Have you ever had shoulder pain? Clicking in the shoulder or trouble putting your jacket on? This type of pain is not uncommon and considering how much the shoulder can move and do, it is amazing they are not injured more often than they are. The shoulder joint can move up to 180 degrees in 2 different ranges! This makes it one of the most moveable joints, but also more likely to be injured. Did you know that shoulder pain accounts for around 16% of muscle and joint pain yearly in the US, and tends to become more common as we get older? In fact, after 40 years old the most common reasons why people have shoulder pain change from mostly trauma to begin including more arthritis and muscle tears.
The shoulder plays a huge part in the movements we do every day and shoulder pain can affect those activities to a large degree. Everything from lifting our kids and driving a car, to even getting dressed in the morning can become much more difficult, or even impossible. This becomes even more important for overhead athletes as well. Additionally, there are so many different causes of shoulder pain that self care is often painful, difficult and not very helpful. It only helps if you are working on the correct issue! This blog aims to try and clear up some of the many types of injury and how to best rehabilitate them.
Today, I will try to help explain common causes of shoulder pain and injury, the most common
missed causes, how we address YOUR shoulder pain, as well as some at home exercises and
stretches you can do to relieve your pain and tension. I have seen a lot of shoulder cases over
the years, and there are definitely patterns and commonality among several different types. I will
also share an example of a patient with a stubborn shoulder case and how we solved it for her.
Types of Shoulder Pain
There are many different types of shoulder pain because there are many muscles involved in moving the arm and shoulder as well as 2 joints involved. The two joints are the acromioclavicular joint (AC) and the glenohumeral joint (GH). The joints can be sprained, which happens sometimes with trauma or with some gym exercises like the bench press. They can also become arthritic over time due to too much movement/not enough stability.
Additionally, the muscles of the rotator cuff can be torn, inflamed, or unbalanced. The labrum or capsule around the joint itself can be inflamed or torn. The muscles in the neck, arm and upper back, as well as the chest can also also affect the shoulder. Nerves coming out of the neck and weaving around some of the previously mentioned joints and muscles can also be pinched, or impinged and cause pain as well. Additionally, due to the large range of motion of the shoulder, it is one of the more easily dislocated joints.
Pain also needs to be broken down into acute or chronic. Acute meaning relatively new, and chronic is defined as if you have had the pain for six months or more. So as you can see, there are a lot of potential ways to have pain that need to be ruled in and out to make sure the correct issue is addressed. Descriptions are also needed to help narrow down the source of the pain and save time, so you
are only treating the primary issue.
Common descriptions given of shoulder pain include pain that is worse at night, worse with movement, and radiates down the entire arm. It can be described as achy, dull, sharp, throbbing, burning, or radiating. The shoulder can click or grind with movement or lose strength in certain positions. It can also be stiff, sore, or even numb. Not everyone that has the same issue has the same symptoms, but there does tend to be patterns. For example, clicking and pain that is worse at night, is usually muscular in nature. Grinding pain may have an arthritic
component. Burning and shooting pain would be more likely with nerve involvement. Weakness needs to be screened out for nerve involvement or may be a tear in the tendon itself. There are even some organs that can refer to pain in the shoulders, such as the heart and gallbladder. If the original injury was traumatic it may be a rotator cuff tear, frozen shoulder, a labral tear, an AC joint sprain, or just a lack of balance of musculature due to a fall years ago. Of course if the pain seems to be referred from the heart or gallbladder or a full thickness
tendon tear, a referral is necessary.
Rotator cuff tears, frozen shoulder and various strains and sprains usually responded well to a combination of dry needling, soft tissue work, progressive movements and functional rehabilitation. Dry needling and soft tissue manipulation works on releasing knots and fascial tension in order to restore full mobility as well as significantly helps in reducing pain. Chiropractic adjustments aim to restore mobility to joints in the upper and mid back that may be contributing to a loss of mobility. Finally, and most importantly, functional rehab exercises are what retrain the proper motion once full mobility has been restored. This makes sure that the area is not vulnerable to future injury and that the pain does not return. It is really important to make sure the mobility is back prior to adding weight and resistance. You don’t want to work on strengthening a bad pattern or strengthening only a small portion of the range of motion. There are also a few often missed issues that commonly slow or delay progress.
Commonly Missed Culprits
These are several types of muscular causes of pain that I frequently see and a few that are a little harder to spot. Even when patients have already been seen by another provider, if they have not had the best results. These are the ones I check for first! These are several common culprits if I am seeing a patient that is not progressing as well as expected or has come from treatment elsewhere and not had great improvement. These sneaky additional causes of shoulder pain or lack of progress are:
• Jaw Clenching
• Rigid Scapula
• Prematurely Stopping Therapy
In the first two cases, the patient may not even have any jaw or shoulder blade pain….but they can really affect the tension and movement of the rest of the shoulder. Prematurely stopping therapy is where the progression of exercises was not completed all the way through to standing and full arm movements. If you have shoulder pain and are being treated, look out for these if you are not progressing. They may be the missing piece to resolving your pain.
If you have narrowed down your pain to a strain, tendonitis, or a lack of balance in the muscles, then there are several at home exercises and stretches that can be really helpful. The muscles of the pectoralis, supraspinatus, subscapularis, and infraspinatus can be released using a tennis or lacrosse ball at home and the wall. Just place the ball over the muscle and exert gentle pressure while moving a few inches to the right and left, up and down. For the subscapularis, it helps to cross the same side arm in front of your chest, so the scapula moves out of the way.
For reference, the ball would be in between the spine and the shoulder blade for subscapularis at the top of the shoulder blade for supraspinatus, and in the mid to lower shoulder blade and towards the armpit for infraspinatus and teres minor. This soft tissue work is most often described as a ‘good hurt’ and should not be too painful. Your arm movement and tension levels should be improved following the work.
How do we make sure we are on the right track AND progress quickly? At Integrated Health Solutions, each exam for a shoulder pain patient will have a mixture of range of motion, orthopedic tests, functional movement screens, as well as hands on checking to see what muscles and joints are involved. We want to know what you can and can’t do, and what is painful or feels better. We will be looking for patterns of movement to determine what needs to change for improvement. Treatment plans are explained in detail so the progression of exercises is understood and everyone is on the same page as far as where we should end up. Additionally, if the progress is not as expected we re-evaluate and send out for imaging or referral if needed. Our #1 goal is your pain-free return to full activity!
Patient exercises are advanced based on individual ability…so some people improve faster than others. There is no set time table and the exercises can be switched out if needed to accommodate disability or even the equipment you already have at home.
A good example of this type of progression is Linda, a recent shoulder patient at IHS.
Linda is a 20 year old female with a history of chronic shoulder pain. As a college athlete swimmer, she had already had extensive physical therapy including dry needling prior to becoming a patient. The shoulder pain had plagued her for years and was improved by prior treatment, but never resolved and would return within several months of stopping treatment. Her original cause was a nerve irritation in her back from an illness that caused the muscles in her upper back to tighten and affected her shoulder movement.
Based on our examination, Linda had already had a lot of great work done, but one important muscle had been totally overlooked. Her subscapularis, which is a muscle underneath the shoulder blade that attaches your shoulder blade to the upper arm. Linda’s was extremely tight and full of knots. She had great shoulder movement, but could barely move her shoulder blade at all. This lack of motion was causing her shoulder to have to move more than it should and take on additional strain. We worked on restoring her scapular movement with soft tissue work and dry needling her subscapularis. Next, we practiced exercises to add the shoulder blade movement to her shoulder movements, so she began using her arm in a more ideal way. Linda got stronger over the treatment plan and her shoulder pain went away. All the previous physical therapy was excellent, but she was never going to really fully improve without this missing piece.
As you can see that even though there are a myriad of different types of shoulder pain, if you can figure out what your primary cause is, it becomes increasingly likely that you find the right fix! The shoulder can be a complicated area to rehabilitate, but choosing the correct issue to focus on is essential for complete and fast progress. A provider that can help you isolate the issue and focuses on rehabilitation is invaluable in a fast and complete resolution. If you think you could benefit from help solving your shoulder pain, reach out to IHS! We have
Chiropractic offices in Fishers, Carmel, and Indianapolis.
Content Provided by Dr. Elizabeth Bouse
Sources:
https://www.aafp.org/pubs/afp/issues/2008/0215/p453.html
https://my.clevelandclinic.org/health/symptoms/25122-shoulder-pain
