''An Osteopathic Treatment for Shoulder Pain''
Osteopath Gareth Milner
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The shoulder. It’s one of those joints that we need in life to work. It moves our arm in different directions so our hand can do what it needs to.
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As an Osteopath people consult us regularly with shoulder pain and dysfunction. Out of say 100 patients I would say around 10 present with pain in the muscles, tendons and ligaments especially. We will go into the anatomy and biomechanics of the shoulder in simple terms shortly, but a quick reminder. Ligaments connect bones to bones and provide joint stability preventing excessive movements. Tendons join the engines (the muscles) to the bone allowing the forces generated by muscle contraction to move the bone around the joint.
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What can cause Shoulder Pain?
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The obvious being accidents where a fall has happened directly onto the shoulder or where the arm has been stretched out to break the fall. Sporting accidents, especially on the rugby field are commonplace. Concerning repetitive strain, occupational hazards are an issue for the shoulder.
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Anyone who is raising their arm above shoulder level risks painful tendonitis. Jobs like Plasterers and Painters. Hairdressers with the constant shoulder flexion will fatigue the shoulder muscles like the Deltoids and Rotator Cuff. Even using a mouse for long periods can slowly but surely lead to shoulder pain and dysfunction. This would generally be precipitated by poor desk ergonomics like overuse of a laptop and mouse position too far from the keyboard.
I don’t want to scare you but if you have a history of high blood pressure, a family history of cardiovascular disease and you are of an age older than 60; this is not to say this can’t happen sooner; and you have left sided shoulder pain with no real onset or causation then it is best you get an ECG via your nearest A&E as yes … the start of a heart attack can refer pain to the left shoulder.
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Basic Shoulder Anatomy & Biomechanics
Like with what Osteopathic Solutions' UK and Malta Team (of Occupational Osteopaths) teach in our Manual Handling Instructor Assessor Courses where we qualify Instructors to prevent musculoskeletal disorders in the workplace including shoulder injuries … I will keep the anatomy oh so simple.
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The shoulder complex is composed of 3 bones, the shoulder blade (anatomically the scapula), the collar bone (anatomically the clavicle) and the upper arm bone (anatomically the humerus).
Of the 3 articular joints, the most commonly clinically that we see as an Osteopath is pain and dysfunction in the Glenohumeral Joint and the Acromioclavicular Joint. The Glenohumeral Joint (GH) or the true ‘shoulder’ joint has a greater mobility than any other joint in our body. This is why the GH Joint gets into such trouble.
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The Shoulder Complex can contribute as much as 180 degrees of upper arm elevation (shown in the image to the right).
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From an Osteopath’s clinical perspective, any mechanical dysfunction with associated muscle tension in the Thoracic Spine (the mid-back), especially from the levels of T1-T7 (see vertebral column and shoulder blade image below left that details in blue the T1-T12 levels of the Thoracic Spine), will lead to insufficient movement in shoulder blade when raising the arm to the side or the arm forward, which in turn places more of a movement burden on the GH and AC Joints. As we will see shortly in the Blog, Osteopathic Manipulative Techniques to the Thoracic Spine is default when treating a person with shoulder pain and dysfunction.
Let’s now look at what Shoulder injuries can happen. I won’t be delving into fractures from traumatic accidents as if you have fallen off a horse, your first port of call won’t be an Osteopath. After your bones have healed and are out of a cast or brace, Osteopathy is a necessary investment into your body, to improve the biomechanics of the shoulder movement, which in turn will reduce pain, and also to prevent long term osteoarthritis.
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Supraspinatus Tendonitis​
Pain is felt in the shoulder when raising your arm to your side or to your front. It is a inflammatory condition of the supraspinatus muscle which forms part of the Rotator Cuff (see image below left). Supraspinatus tendonitis can be very painful and is common when people have jobs that are repetitive in arm movement. As I say to all my patients, Osteopathic Treatment is part of a rehabilitative strategy. People need to practise daily their prescribed exercises as well as remove certain bad habits that are supporting the pain and dysfunction.
A shoulder can be slow and somewhat tricky to get better, let alone when it is hampered by a person’s lack of self-help. At the end of this Blog after the detailed but simple description of the Osteopathic Treatment, I will present Rehabilitative Exercises you can do every day to self-help your shoulder to one that is pain-free and functions.
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Biceps Rupture
With regards to Manual Handling a rupture of the biceps can happen when lifting a load that is too heavy for your capability, whether in a single person lift or a team lift. Contact sports including rugby can cause this injury. The biceps tendon comes off its bony attachment, leading to bruising (shown in the photo to the right), pain and dysfunction in shoulder and elbow movements.
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Frozen Shoulder
Frozen Shoulder (clinically Adhesive Capsulitis shown in the below image) is exactly what it says on the tin, the shoulder is frozen and stiff in all ranges of motion. Most people who present with this debilitation injury have a history of trauma and/ or occupations that physically strenuous on the shoulder soft tissue structures. With a Frozen Shoulder, rehabilitation is long even with weekly Osteopathic consultations. But nonetheless Osteopathy supported with good life practices, healthy nutrition and a self-help daily exercise rehabilitation routine can beat this painful condition.
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Shoulder Complex Osteoarthritis
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The most common joint of the shoulder complex to suffer the wear and tear process (of osteoarthritis) is the Acromioclavicular Joint (AC). People with jobs that involve repetitive arm use, especially with raising the arm high like for Painters and Hairdressers, osteoarthritis of the the Acromioclavicular Joint would be common. It is rare to have osteoarthritis in both the left and the right Acromioclavicular Joint. Pain is experienced even at rest in a majorly arthritic joint. Pain will be increased for any shoulder movement. Physical Therapy is essential to improve shoulder joint mobility and reduce pain, however surgery may be need to remove bony growths around the joint that may be pushing on soft structures like the rotator cuff’s supraspinatus.
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The Glenohumeral Joint (GH) or the true ‘shoulder’ joint can suffer Osteoarthritis (pictured far right) which generally would only happen after a history of shoulder dislocation from a trauma.
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The Sternoclavicular (SC) Joint can also suffer Osteoarthritis and again would be precipitated by an accident being notably a fracture to the collar bone.
Osteopathic Principles
Osteopathy first and foremost is NOT a joint pain therapy. As we are Manual Therapists using hands-on manipulation techniques that affect the musculoskeletal system it is easy to think we solely were put on this planet to help alleviate people’s aches and pains.
Osteopathic principles are treating the patient as a whole, restoring alignment to the spine and peripheral skeletal system (i.e. the arms and legs), thus placing their body in a better level of biomechanic and neurological function, allowing the patient’s physiology to bring them from dis-ease to one of ease.
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With regards to our manipulative techniques, our aim is reduce muscle and joint strains allowing a more functional range of motion in the joint. With regards to the shoulder we are educating the shoulder to have improved flexion, extension, internal and external rotation, abduction and adduction as well as shoulder blade protraction and retraction, and elevation and depression (see photos to the left).
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​As touched upon in my other Blogs on Back Pain, Neck Pain and Knee Pain we use a range of manipulative techniques that affect a person’s physiology on a variety of crucial levels including biomechanical, neurological (nervous system), endocrinological (hormone system) and pychological.
Techniques include muscle soft tissue stretching and kneading, articulation with rhythmic joint movement, strong neuromuscular technique using thumb or elbow pressure, high velocity thrust techniques, visceral techniques to improve function of your thorax and abdominal organs, subtle but powerful cranio-sacral/ involuntary mechanism release techniques (I will elaborate on this later in the Blog).
Essay 33 - Grow the Osteopathic Profession ... from Sorry! We're Closed
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Here's an extract ...
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Osteopaths qualify through a 4 year BSc degree in Osteopathy and in the UK (only) are registered with the general osteopathic council (gosc). You can view many quality Videos on YouTube of Osteopaths and Chiropractors (remember these Professions are the same) perform manual techniques. I will briefly go into the types of techniques we use to encourage the body, via the musculoskeletal system, to heal itself.
Patient Presentation
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Following a thorough Case History including their presenting complaint and their general Medical History the Osteopath conducts a Physical Assessment. If for example the patient presents with a medical condition like high blood pressure the Osteopath will check their pulse rate and their blood pressure.
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As with every Patient the Osteopath will observe their total body posture from the rear, the sides and the front looking for any obvious signs of disease and pathology, biomechanical asymmetries, spinal curves, pelvic levels, weight bearing et cetera.​ With the shoulder presentation the Osteopath will observe the muscle size around the shoulder looking for possible decrease in muscle bulk following injury.
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Depending on the onset of the injury the Osteopath will observe how the patient holds their shoulder complex for example if the patient has had a trauma and fallen onto the shoulder they may have fractured (broken) their collar bone and/ or dislocated their shoulder (GH) joint. ​As pain in the shoulder area can be referred from the neck, if the patient presents with neck pain as well as pain down the arm into the hand, pins and needles in the arm or fingers and possible arm and hand weakness in grip then a neck neurological assessment is indicated. ​Old fashioned neurological tests work taking the reflexes, assessing arm and hand muscle power as well as testing sensation across the arm and hand. Orthopaedic tests like neck compression also give the Osteopath more information so they can formulate their diagnosis.
If there are no neurological symptoms coming from the neck then the Osteopath will feel (palpate) the soft tissues of the shoulder complex including the muscles, joints, tendons and ligaments feeling for points of tenderness and pain as well as swelling and fibrous ‘ropey’ scar tissue caused by the time length of the injury.
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The Osteopath then instructs the patient to perform active movements of the shoulder, with the Osteopath taking their clinical notes on the ranges and limits of shoulder motion.
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Then the Osteopath will have the patient sit up on the clinic bench and the passive range of motion of the shoulder complex will be assessed with the Osteopath moving the shoulder in its normal ranges of motion, again assessing range and limit of motion as well as if any pain is elicited.
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Muscles tests and classic Orthopaedical tests may also be conducted in order for the Osteopath to formulate their diagnosis of the injury, the treatment plan as well giving the patient a prognosis on how many treatments may be needed, in order to bring their shoulder to a more comfortable state, with the intention to restore the shoulder to full function with zero pain.
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Osteopathic Manipulative Treatment for Shoulder Pain & Dysfunction
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The following Osteopathic Manipulative Techniques are a range of techniques that we would apply to a patient. In one Consultation we would not perform all these techniques but I present them as you the reader, can gain an in depth understanding of how we clinically treat the patient who presents with shoulder pain and dysfunction.
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Soft Tissue Techniques
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One of the main differences between an Osteopath and a Chiropractor is that we spend more time treating the soft tissues. The muscles, tendons and ligaments. That is not to say we don’t perform High Velocity Thrust (HVT) techniques, we do. Our Therapy founded HVTs. Chiropractic was founded by a student of Andrew Taylor Still, our founding Father of Osteopathy.
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Therefore commonly for shoulder dysfunction we will start by preparing the joints for mobilisation and manipulation, by releasing the muscle strain with soft tissue release techniques using our hands and thumbs. The rotator cuff muscles, the upper fibres of the trapezius, the latisimmus dorsi, the deltoids, the biceps and the pectorals are all target muscles for elongating, removing inelastic scar tissue. From the Clinical Assessment the Osteopath will decide which muscles need direct soft tissue treatment. Of course as there is an injury, this can be painful to receive. However stimulating the body’s reparative physiology is what us Osteopaths do in order to help the patient recover.
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Soft tissue release can take other forms. A more recent development in the Physical Therapy World has been the development of Muscle Energy Techniques (MET), which uses contraction of the muscle and then relaxation, with a Therapist applied stretch to elongate the muscle as well as reduce the pain causing tension. View the gallery of photos with descriptions to the …
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Releasing the connecting fascia is also very effective at restoring optimal shoulder complex alignment and biomechanic function. Using our highly developed sense of touch, Osteopaths feel the involuntary movements that occur across our body. By feeling these physical strains and movements, we can gently release strain in the musculoskeletal system. These techniques are closely linked with Craniosacral Osteopathy, which focuses on releasing the cranial bones and pelvic sacrum again using the involuntary mechanism.
As detailed in the video … articulation of the shoulder complex is an important part to rehabilitate the injured joint and its soft tissues. Articulation supports stimulation of blood flood, release of tight muscles, fascia (the connective tissues), tendons and ligaments. Improving the blood flow will help bring the builders in to reconstruct the damaged tissues using protein gained from our food. Having excellent nutrition eating lots of fruit and vegetables, fish and lean meat and supplementing on oils such as flax seed oil and Omega 3-6-9s are also key parts of the rehabilitative process. As I say to all my patients Osteopathic Treatment is part of the process. Self-help is a must.
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​High Velocity Thrust techniques. The techniques that in the spine make the audible crack sound. As I have detailed in my Blogs about Osteopathic Treatment of Back Pain and Neck Pain … safe techniques in the right hands. A 4 year Degree Qualified Osteopath’s hands. At the European School of Osteopathy we were taught High Velocity Thrust techniques for the upper extremity and lower extremity. I personally practise them in the wrist, elbow, hip, ankle and foot; but with the knee and the shoulder, because they always have tissue damage and inflammation especially in the ligaments, I tend to avoid High Velocity Thrusts to the Shoulder. They can of course help with shoulder dysfunction. But for the patient, they are not comfortable and there has always got to be a ‘patient experience’ part of clinical treatment, whatever Therapy that is.
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Electrotherapy has its place in a modern Clinic. Ultrasound is especially useful in treating shoulder tendonitis and bursitis. TENS and Interferential are especially useful with chronic conditions like Frozen Shoulder at the start of a session as this will allow the Osteopath to apply articulation techniques to the shoulder complex which support the breakdown of scar tissue.
Self-Rehabilitation
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The following are key to supporting your Osteopath in your rehabilitation:
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Physical rest
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Cutting out unnecessary manual handling tasks at home & at work
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Drinking 2-3 litres a day of pure water, helping to improve blood flow & repair
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Eating a nutritious diet full of protein, natural vitamins & minerals, & Essential Fatty Acids (EFAs) derived from fresh fish especially
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Supplementing with Fish Oil & Flax Seed Oil for EFAs
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A daily 20-30 minutes Stretching and Pilates routine
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Weekly Cardiovascular Exercise to support a healthy weight & good spinal posture
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A light weight gym routine focusing on cable machines
For a broad range of Stretching, Foam Roller, Theraband and Pilates Exercises which improve whole body biomechanics and therefore shoulder function click here.
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The following Cable Exercises that I demonstrate should only be performed after the acute phase of shoulder pain has reduced following at least 4 Osteopathic treatments in a 3-4 week period. These exercises support shoulder strength helping to grow muscles that have lost size with injury to the joint and surrounding soft tissues.
​As mentioned earlier, as us Osteopaths are more patient holistic practitioners, even in Consultation 1 we will be addressing biomechanic dysfunction in the neck and/ or thoracic spine. As the diaphragm receives nerves from the mid-neck spinal cord and the shoulder muscles receive their nerve supply from the mid to lower neck spinal cord, the diaphragm is also regularly treated and released when patients present with shoulder pain. There is not just mechanical and fascial links with the shoulder, there is a nervous system link. Release the shoulder only, generally the prognosis is slower. Improve biomechanics of the neck, mid-back, the shoulder blade, the diaphragm and even the pelvis and the prognosis is better. That’s Osteopathy, and that’s why it’s the clinical Therapy of choice for Shoulder pain and dysfunction.
The following exercises help the shoulder blade and thoracic spine function.
And there you have it. Shoulder pain and dysfunction … say goodbye to it.
A message from the Author of
Sorry We're Closed ... Gareth Milner
I have written Sorry! We’re Closed for Business Owners who make continual life sacrifices. Those Business Owners who bust a gut to make their Business profitable and positive for all involved.
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I have written Sorry! We’re Closed for Health & Safety Professionals who are serious about lifelong learning. Those that want to sincerely help people. Those that have ambition for Professional development and a better salary.
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But I have also written this Book to prevent normal people, who work hard in their employment, to go home with a body that doesn’t hurt. To go home with a body that will allow them to play their favourite sports or partake in their most loved hobbies. A lot of the time you need a pain and injury free body for this.
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I wrote Sorry! We’re Closed as I have passion to rid the UK of musculoskeletal disorders, not just the ones that hurt a little now and then, but the ones that ruin lives. I should know. I had the misfortune of suffering a serious neck injury at 24 years old which ended my Osteopathy career when it had just started.
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Of course Sorry! We’re Closed is a Business Book. However as I have written it with a solid dose of passion; have put my storytelling hat on, both fictional and true to my life; I teach you something new, well actually a lot of new; deliver Jaw-Dropping moments like in Essay 35 ‘Call on Me ... Call on Me!’; permeate with humour whilst delivering repeated Expert content … and with this Sorry! We’re Closed is a Book you can take to read in a coffee shop on a weekend morning (like Giovanni Bruno), at the park, on the plane to your holidays … it is a Book that will entertain, make you laugh and educate at the same time.
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Supported by Emma Farrell’s remarkable illustrations, I am confident we have delivered a Business Book, and not forgetting a past-time Book ... that is emotional, novel and memorable. Enjoy the read.’
