shoulder
Frozen or Stiffening stage = lasts 4-20 months; reduced pain with restricted shoulder
Thawing or Resolution stage = lasts 5-26 months; improving movement and pain

These timings will vary depending on the resource you quote but from onset to resolution, Frozen Shoulder can last anywhere between 1 and 5 years.

Typical symptoms depend on the stage of the disorder but may include:

Insidious onset with dull pain around the shoulder
Disturbed sleep due to pain
Significant loss shoulder mobility
Sharp pain with movement
May follow minor trauma

Treatment plan: Frozen Shoulder natural progression varies in time taken however it will resolve and the long-term outcomes are fundamentally the same. **UPDATE: Recent systemic reviews of the evidence suggest that Frozen Shoulder does not improve of its own accord without treatment³ and encourages early intervention and treatment for optimum recovery**

Together, you and your osteopath will discuss a course of action and treatment which best suits you. Common key areas to be addressed may include:

Exercise regime to help restore motion and reduce pain
Reduce muscle tension around the shoulder
Treat Myofascial Trigger Points (MFTPs)
Improve movement patterns of other areas: scapulothoracic, thoracic spine, etc
Joint mobilisation/ traction therapy
Education on Frozen Shoulder and natural progression
Expectation
Anti-inflammatory medication
Address risk factors (diabetes, hypothyroidism, ischaemic heart disease)
Referral for corticosteroid injections
Surgery reserved for patients who do not respond to conservative treatment

1.Zuckerman & Rokito. 2011. Frozen shoulder: a consensus definition. J Shoulder Elbow Surg. 20(2): 322-5

2.Medscape 2017. Adhesive Capsulitis (Frozen Shoulder). Available at: http://emedicine.medscape.com/article/1261598-overview [Accessed on 21/06/2017]

3.Wong, C.K. et al. 2017. Natural history of frozen shoulder: fact or fiction? A systematic review. 103(1):40-47