A large number of people suffer from shoulder pain . Our work in the Central Osteopathic Clinic Cambridge, working with a vast range of physical capabilities, and our athlete work in London, allows us to have very positive contact with such symptom sufferers. This is why we are one of the best osteopathy clinics in Cambridge.
In fact, shoulder pain (including shoulder impingement pain and frozen shoulder) is currently a common musculoskeletal illness, and the burden is most likely underestimated. Musculoskeletal illnesses are believed to generate some of the highest costs to society. Shoulder pain seems to cost more, with the longer the wait time for care and the more time that is taken off work, and when working costs increase, the more reduced the productivity can be.
Some of the most commonly ‘diagnosed’ issues leading to an episode (acute), or multiple episodes (chronic), of shoulder pain, with or without ‘swelling’ (filling of the shoulder joint and capsule or fluid around the joint area) are:- ‘frozen shoulder’ (adhesive capsulitis), functional shoulder instability, rotator cuff strain, ‘rotator cuff disorder’, shoulder impingement (impingement syndrome), biceps strain, motor control imbalances, tendonitis, ligament sprain, muscle strains, muscle spasms, over use syndromes, degeneration, arthritis, cartilage injury, ‘acromioclavicular sprain’, ‘bursitis’, ‘inflammation’, ‘shoulder pain’, ‘throwers shoulder’, ‘subluxed shoulder’, ‘wear and tear’, ‘anterior shoulder pain’, ‘posterior shoulder pain’, mechanical shoulder pain, shoulder stiffness, shoulder swelling, fluid on the shoulder, ‘subacromial shoulder pain’, ‘subacromial impingement’, glenohumeral arthritis, tendon sheath inflammation (tenosynovitis), thoracic outlet syndrome, ‘shoulder dislocation’.….The list goes on!
The quality of some of these diagnosis concepts, and the actual correlation to your pain, are even more fascinating!
How This May Affect People
When this doesn’t go well, it often leads to a very dissatisfying outcome. This can manifest itself as: deconditioning, disability development, depression, loss of confidence in yourself and your body, which ultimately often leads to a dependency on pain altering medications, and poorer physical health.
So, what are we to do? Are we to:- be immobile?, be mobile?, be active?, or minimally active?, train into pain (‘no pain no gain’)?, or train avoiding pain?, use medication management?, topical or oral?, use massage?, use mobilisation?, Osteopathy or chiropractic or physiotherapy?, use prescriptive exercise?, regular treatments or minimal treatments?, have imaging or not to have imaging?, surgery?, should we focus on structure or function?, or is it just age?!!!
I only started seeing Michael for less than a year but I must say he is one of the best ones I have consulted, for my neck and shoulder pain. His recommended strengthening exercises have improved my pain management, and he was always attentive to details such as my body responses after a couple of weeks of doing these exercises.
Our understanding of the shoulder, is still changing and evolving. Sometimes additional investigations are needed. However, for ‘non-specific shoulder pain’, they are rarely needed as a primary input into your assessment and treatment.Imaging was originally seen by most, as a tool to rule out pathology or disease states, and less to diagnose specific musculoskeletal causes. Often this was due to a poor correlation of images and symptoms. New imaging approaches have developed, and our dependency on them has increased! However, recent studies show that by performing a thorough clinical case history and physical examination you can often, very effectively decide if MRI or additional imaging or other investigations are needed. There are also recent studies that show that MR Imaging (MRI), may actually increase the patient’s likelihood of continuing in pain or disability status, and elongate their symptom picture. Then there are studies showing that degeneration changes, are just a part of function and use. These however, have no correlation with pain, or perceptions of illness, or illness behaviour i.e. age and degenerative changes have no clear causal link with pain.
MRI imaging of the shoulder maybe a little misleading, as healthy professional baseball pitchers, who are not injured and have no pain, have been found to have a high percentage of abnormal rotator cuff tendons and abnormal shoulder cartilage. This leads to misinterpretation and ‘can result in misdiagnoses’, which then may lead ‘to unnecessary or even harmful treatments’.
Study findings show that subacromial pain syndromes (shoulder impingement syndromes), are associated with central sensitisation, and may have an effect on surgical outcomes.
These findings coincide with findings from Shoulder pain sufferers, who may have central nervous system involvement, with widespread body sense alterations (somatosensory abnormalities), perhaps suggesting a central origin for their pain, and a predisposition to developing central sensitivity (nervous system sensitivity). These findings triggered the authors to call for more ‘dynamic methods’ of assessment.
Interestingly people with shoulder pain shift their weight, and seem to have difficulties balancing and maintaining postural stability.
What Can Help
Exercise therapy has been shown in research to reduce shoulder pain symptoms, and help restore normal daily activity.
Local shoulder treatment of manual therapy on the shoulder has been shown to help restore normal function of the shoulder, with more effect than if just doing stretches alone.
In fact, there is now a Cochrane review assessing studies, clearly showing that stretching does not have a positive effect on joint motion and muscle contracture.
Studies show that those slightly less active people, like an office worker, can also obtain effective pain relief from manual therapy, which is also useful to help with rehabilitation.
Even when there is a full thickness tear in the supraspinatus muscle (part of the rotator cuff), exercise therapy was successful at aiding improvements in joint motion and patient feedback, with increases in muscle strength and joint stability.
Subacromial impingement sufferers, have similar responses from exercise rehabilitation, as they would do with surgical intervention.
Then there are results suggesting that there is no clinically important difference in function and pain outcomes for patients who have surgical rotator cuff repair. Regardless of the integrity of the repair, the function and pain were similar. The only difference found was that strength was greater if the repair did not fail.
In the cases where surgery has already been performed, either of the shoulder joint or around / nearby the joint, exercise and manual therapy have been shown to be effective at reducing pain, and increasing the range of motion of the shoulder joint.
Additionally, it is possible to manage many shoulder issues, such as rotator cuff tears, without surgery, with high satisfaction levels and improvements in function. This is especially true in degenerative tissue changes, such as rotator cuff tendinopathies, partial thickness tears and small full thickness tears, which seem to actually respond better to exercise rehabilitation rather than surgery.
Whole Body Integration
Shoulder blade stability training can help shoulder joint stability. This shows that training of one part of the arm, and its links with the trunk, including muscle mass and motor control, can help the other joints in the rehabilitation process.
Then we can start to look at a more global pattern, and treatment plan.People with shoulder dysfunction, have less balance, and alterations in core control, compared to healthy individuals. Diminished core stability measurements correlate with the extent of shoulder dysfunction. This indicates that, balance and core stability training, may be a successful rehabilitation protocol for shoulder dysfunction.
Training the control of motion and stability, in the presence of change, plus training core stability, may help shoulder mechanics and normal shoulder function, in relationship with the body’s trunk.
If it is one shoulder or both shoulders; it does not matter, both presentations can be treated with osteopathy and dynamic exercise therapy effectively.
It does not matter whether the issue is of a primary or secondary origin, both will have significant improvement.
Perhaps this shows why whole body assessment and treatment, is reported anecdotally in clinic to be so effective. These positive effects from manual therapy and exercise, may be linked to the increasing body of evidence, that pain is a brain interpretation of data, and that the local structure itself, cannot consistently be linked with pain or general function.The point here is that there are many opinions and many solutions, to hip pain (femoro-acetabular pain). Perhaps some, in our opinion, are more rational than others and some statistically safer than others, and some more empowering than others.
Additionally, manual therapy by an osteopath including the use mobilization and manipulation, and prescription exercise therapy, are all safer than long, or even short term medication treatments, such as non-steroidal anti-inflammatory drugs (NSAIDs).
There are many opinions and many solutions, to shoulder pain (glenohumeral pain). Perhaps some, in our opinion, are more rational than others and some statistically safer than others, and some more empowering than others.
The NICE guideline for ‘shoulder pain’, includes the guidance to remain as active as normal, seek support and advice at a specialist clinic, for education, management advice, manual therapy including mobilisation and manipulation, mobilisation and soft tissue treatment, hydrotherapy application, increase in muscle strength and specialist exercise therapy for rehabilitation.
At Elementary Health we provide a seamlessly layered combination approach, of education and therapeutic application. This includes education of anatomy and pain theories, manual therapy, osteopathy, posture advice and training, lifestyle advice, hydrotherapy guidance, dietary overviews, and dynamic exercise therapy with motor control training rehabilitation. All of these work together to provide a uniquely structured approach, towards the aim of restoring your brain’s interpretation, or ‘mapping’ of your healthy functioning body, giving you back the control!
If there are any other questions, or, you wish to book a consultation with Michael Parr the consulting osteopath in Cambridge, based at Elementary Health. Please don’t hesitate to call or email.