Shoulder Pain and Shoulder Injuries

Having pain in any joint limits what you want and love to do, but when you have shoulder pain and shoulder injuries you have to give up a whole lot more.  Shoulder injuries affect us all and as we age the rate of injury goes up.  Surgery is feared and usually the first thing that most people think of.  The great news is that the majority of shoulder injuries can be successfully treated with conservative care.  This page will discuss the most common injuries we see in the office, what they are all about and how we successfully treat shoulder pain and shoulder injuries.

AC Joint Sprain(Acromial Clavicular)

The acromioclavicular joint (AKA AC joint) is the joint between the clavicle and shoulder blade. The joint is held up by four ligaments (superior, inferior, anterior, and posterior AC ligaments) which protect the clavicle from excessive movement in any direction.  AC joint sprains come from a fall or trauma, like a lift gone wrong.   If you have sprained this joint it will limit how stable you feel in your shoulder and you will often notice pain with specific movements.   AC joint injuries are graded on a scale: 

• Grade 1: mild, unseparated sprain of the AC ligaments with no disruption of the coracoclavicular ligaments.
• Grade 2- complete disruption of the AC ligaments with joint separation (less than 4 mm or 40% difference) and sprained but intact coracoclavicular ligaments.
• Grade 3- complete disruption of AC and coracoclavicular ligaments with joint separation and inferior displacement of the shoulder complex.

How does an AC sprain happen?

AC sprains most commonly occur following a fall onto the top of the shoulder with the arm close to your side (adducted) (2). This force on the outside of the arm causes the acromion to separate from the clavicle.  We see it most commonly with seat belt injuries during a car accident and in contact sports when a player lands on an outstretched arm.  AC joint injuries are responsible for 40-50% of all athletic shoulder injuries (3). 

Do you have an AC joint sprain?

• The classic presentation involves pain and swelling on the top of the shoulder following a recent trauma. Pain, swelling, and/or bruising initially is over the entire shoulder region, but as swelling decreases, it becomes more localized to the AC joint region.
• Specific movements cause pain & limited shoulder mobility
• Rolling on the side in bed is aggravating
• Pinpoint tenderness over the AC joint
• Bulge in the shoulder
• Elevated clavicle

Do you need imaging for an AC joint sprain?

In most cases of sprains and strains, you will not need additional imaging.  X-rays rule out fracture and that can also be accomplished through a thorough examination of the injury in most cases.  During your consultation and examination, your chiropractor will evaluate the injury and determine if imaging is appropriate for you.  In some cases, MRI can be a useful tool to determine if there is a need for surgical repair but in nearly all cases surgery is considered not necessary for recovery.

How can a chiropractor help with an AC joint sprain?

A conservative approach is typically the primary method used for managing Grade I & II AC joint sprains (5). The initial phases of injury include the PEACE & LOVE approach to soft tissue injury. This is where we rest the joint and give it some time to heal, to try to decrease pain & inflammation.  Everyone responds a little differently to this kind of trauma. The goal is safe and painless movement as quickly as possible to aid in recovery. The middle phase of care typically involves mobilization and gentle adjustments (if needed). This phase starts the strengthening process and gets you on the road to recovery.  Our approach to treating an AC joint sprain depends on where you’re at in the healing or rehab process.

Treating an AC joint sprain in the first 2 weeks:

• Deep Tissue Laser Therapy– This is a great tool we have to help with the initial phase of healing when it comes to decreasing pain & inflammation, as well as speeding up your healing process
• Dynamic Tape-Using supportive taping we can assist your ranges of motion and give the tissues a break from their normal activity without overly restricting your mobility.

Middle Phase of Injury:

• Mobilizations and Adjustments-These techniques allow your chiropractor to help the joint return to its normal positions and improve its natural pain-free range of motion.  All hands-on techniques during this phase are dependent on pain and it helps us determine when you are ready for this therapy.
• Light weight resistance activity-it is important to use the pain response to help determine when you are ready for this but, using resistance bands and body weight through your natural ranges of motion will help you recover your full mobility and reduce pain more quickly.

Final Phase of Injury:

• Strengthening- exercises in a controlled environment will be demonstrated and then performed to return the shoulder to pre-injury status. Starting easier and progressing to more difficult as your shoulder begins to strengthen.

 

 

Source

1. Rockwood CJ, Williams G, Young D. Disorders of the acromioclavicular joint. In: Rockwood CJ, Matsen FA III, editors. The shoulder. 2nd edition. Philadelphia: WB Saunders; 1998. p. 483–553.
2. https://www.brighamandwomens.org/
3. https://www.sciencedirect.com/science/article/abs/pii/S0031940605611261
4. https://journals.sagepub.com/doi/abs/10.1177/036354657800600402?journalCode=ajsb&
5. Rockwood, C. A., and D. P. Green. “Injuries to the acromioclavicular joint. Fractures in adults.” (1984): 860-891.
6. https://www.sciencedirect.com/science/article/abs/pii/S003058980800028X

Shoulder Impingement Syndrome

Impingement syndrome is the most common disorder of the shoulder, nearly 60% of office visits for shoulder pain(1). Historically it has been believed that impingements happen when the tendons inflame and do not have enough room to move through the narrow spaces in the shoulder.  What research is showing us is that the shoulder naturally accommodates the tendons in the shoulder but when inflammation in those tendons gets too high it triggers pain with movement.  When impingement syndrome is left untreated, it can progress and become more limiting to your normal activities. This is why it’s important to detect it and fix it early before it advances. 

What are the signs and symptoms associated with impingement syndrome?

You might notice it when reaching across your body putting something on the shelf, or when lifting something away from your side and reaching overhead. Usually you’ll feel pain in specific positions during a movement. If impingement syndrome progresses it can lead to avoidance of activity and in some cases frozen shoulder syndrome .

• Nighttime pain that can disrupt sleep
• Sleeping on the affected side aggravates pain
• Pain on the front and side of shoulder
• Painful arc when lifting your arm away from your side
• Diminished strength in shoulder
• Pain when you try to massage or have someone touch the area.

Frozen Shoulder

Adhesive Capsulitis, more commonly referred to as frozen shoulder, is caused by a hardeneing and thickening of the shoulder joint and the soft tissue around it. When this joint capsule hardens it makes it painful to move our arm and over time you lose more ability to use your shoulder.

What causses Frozen Shoulder Syndrome it and who is most at risk? 

• Diabetics
• Following a period of shoulder immobilization (typically following an injury, trauma, or surgery)
• Women over 40
• Thyroid disorders (both underactive and overactive)
• Cardiovascular disease
• Parkinson’s Disease

How do I know if what I have is frozen shoulder or something else?

Frozen shoulder can be commonly misdiagnosed, so it’s important to see a clinician that’s well versed in dealing with and treating shoulders because treatments can vary depending on the type of shoulder injury you have. 

What are the most common symptoms of Frozen Shoulder?

• Progressive pain, or pain that has gradually gotten worse over time
• Pain that intensifies at end range of motion
• Pain at night, especially when lying on the affected shoulder
• Disturbed sleep
• Limited range of motion when attempting to reach overhead (flexion), behind the back (internal rotation), or to the side (abduction).
• Difficulty with grooming, or dressing

How do you treat Frozen Shoulder Syndrome? 

There is no 1 best treatment strategy when it comes to frozen shoulder.  The good news is that conservative care with a mixed approach of chiropractic, therapy and deep tissue laser therapy is often very effective. It can take a while to see significant improvements, which is important to understand so that it limits frustrations that may arise while working through a diagnosis of frozen shoulder. The following are some of the better ways that we’ve found to be effective at working through frozen shoulders:

1. Joint mobilization of the shoulder and scapula- passive mobilization of a joint has been proven to decrease pain and range of motion in those experiencing adhesive capsulitis (2)
2. Stretches- targeting areas of decreased range of motion
3. Exercises- Strengthening the scapular stabilizers improves shoulder mobility outcomes in those experiencing frozen shoulder (3).
4. Laser therapy- helps decrease pain & inflammation in the shoulder and speed up the healing process
5. Graston/IASTM- breaks up adhesions, or areas of tension and tightness in the shoulder and supporting structures
6. Adjustments- shoulder problems are oftentimes linked to the neck and thoracic spine. By freeing up joint restrictions in those areas it improves outcomes when treating shoulder dysfunction (4, 5).
7. Nutritional advice- can be used to support our joints and soft tissues, and decrease inflammation in the body

 

Using a combination of the options we have to work through frozen shoulder is important to achieve the best results possible. When it comes to frozen shoulder what we do in the office is very important, but what you do outside of the office is almost of equal importance. 

 

Sources:

1. https://ard.bmj.com/content/43/3/361.short
2. https://www.jospt.org/doi/abs/10.2519/jospt.1985.6.4.238
3. https://www.sciencedirect.com/science/article/abs/pii/S1356689X07001270
4. https://www.tandfonline.com/doi/abs/10.1179/106698109791352102
5. https://www.sciencedirect.com/science/article/abs/pii/S1556370712001186
6. https://journals.lww.com/jaaos/fulltext/2011/09000/adhesive_capsulitis_of_the_shoulder.4.aspx

Scapular Dyskinesis

Our scapula (shoulder blade) articulates with our humerus (arm bone) to provide shoulder joint movement and function. When the muscles around the shoulder blade or arm are injured it can lead to poor movement in the region.  When our shoulder blade doesn’t move the way it’s supposed to it adds additional stress to that joint and the muscles in the area.

What does Scapular Dyskinesis feel like?

Symptoms of scapular dyskinesis include pain that typically starts in the front or back and top part of the shoulder and then can have pain that shoots towards the outside part of the upper arm. Scapular dyskinesis can also cause diminished range of motion, musculature tightness around the shoulder, or fatigue, especially with overhead activities. 

What causes scapular dyskinesis?

The most common reason for scapular dyskinesis is muscular imbalance resulting from muscle weakness, tightness, fatigue, and altered muscle strength. Some other potential causes of scapular dyskinesis include:

• Nerve and brain injury
• Spinal and Joint injury
• Tight pectoral muscles or bicep- this causes excessive pull on the scapula, where these muscles attach (3)
• Weakness or fatigue in the lower Trapezius or Serratus Anterior
• Excessive mobile phone use
• Poor posture
• Core weakness
• Decreased thoracic spine mobility

How do you fix scapular dyskinesis?

Conservative care has proven to be an effective way to decrease pain and regain strength in the region. There are many ways we can go about treating scapular dyskinesis but some of the more effective ways to manage it include:

• Soft tissue therapy-  aimed to decrease muscle tightness in the rotator cuff, pec, bicep, and deltoid, and upper traps
• Stretches- to maintain muscular flexibility and range of motion
• Exercises- provide strength and stability for the shoulder. Targeted toward muscles that typically are weaker when it comes to scapular dyskinesis- serratus, lower trap, and mid trap (4)
• Adjustments/Mobilization- restore normal joint motion & retrain proper movement patterns
• Kinesiotape/ K Tape- assist in re-training of normal joint movement and function

 

Thorough evaluation is the best way to determine if the pain you’re experiencing is due to scapular dyskinesis. 

 

Sources:

1. https://journals.sagepub.com/doi/abs/10.1177/0363546507303560?journalCode=ajsb
2. https://pubmed.ncbi.nlm.nih.gov/32373599/
3. https://www.jospt.org/doi/abs/10.2519/jospt.2005.35.4.227
4. https://journals.sagepub.com/doi/abs/100363546503258911?journalCode=ajsb