Chronic shoulder pain or shoulder issues are a very common condition. Steroid injections, medication, exercise programs and Physical Therapy can be tried to address shoulder pain but what if pain persists and symptoms continue? Here are some tips to help determine the underlying cause of chronic shoulder pain and how to treat them. 

A common shoulder clinical pattern is posterior shoulder pain and tension with loss of horizontal adduction or bringing your arm across your throat. Infraspinatus trigger points and pain and weakness are present. Medial scapular border tension and loss of distraction of the shoulder blade occurs, and finally a second rib restriction and pain with upper thoracic stiffness is present. The pain pattern common for this is pain to the back of the shoulder and down the lateral arm. Patients with this condition will place their hand on the back of their shoulder and trapezius and slide it over the shoulder and down the side and back of the upper arm. This shoulder dyskinesia can cause pain with raising the arm, as well as with lifting weight, and also shoulder blade joint sounds with movement. Sleeping on the affected side is usually difficult and painful. If this problem persists then putting on clothing can be difficult as well. This can lead to shoulder impingement.

Symptoms to look for

• Shoulder joint sounds with movement
• Pain with reaching up or behind the back
• Difficulty putting on a jacket or bra
• Pain with sleeping on the side
• Changes to activities due to shoulder pain
• Continued shoulder pain with treatment

Impingement then is poor mechanics and a decreased space between the acromial process and the greater tuberosity of the humeral head. Every time you raise your arm you are ‘pinching’ the rotator cuff and biceps tendon. This will cause irritation and swelling, or inflammation. Chronic inflammation can weaken the soft tissue and cause damage and even tearing with a minor injury. A common injury to the rotator cuff in this condition is reaching into the backseat of your car, putting your rotator cuff in a compromised position, and injuring your rotator cuff when lifting a purse or bag.

Most rotator cuff injuries do not happen with a serious injury but progress over time.

Shoulder Screen

Testing for a Shoulder Dyskinesia or Scapular Humeral Dyskinesia

Have your client raise their arms to the ceiling. Look at the spacing between the neck and shoulder. Feel the scapular point or inferior angle for symmetry. If they are not the same then there is an alignment issue of the shoulder complex.

“One of these things is not like the other.”

Further testing reveals limited mobility to the joints as well as trigger points to the supporting muscles.

Look for scapular winging or one shoulder blade sticking out. Look to see if one shoulder is more rounded than the other. This can be an indicator of a shoulder dyskinesia.

Restore the alignment

You have determined that your car has an alignment issue. Your front end vibrates at higher speeds, the steering wheel pulls to the side, and you are noticing odd tread wear on your front tires. You bring your car into your mechanic and the advice you get is this; “drive faster, corner harder and aim for potholes.” I doubt if any of us has gotten this advice for our vehicle and yet this is the approach taken with most rehabilitation practitioners. They start exercising the shoulder!

Restore the alignment

When the underlying problem that has created the shoulder issue, a loss of glenohumeral mobility, a tight muscle, limited rib rotation creating tension, if this has been addressed then exercise or strengthening can occur. The only exercises that should start earlier are movement or control type exercises to reduce pain and tension.

Strengthening should never be first for a shoulder problem or impingement issue.

How to treat a chronic shoulder problem

Manual Medicine

Identify the restricted areas and restore motion through manual medicine techniques. Manual therapy interventions can effectively restore normal mechanics to the shoulder. 

Spinal Involvement

Check the neck for involvement. The upper cervical spine, as well as thoracic spine, are commonly involved with a shoulder impingement problem.

Trigger Point Dry Needling

Check for myofascial trigger points. Two common muscles that respond well to dry needling or trigger point injections are the levator scapula and the infraspinatus. The levator scapula has a strong attachment to the front of the transverse process of the atlas and can affect upper neck mechanics.

Reduce tension to the postural or tight muscles through dry needling, manual therapy and a home program of targeted soft tissue release.

This is the information that we give to our clients regarding trigger point dry needling.

Postural Corrective Exercises and restoring phasic muscle control

A common muscle that gets inhibited or weaker with a shoulder dyskinesia is the lower trapezius. Getting these muscles to fire help support scapular position and rhythm during arm motion. Addressing posture will reduce tension to supporting muscles and will relieve neural tension to the shoulder and arm nervous system.

Re-check that the alignment issue has resolved by doing the screening test.

Tips

Don’t start with exercises – restore the alignment first

Check the upper neck for involvement

Look for scapular ‘winging’

RE-check the shoulder screen for symmetry after treatment

Functional Diagnostic Ultrasound

A great screening tool is diagnostic ultrasound. We have found ultrasound imaging to closely match MRI findings in our clients over the years. This is a great way to alleviate fear and help guide treatment through imaging of the rotator cuff and biceps tendon. Assessment of humeral mechanics with active elevation is conducted to check for humeral depression from the acromial process. If this space is limited then impingement is likely.