Many osteopaths seem to find the shoulder complex a daunting part of the body to work on due to its complexity and wide range of potential problems. As an osteopath working in Finchley I see shoulder problems on a regular basis and actually find them really interesting! With such a diverse population, North Finchley has a complete mixture of people from elderly to athletes making each shoulder presentation completely different and equally challenging!
The shoulder joint is a complicated but interesting part of the body. It is made up of two bones; the Scapula (the shoulder blade) and the Humerus (the upper arm bone) and forms a “ball and socket” joint. To the right you can see a picture of a right shoulder blade, viewed from the back and from the side..
The socket is called the Glenoid Fossa and the “ball” is called the Head of the Humerus. Therefore the joint is known as the Glenohumeral Joint (GH). Ball and socket joints are the largest joints in the body and have the ability to move in all directions due to their shape. The hip joint is also a ball and socket joint but it has a much deeper “socket”, giving it more stability and less range of motion than the shoulder. The shoulder sacrifices the stability of the hip joint for greater range of motion.
Given that the shoulder has such a large range of motion there needs to be a large number of muscles that cross the joint. There are 9 muscles crossing the GH joint, which means that there is plenty that can go wrong! Like with any part of the body there are the common conditions and the not so common conditions both of which we will touch on here. Below you can see a complete upper limb with the scapula and humerus together.
Structural Shoulder Problems
In general there are three levels that can cause pain in the shoulder (but often more than one level will be affected); 1) the joint itself, 2) the capsule, ligaments and tendons, and 3) the muscles.
At the joint level
Osteoarthritis is a degenerative condition of the articular surfaces (the layers of cartilage that slide over each other) of the joint usually due to some form of overuse or trauma. As the joint wears away the protective space between the joint becomes reduced so during movement the bones rub against each other causing pain. The picture below shows a X-Ray of a normal GH joint compared with an arthritic shoulder. The picture on the left is the normal joint and the one on the right is the arthritic joint.
Osteoarthritis is characterised by stiffness, particularly in the morning, and pain in the joint with reduced ranges of movement. There is no way of reversing the damage to the cartilage but there are steps you can take to help prevent further degeneration. This includes exercise, good nutrition and physical therapy.
With the shoulder joint capsule being so shallow it doesn’t take much force to dislocate the joint. Dislocation is where the joint is taken past its anatomical range of motion (further than its structure allows it to go), making it “pop” out and remain in a different place. This usually happens with some king of external force or trauma such as a fall or a rugby tackle with the arm positioned in a vulnerable position. For some people this is a regular occurrence, with the joint dislocating and relocation on its own. For others it may only happen the once but when it does it is extremely painful.
Dislocations should be realigned by a professional, usually a doctor or surgeon in a hospital so they can test for nerve damage or blood vessel damage. The Axillary nerve is the most likely structure to be damaged during a dislocation or relocation but on occasions the Axillary artery can be compressed. After the relocation of the joint the clinician will test for both blood supply and nerve damage.
Capsule, Ligaments and Tendons
Frozen Shoulder/Adhesive Capsulitis
The terms Frozen shoulder and Adhesive Capsulitis are both words for the same condition, but adhesive capsulitis is the more scientifically named of the two. This is a fairly common condition affecting 3-5% of the population with females being the most susceptible.
This condition also seems to be more prone in those with diabetes and females post menopause. The theory for the higher incidence in diabetes sufferers seems to be related to the higher concentration of blood sugar changing the structure of the collagen that makes up the joint capsule.
The progression is gradual and can be divided into stages; Freezing, Frozen and Thawing.
Stage 1- Freezing
Freezing is the stage where pain and inflammation are causing the shoulder to remain immobile and gradually stiffen, reducing the full range of motion at the GH joint. The Freezing stage can take between 1 and 8 months if left untreated.
Stage 2- Frozen
When the shoulder becomes “frozen” the range of motion is severely reduced compared to normal and the shoulder remains painful, especially at night. Normal activities may prove to be extremely difficult and painful such as putting a jumper on, doing up a bra clip or combing your hair. The Frozen stage can last 9 to 16 months if left untreated.
Stage 3- Thawing
Thawing may take up to 40 months for the shoulder to return to normal without treatment. Without treatment the shoulder may not return to its previous full range of motion.
The exact causes of frozen shoulder are not fully understood but the general consensus is that there is an initial injury or “tweak” causing pain followed by muscle spasm which causes you to restrict your movement to avoid pain. Inflammation around the area may cause the joint capsule to become inflamed and thickened causing restriction in movement.
Tendonitis can occur anywhere in the body that has a muscle attachment. Some tendonitis presentations are more common than others and the shoulder happens to be one of the most common body parts that get affected. Tendonitis is the inflammation of a tendon. Tendons are the white structures that attach your muscles to the bones.
There are actually 2 tendons in the shoulder region that are very commonly affected; The long head of the Biceps tendon, and the Supraspinatus tendon, both of which you can see below.
These tendons become inflamed primarily due to overuse. The supraspinatus is probably the most common out of the two based on what we see presenting to the clinic. The supraspinatus is usually irritated during sports such as bowling in cricket, barbell bench press and even cycling.
With a supraspinatus tendonitis there is often a classic painful arc where there is pain in the middle third of raising the arm up from the side. This is one of the diagnostic tests we use in practice.
Similar to the supraspinatus, bicep tendonitis occurs in repetitive movements, particularly sports such as tennis, boxing and weight lifting.
Labral tears usually occur in young people following impact through a sporting injury or a fall onto the shoulder. Labral tears are also associated with dislocations as mentioned earlier.
There are different locations on the Glenoid Labrum that tears can happen depending on the mechanism of injury and can be diagnosed using MRI or CT scans.
The symptoms of a labral tear include; Pain; a feeling of instability; locking, popping or grinding; a decreased range of motion and sometimes a loss of strength.
The rotator cuff muscles are the most common muscles injured in and around the shoulder. Even when they are not injured, it is almost certain that they will be tighter than they should be.
The rotator cuff is made of 4 muscles;
- Teres Major & Minor
Injuries in the rotator cuff tend to occur due to incorrect training or constantly doing repetitive movements like throwing or even hoovering. If they are not injured then they will become shortened over time due to poor posture especially in those who work at a desk. The arms are in the same downward position for many hours every day without much, if any, overhead reaching or pulling. Therefore over time the rotator cuff muscles lose their elasticity and become shortened.
The most common muscle injured in the rotator cuff is the Supraspinatus, as mentioned earlier.
Ischaemic Muscle Changes
Think of muscles like a sponge and blood like water. When a muscle is relaxed and loose, blood will be able to flow through easily, much like a sponge being able to absorb water easily. But when a muscle becomes injured it will often spasm to protect it and the joint from further injury. This tightening forces the blood away and prevents circulation of fresh blood; think of it like you are squeezing a sponge under running water.
This lack of blood is called ischaemia and if this continues, the cells of the muscle tissue start to die becoming rigid and turning into a scar like structure.
Fibrosis is the formation of scar tissue within muscle tissue after a period of damage. The scar tissue forms in the damaged space to allow new muscle tissue to attach to it. As more and more fibrous tissue is formed there becomes less space for contractile muscle tissue to form eventually causing the muscle to become progressively weaker. In order for the fibrosis to be reduced it needs to be broken down by deep tissue techniques to allow blood to circulate better and allow the reformation of new muscle tissue.
Rheumatic and Referred
Polymyalgia Rheumatica (PMR)
Polymyalgia Rheumatica is not very commonly seen in osteopathic practice compared with the usual muscular type issues. The most likely scenario is that someone will present with the symptoms not knowing about what it could be.
Polymyalgia Rheumatica is a systemic inflammatory disease which can cause a sudden onset of pain and stiffness in the shoulders and neck, and also the hips and lower back. The term Polymyalgia comes from the Greek “pain in many muscles”. PMR is two times more common in females than males and usually occurs in people around 70 years old although anyone over 50 can develop this problem and may be associated with an inflammatory condition called Temporal Arteritis, a potentially dangerous condition which causes inflammation of the blood vessels in the face.
Symptoms of PMR include pain in the hips, low back, shoulders and neck; fatigue and general feeling of unwellness and anaemia.
The treatment for PMR is usually Corticosteroids but it is also recommended to exercise and eat an anti-inflammatory diet.
Sometimes pain can be experienced in the shoulders but may not actually be due to any damage in or around the area. It may actually be pain referred from somewhere else in the body, usually an organ; much like pain in the jaw or down the left arm when someone experiences a heart attack.
Pain in the right shoulder may be a referred pain from an inflamed liver or gallbladder, which could also explain why it is reported that frozen shoulders respond well to performing a liver and gallbladder flush.
How can we help you at Precision Wellbeing?
Our osteopath will thoroughly assess you, taking into consideration your lifestyle, causing factors, predisposing factors and maintaining factors to build up a picture of the exact problem. Our aim will be to help you regain the normal pain free function of your shoulder using many specific hands on techniques and advise you what to do in between treatments, whether that is in the form of exercises, hot or cold packs or some other advice.
One thing you can be sure of is that we will do everything we can to get you better as soon as we can! So why don’t you give us a call on 0203 356 7060 or
Click here to book an appointment online.