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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.

Diagnosis

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?!!!

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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.

Investigations

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

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.

General Imaging

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.

Ultrasound

When assessing the prevalence of asymptomatic findings (findings in people who have no symptoms) from ultrasound imaging (sonography) of the shoulder. ‘Ultrasound showed subacromial-subdeltoid bursal thickening in 78% of the subjects, acromioclavicular joint osteoarthritis in 65%, supraspinatus tendinosis in 39%, subscapularis tendinosis in 25%, partial-thickness tear of the bursal side of the supraspinatus tendon in 22%, and posterior glenoid labral abnormality in 14% (7/51). All other findings had a prevalence of 10%’ or less.

Showing that ‘asymptomatic shoulder abnormalities were found in 96% of the subjects. The most common were subacromial-subdeltoid bursal thickening, acromioclavicular joint osteoarthritis, and supraspinatus tendinosis’.

Ultrasound findings should be interpreted closely with clinical findings to determine the cause of symptoms. As the imaging alone, seem to not be a viable assessment, as the false positive rates are just too high.

Likely why, diagnostic ultrasound as a work-up component, does not seem to influence diagnosis or recovery but does influence the choice of treatment modality.

Frozen Shoulder

The coracohumeral ligament (CHL) maybe shortened and thickened in a frozen shoulder. The CHL thickness in the patients with frozen shoulder is found to be significantly greater. MR Imaging is a satisfactory method for CHL depiction, and a thickened CHL is seen to be highly suggestive of frozen shoulder.

Labral Tears

There is a high prevalence of Superior Labral Tears Diagnosed by MRI in middle-aged patients with asymptomatic shoulders. Superior labral tears are diagnosed with high frequency using MRI in 45 to 60 year-old individuals with asymptomatic shoulders. ‘These shoulder MRI findings in middle-aged populations emphasize the need for supporting clinical judgment when making treatment decisions for this patient population’.

‘To avoid overtreatment, clinicians should ‘realize that superior labral tears diagnosed by MRI in individuals between the ages of 45 and 60 years may be normal age-related findings’.

Therefore, may not have any correlation to the presenting patients symptoms

Muscle Strain

When using ultrasound imagary, Tendinopathy was the most observed abnormality,  followed by calcification. The choice of treatment slightly differed between the ultrasound groups. Additionally, advise was the most common treatment approach regardless of clinical diagnosis.

Subacromial pain syndromes

‘Subacromial’ shoulder pain has traditionally been understood from a specific structural perspective, that is, bony and soft-tissue structures under the acromion impinging on subacromial structures.

Rotator Cuff Strain and Rotator Cuff Tear

A rotator cuff tear is the most common shoulder diagnosis in patients with shoulder problems.

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’.

Interestingly, ultrasound (ultrasonographicall) diagnosed partial thickness rotator cuff tears, by themselves are not linked with, and do not cause pain or weakness in the shoulder. The researchers concluded that ‘Most so-called articular-sided partial-thickness rotator cuff tears may not be pathologic tendon tears’.

When looking at the prevalence of symptomatic and asymptomatic (no symptoms) rotator cuff tears in the general population, using ultrasonography on bilateral shoulders (both shoulders) was performed in all the participants.

A surprisingly large 22.1% of people had full-thickness rotator cuff tears. The prevalence of a tear in each decade was 0% in the 20s to 40s, 10.7% in the 50s, 15.2% in the 60s, 26.5% in the 70s, and 36.6% in the 80s.

Symptomatic rotator cuff tears accounted for only 34.7% of all tears, while asymptomatic tears for 65.3%. The prevalence of asymptomatic rotator cuff tears was one-half of all tears in the 50s, whereas it accounted for two-thirds of those over the age of 60.

The study concluded from this that ‘the prevalence of rotator cuff tear in the general population was 22.1%, which increased with age. Asymptomatic tear was twice as common as symptomatic tear’.

 

Physical Assessment

Shoulder pain is the third most common reason a person may consult a physical therapist.

Physical assessment by a clinician is vital in all cases of shoulder pain. Study findings support a need for a comprehensive clinical examination including history and physical examination.

The glenohumeral joint is a complex anatomic structure commonly affected by injury such as tendinopathy and rotator cuff tears. To effectively assess and then treat shoulder pathologies, clinicians need to look at whole shoulder stability and function.

Subacromial pain syndromes

Sub-acromial impingement is not really impinging. ‘New findings challenge this dogma’ as the two groups that did not undergo sub-acromial decompression (SAD) reported similar outcomes to the group that did.

This means that ‘impingement’ does not adequately explain ‘subacromial’ pain and hence is not a valid diagnosis.

Furthermore, a diagnosis of ‘impingement’ might be unhelpful or even harmful given that such terminology and understanding can negatively impact on clinical outcomes, through enhanced fear avoidance and hence iatrogenic disability.

We should stop thinking about ‘subacromial’ pain from an ‘impingement’ perspective and consider alternative terms, as we still don’t fully understand the mechanism of pain (nocioception) generation.

The guidelines are to stop using the term impingement (shoulder subacromial impingement syndrome), and start appreciating that the humeral head and sub acromial structures often contact the acromial arch in pain free healthy human subjects.

Therefore it is becoming more common to refer to this form of pain as subacromial pain syndrome.

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.

Tendinopathy and Tendinitis

Rotator cuff tendinopathy has a multifactorial origin. The natural history of rotator cuff tendinopathy probably plays a significant role in the results in the long-term.

Motor control deficits associated with a rotator cuff tendinopathy have been found.

Frozen Shoulder

Frozen shoulder, also known as adhesive capsulitis, is a commonly diagnosed condition involving scapulohumeral pain and loss of motion. Our understanding the definition and diagnosis of this disease has slowly progressed. Diagnosis of this condition are often inaccurate. It is likely that the actual diagnosis is provided far more often than the true clinical presence.

Ligament Sprain

Shoulder physical functional performance can be assessed for stability, using closed kinetic chain upper extremity stability tests, with excellent reliability. It is worth noting that it is necessary to perform at least three sessions of assessment to obtain reliable data.

Differences in shoulder range of motion is a significant predictor for future episodes of shoulder injury. Strength tests in certain shoulder movements was found to be a significant predictor for future episodes of shoulder injury. The study found that reduced shoulder strength and changes in range of motion are risk factors for shoulder injury. Therefore, pre-season shoulder range of motion and strength can be used to identify athletes at risk of future shoulder injury.

Muscle Strain

Interestingly it seems that, higher pain intensity with physical tests is associated with a poor clinical outcome.

Shoulders are strong complex structures of ‘muscles within muscles’, in a co-ordination of 19 muscle segments within three shoulder muscles during isometric motor tasks.

‘Intra-muscular segments of the three shoulder muscles were coordinated to produce isometric force impulses around the shoulder joint and how muscle segment coordination was influenced by changes in movement direction, mechanical line of action and moment arm (ma).

The results of this investigation have suggested that the timing and intensity of each muscle segment’s activation was coordinated across muscles and influenced by the muscle segment’s moment arm and its mechanical line of action in relation to the intended direction of shoulder movement. Also, evidence that motor unit task groups were formed for individual motor tasks which comprise motor units from both adjacent and distant muscles.

Therefore, for any particular motor task, individual muscle segments can be functionally classified as prime mover, synergist or antagonist, and that the classifications are flexible from one movement to the next’.

Rotator Cuff Strain and Rotator Cuff Tear

‘Rotator cuff tears may be caused by intrinsic (biochemical) or extrinsic (physical) mechanisms, or a combination. They may also be classified as traumatic (acute) or non-traumatic (sub-acute)’.

Anatomic features defining the severity of atraumatic (non-traumatic) rotator cuff tears are not associated with the pain level.

Patient mental health may play an influential role in patient-reported pain and function in patients with full-thickness rotator cuff tears. As mental Health has a stronger association with patient-reported Shoulder Pain and Function than the tear size itself, in patients with full-thickness rotator cuff tears.

Partial-thickness rotator cuff tear-by itself, did not cause shoulder pain and muscle weakness. ‘Most so-called articular-sided partial-thickness rotator cuff tears may not be a pathologic tendon tear’.

What Can Help

Stretching

Shortness of the pectoralis minor (PM) muscle has in the past been hypothesised as a potential mechanism underlying ‘shoulder impingement syndrome’. Pectoralis minor stretches for 6 weeks have no effect on length of the muscle. Showing that intervention with static stretching alone has no effect on muscle length. Interestingly, taping methods may help more, facilitating greater improvement in pectoral muscle length than a stretching protocol alone. Perhaps this is indicating a stability issue, not a mobility issue?

Injections

Studies are not able to show a convincing benefit from hyaluronic acid injections compared with corticosteroid or placebo injections.

Review has been performed investigating the effect of corticosteroid injections on shoulder pain. For those relating to rotator cuff disease they concluded that there was a small benefit at 4 weeks for subacromial corticosteroid injections compared to placebo, but not compared to NSAID use. Finding that there is ‘little overall evidence to guide treatment. Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained. There is a need for further trials investigating the efficacy of corticosteroid injections for shoulder pain’.

This further study need has then been met, with the finding that ‘corticosteroid injections produced a significant reduction in pain in the short term (three to 12 weeks), but in the long term the placebo injection produced the best results’.  In the long term (followed up at 26 weeks), the placebo injection had a 21% reduction in pain compared to the corticosteroid injections’ 20% reduction.

Standard subacromial injections / injection therapy, has only a short term benefit. Ultrasound guided dual-target corticosteroid injection has been shown to be no more effective to reduce pain (no significant difference). The Shoulder Pain and Disability Index (SPADI) and the pain score (VAS) improvements after the first month. The standard injection had more patients reporting worsening pain within 1 day post injection. With dual-target injection, there was slight less pain introduced after the injection, and the affects seemed to last a little longer before symptoms rebounded / returned. As the dual-target injection patients had less rebounding pain at the 3-month follow-up.

One in three patients who undertake corticosteroid injection into the shoulder, developed delayed post-injection pain, known as a ‘flare phenomenon’. There is no benefit in this increased pain phenomenon, on outcomes, short term or long term.

Surgery

The best predictor of if a patient will have surgery, is ‘if they think they need surgery’ and their ‘perception of physical therapy’. It is not the size of the tear or the length of time the person has had the problem.

When treating sub-acromial pain syndrome, there was no differences in outcome between the two surgical groups at any time point. This finding suggests that the treatment effect is not due to the principal clinical justification for the surgery, which is the removal of bone, bursa, and soft tissue to relieve impingement on the underlying tendons during movement of the arm.

‘Surgical groups had better outcomes for shoulder pain and function compared with no treatment but this difference was not clinically important. Additionally, surgical decompression appeared to offer no extra benefit over arthroscopy only. The difference between the surgical groups and no treatment might be the result of, for instance, a placebo effect or postoperative physiotherapy. The findings question the value of this operation for these indications, and this should be communicated to patients during the shared treatment decision-making process.’

Pre-Surgical and Post-Surgical Rehabilitation

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.

Osteopathy and Manual Therapy

Osteopaths as, primary health professionals specialising in musculoskeletal disorders, are well equipped to both diagnose and manage conditions of the shoulder.

Osteopathy has research data that shows that shoulder pain is a common presenting issue, for people seeking osteopathic assistance, showing very positive outcomes and satisfaction levels.

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.

Physical Exercise Rehabilitation

Exercise therapy has been shown in research to reduce shoulder pain symptoms, and help restore normal daily activity. Among all the interventions, exercise probably exhibits the highest level of evidence.

Combination Therapy

A combined approach utilising manual therapy and exercise is recommended. This includes, manual therapy such as osteopathic treatment of the shoulder and exercise rehabilitation such as dynamic exercise therapy of the shoulder. Meta-analyses support that the combination of exercise with other treatments (manual therapy), with a trend toward better effectiveness than exercise alone.

 

Non-Specific Shoulder Pain

In non specific shoulder pain (NSSP) physical Exercise Rehabilitation improves shoulder pain and disability.

Tendinopathy and Tendinitis

Subacromial decompression in the treatment of rotator cuff tendinopathy has been assessed long term, with a follow-up of ten years.

Even though ‘the patients who underwent operative treatment had a stronger belief in recovery, which is likely to be surgical and the effect of placebo, the exercise group obtained similar results’.

Therefore ‘arthroscopic decompression is not recommended in the treatment of rotator cuff tendinopathy’.

Instead, ‘exercise programmes are the accepted first line treatment’. An ‘optimum exercise regime’, as ‘the most clinically and cost-effective conservative treatment for rotator cuff tendinopathy’.

Sub-Acromial Pain Syndromes

Subacromial impingement sufferers, have similar responses from exercise rehabilitation, as they would do with surgical intervention.

In another study, they interestingly found that, ‘Subacromial decompression surgery provided no important benefit compared with placebo surgery or exercise therapy, and probably carries a small risk of serious harms’.

The current literature most strongly supports the use of therapeutic exercise (exercise therapy) to strengthen the rotator cuff and scapular muscles and to ‘stretch’ the soft tissues of the anterior (front) and posterior (back) of the shoulder.

Therapeutic exercise appears to be more effective when combined with joint mobilization techniques focused on the shoulder and upper quarter.

Therapeutic exercise is recommended over surgical intervention for the first treatment option.

Rotator Cuff Strain and Rotator Cuff Tear

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.

Review of the initial management of complete rotator cuff tears identified studies demonstrating the successful conservative management with physiotherapy, with results of success ranging between 75% and 91% for full thickness non-traumatic tear.

The rotator cuff muscles work synergistically (together) and the capsule, the local ligaments and cuff of muscles, are all blended and not always seen as distinct individual structures. The supraspinatus and infraspinatus have a joint tendon function and can off load each other. These combination of structures means, one bit of one structure can be damaged and integrity of the area and the shoulder remains.

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.

Frozen Shoulder

There was an evaluatıon of the effectiveness of certain frozen shoulder treatments. Assessment of the treatments with interferential current, hot pack, ultrasound therapy, stretching, strengthening and range-of-motion exercises (strengthening with a Theraband in all directions and post-exercise proprioceptive neuromuscular facilitation techniques). Assessed by scales for pain, in addition to passive and active range of motion.

‘The combination of physical therapy, exercise, and manual techniques is effective in treating frozen shoulder. The location of the lesion in the right or left shoulder does not, in itself, affect the prognosis or treatment outcome’.

Ligament Sprain and Labral Tears

Multiple postures, positions and tests, is the best approach for maximal shoulder stability / activation. Helping optimal normalization for muscle activation. A series of positions for normalization procedures rather than a single exercise, will increase the likelihood of recruiting the highest activity in the scapulothoracic muscles, and optimal muscle activity.

Degeneration and Osteoarthritis

In chronic rotator cuff disease, greater improvements were apparent at follow-up, particularly in shoulder function and strength, suggesting that benefits with conservative methods of manual therapy, and active treatment may take longer to manifest.

Whole Body Integration

Psychological factors have been found to be associated with the outcome of physiotherapy for people with shoulder pain. ‘Psychological factors were consistently associated with patient-rated outcome’, whereas clinical examination findings associated with a specific structural diagnosis were not. Poor outcomes are associated with poor self-efficacy, also what has been shown to be relevant is the level of understanding, the number of co-morbidities (other illnesses and factors), and the duration of symptoms. Perhaps showing that people who believe that they are going to get better, do, and those who believe that they are not going to bet better, do not.

‘When assessing people with musculoskeletal shoulder pain, psychosocial and medical information should be considered’.

Central pain mechanisms, which is understood by some to be a central neurological change and neural restructuring, perhaps for more efficient recognition of pain (augmented pain transmission / central sensitisation), is seen in upper limb conditions, especially in the shoulder. However this is less commonly seen in the lower limbs, during pain episodes such as the knee pain and hip pain.

This is seen in patients with shoulder impingement syndrome, rotator cuff tendinopathy. The central nervous system (CNS) has an integral role in the pain experience.

If ‘patients had relatively high levels of central sensitisation pre-operatively, as indicated by higher levels of punctate hyperalgesia and/or referred pain, the outcome three months after subacromial decompression was significantly worse’.

This central neural change, can have a marked influence on central motor control. Alterations and deficiencies may increase over time, with the ‘cortical reorganization correlating with magnitude of pain in neuropathic pain syndromes’, ‘it could be more related to chronicity in the case of musculoskeletal disorders’.

Alterations in central motor representation increase over time in individuals with rotator cuff tendinopathy.

Individuals with rotator cuff tendinopathy present inter-hemispheric asymmetry of infraspinatus active motor threshold.

Chronicity of pain, but not its intensity, appears to be a factor related to lower excitability of infraspinatus representation.

Our understanding of the role central sensitization plays in the shoulder pain population is still in its infancy. However, central motor alteration should be considered in the rehabilitation process. The rationale to explain the favourable response to therapeutic exercises demonstrated by previous studies, is beginning to be applied more clinically.

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.

‘Scapular-setting exercises increase the subacromial space in patients with subacromial impingement syndrome’. ‘During scapular-setting exercises, activity of serratus anterior, middle trapezius, and lower trapezius was significantly greater than without scapula setting exercise’. Scapula-setting exercises seem to be ‘useful for increasing acromial space and scapula muscle activity in with subacromial impingement syndrome patients.’

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.

‘Impairment of one or more kinetic chain links can create dysfunctional biomechanical output leading to pain and/or injury’. ‘When deficits exist in the preceding links, they can negatively affect the shoulder’.

Whole kinetic chain training and shoulder rehabilitation that integrates the kinetic chain throughout the rehabilitation program, have been documented for some time. These ‘exercises in this approach are consistent with biomechanical models, apply biomechanical and motor control theory, and work toward sport specificity. The exercises are designed to stimulate weakened tissue by motion and force production in the adjacent kinetic link segments’.

‘Kinetic chain shoulder rehabilitation incorporates the kinetic link biomechanical model and proximal-to-distal motor-activation patterns with proprioceptive neuromuscular facilitation and closed kinetic chain exercise techniques. This approach focuses on movement patterns rather than isolated muscle exercises. Patterns sequentially use the leg, trunk, and scapular musculature to activate weakened shoulder musculature, gain active range of motion, and increase strength. The paradigm of kinetic chain shoulder rehabilitation suggests that functional movement patterns and closed kinetic chain exercises should be incorporated throughout the rehabilitation process’.

‘Rehabilitation of shoulder injuries should involve evaluation for and restoration of all kinetic chain deficits that may hinder kinetic chain function. Rehabilitation programs focused on eliminating kinetic chain deficits, and soreness should follow a proximal to distal rationale where lower extremity impairments are addressed in addition to the upper extremity impairments. A logical progression focusing on flexibility, strength, proprioception, and endurance with kinetic chain influence is recommended’.

In sports, all ‘non-time-loss shoulder injuries compromised primary skill, while some resulted in changes to throwing technique and fielding position. Thus shoulder injury, whether it results in time loss or not, potentially impacts match performance’. Indicating a need to assure of optimal motor control and therefore performance, with all forms of injury, regardless of the impact to time loss of the sport.

When looking at the functional characteristics of shoulder and hip range of motion (ROM) and isometric strength (ISO), in young athletes with and without upper extremity (UE) pain. Differences in shoulder and hip ROM and ISO exist between those who have upper extremity pain and those who do not. Therefore, findings suggest that both the upper and lower extremities should be considered when treating those with upper extremity pain.

In the sporting shoulder, shoulder and elbow kinematics, were assessed for velocity and accuracy, and pain change, looking at perceived fatigue and pain. The research found that people became progressively more fatigued, had more pain, and moved with a lower velocity, as movement cycle numbers increased. During this, knee flexion progressively increased with movement cycle numbers.

Hip-to-shoulder separation significantly decreased as movement numbers increased, with upper extremity kinematics remained unchanged. However, external rotation and total range of motion in the shoulder significantly increased.

On the basis of these results, ‘there is the potential that core strengthening and leg strengthening may be valuable adjuncts to prevent upper extremity injury’.

Post-treatment effects of a single treatment session with high-velocity thrust, which the study termed “manual physical therapy”, as an interventions at the cervicothoracic spine, thoracic spine and ribs was assessed. This manipulation was provided to patients with primary complaints of shoulder pain. The manipulation to the patients, demonstrated a reduction in shoulder pain, and a corresponding increase in shoulder range of motion. ‘These immediate post-treatment results suggest that thoracic and rib manipulative therapy is associated with improved shoulder pain and motion in patients with shoulder pain, and further these interventions support the concept of a regional interdependence between the thoracic spine, upper ribs, and shoulder’.

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).

The point here is that 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.

With all treatments, it’s important to get the diagnosis, advice, and treatment programme from people who are trained, skilled and prepared to aid your musculoskeletal needs.

 

Treatment Options

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!

Next Steps

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.

Cambridge Osteopathy
& Rehabilitation Clinic

8c Romsey Terrace
Cambridge
CB1 3NH