Getting hands on with shoulders
Shoulder pain is a common complaint in private practice patients. The unique anatomy and range of motion of the glenohumeral joint can present a diagnostic challenge, but a proper clinical evaluation usually discloses the cause of the pain.
There are many different types of shoulder complaints. It is thought that shoulder pain is the third most common reported musculoskeletal condition in primary care. There are many different causes of shoulder pain, some of the most common cases include:
Disorders of the joints, tendons and muscles of the shoulder
According to the World Health Organisation
"Musculoskeletal conditions comprise more than 150 diagnoses that affect the locomotor system; that is, muscles, bones, joints and associated tissues such as tendons and ligaments, as listed in the International Classification of Diseases. They range from those that arise suddenly and are short-lived, such as fractures, sprains and strains, to lifelong conditions associated with ongoing pain and disability."
Musculoskeletal conditions are typically characterised by pain (often persistent) and limitations in mobility, dexterity and functional ability; reducing people’s ability to work and participate in social roles with associated impacts on mental wellbeing, and at a broader level impacts on the prosperity of communities.
The most common and disabling musculoskeletal conditions are osteoarthritis, back and neck pain, fractures associated with bone fragility, injuries and systemic inflammatory conditions such as rheumatoid arthritis.
An interesting statistic is that: Between one in three and one in five people (including children) live with a musculoskeletal pain condition.
The focus for my Blog post today is the shoulder, its movements and treatments.
We, as clinicians, need to see the patient in the same way a coach would train his or her athletes - in a method called: Whole, Part, Whole.
What does this mean?
This is a method of learning a skill in which the learner tries to perform the whole skill from time to time after practising parts of the skill, particularly those parts which are difficult.
When a patient walks into the practice complaining of shoulder pain, a thorough assessment should be conducted. We should take a comprehensive history, LISTENING to the patient and how they describe their shoulder and its movements, pain, limitations and exercise history. Now this is almost the whole picture.
Next, I would break down the entire system into parts, taking apart the whole movements, routine, daily activities and habits and then assess the movements of the shoulder via video analysis and EMG assessment (take a look at my last post on EMG for some more information about this).
The reason a video analysis is important, especially in slow motion, is to show the patient what we see as practitioners. It's easy to tell a patient the shoulder "isn't moving correctly" or "its weak in the rhomboids, and tight in traps", but once a patient sees it, there is a better understanding to what we are explaining.
After this, I explain the whole process of the history, movements and process to come in their rehabilitation.
WHOLE, PART, WHOLE. simple in its name, delicate in its execution.
Let me give you an example.
A male patient, Patient A , 33 years of age, (who has given consent for me to explain this over my blog) complained of neck spasms, irritation in the upper back and shoulder region, right side worse than left . Upon assessment and history taking we identified that Patient A's focus was mainly upper body training at the gym, solely focusing on anterior rotating muscles of the body (pecs, biceps, lats, core, upper traps) and no back work or posterior muscles of the body. He sat 75% of the day behind a desk or computer or specialised equipment without ever compensating for these hours by stretching or strengthening the opposite muscles.
With a video analysis this is what we saw in shoulder movements forward and to the side: (watch all movements of the shoulder blades)
Over 4 weeks we corrected the shoulder blade kinetics with focus on the smaller movers and stabilisers (remember we can't isolate the shoulder muscles in its entirety as seen by Ann Cools' research) so we work them in the best possible load, without allowing for the compensatory muscles to over-ride the sequential movements that are meant to happen - there is still loads of work to be done, but this is what 4 weeks of adjustments in daily activities, stretches and strengthening can do:
This is what the shoulder looks like now:
(see if you can see the difference)
With a shoulder assessment one should focus on:
1. A simple history,
2. shoulder examination (Examination of the shoulder should include inspection, palpation, evaluation of range of motion and provocative testing. In addition, a thorough sensorimotor examination of the upper extremity should be performed, and the neck and elbow should be evaluated to exclude other additional elements to the kinetic chain)
3. Video analysis
4. EMG Assessment of shoulder movers of the anterior and posterior chain
5. Manual muscles tests
Look at the shoulder and what its movements are, understand the patient and their habits and treat them with the entire system in front of you.
WHOLE, PART, WHOLE!