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Shoulder Girdle Trauma
The Chiro.Org Blog
Clinical Monograph 16
By R. C. Schafer, DC, PhD, FICC
he articulations of the scapula, clavicle, and the humerus function as a biomechanical unit. Only when certain multiple segments are completely fixed can these parts possibly function independently in mechanical roles. Forces generated from or on one of the three segments influence the other two segments. Thus, they will be described here as a functional unit. Please underscore this point in your mind as you read this paper.
Shoulder pain can arise from either local or systemic causes. Jaquet points out that about 95% of all shoulder disorders are due to four conditions:
- adhesive capsulitis
- simple tendinitis,
- tendinous perforation and rupture, and
- hyperalgesic calcareous tendinitis.
Note that three of these four conditions are tendinous in origin, but tendon inflammation is not as common in the shoulder as it is in the elbow and wrist. However, because all tendons are relatively avascular, all are subject to chronic trauma, microtears, slow repair, and aging degeneration.
As in so many musculoskeletal disorders, thorough investigation of the history of shoulder pain may reveal that trauma did not initiate the first attack or an injury was just a precipitating event that revealed an underlying degenerative disorder. Besides direct injury, shoulder pain may have an inflammatory, a neurologic, a psychologic, a vascular, a metabolic, a neoplastic, a degenerative, a congenital, an autoimmune, or a toxic origin.
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Deciphering Shoulder Complaints
Shoulder pain has a high incidence. Cailliet says that it ranks third to low-back and neck pain. Despite its prevalence, posttraumatic shoulder pain can be deceiving. Accurate diagnosis is not an easy task. For example, there may be unavoidable occupational stress in the clinical picture that is aggravating the condition and delaying healing. How should the patient react when a doctor says “avoid overhead work” and the patient makes his living as a painter or pipe fitter of ceiling sprinkler systems? Temporary rest can be provided but not permanent relief from such occupational stress. It may have taken the patient many years of effort to reach his present status. This is not easily put aside. Counsel the patient thoroughly — from his or her viewpoint.
Normal mobility is extensive. The glenohumeral joint alone expresses abduction, adduction, elevation, extension, external rotation, flexion, horizontal abduction, horizontal adduction, and internal rotation. Thus, a thorough knowledge of shoulder kinematics, neurology, angiology, myology, and kinesiology is required for proper treatment to be applied.
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Passive Range of Motion Testing and Post-isometric Relaxation of the Shoulder
The Chiro.Org Blog
Passive range of motion (ROM) testing of the shoulder is accomplished with the patient supine, and the shoulder joint slightly off the table. The humerus should be abducted to 90° away from the body, so that full internal and external rotation of the humerus can be explored. From the neutral position (with the forearm pointing at the ceiling) normal ROM findings would involve a full 90° of external and internal rotation.
Passive Range of Motion Testing
Internal Rotation. Internal rotation of the shoulder is controlled by four muscles: the subscapularis (C5-C6), pectoralis major (C5–T1), latissimus dorsi (C6–C8), and teres major (C5-C6). The anterior deltoid assists.
The starting position would be with the patient’s forearm pointing straight up at the ceiling. From this position the arm can and should be able to rotate a full 90° in either direction.
The individual on the right has lost almost half of his ability to internally rotate at the humerus, due to shortening of the external rotators.
The common link between all these muscles is the C5 segment. Subluxation of C5 is common in those who present with shoulder complaints.
External Rotation. External rotation of the shoulder is conducted by the infraspinatus (C5-C6) and teres minor (C5), with assistance by the posterior part of the deltoid.
The individual on the right has lost about a third his ability to externally rotate at the humerus, due to shortening of the internal rotators.
Mild over pressure on the forearm during this test will usually elicit pain and withdrawal sign by the patient.
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Clinical Chiropractic: The Shoulder and Arm
The Chiro.Org Blog
We would all like to thank Dr. Richard C. Schafer, DC, PhD, FICC for his lifetime commitment to the profession. In the future we will continue to add materials from RC’s copyrighted books for your use.
This is Chapter 7 from RC’s best-selling book:
“Clinical Chiropractic: Upper Body Complaints”
These materials are provided as a service to our profession. There is no charge for individuals to copy and file these materials. However, they cannot be sold or used in any group or commercial venture without written permission from ACAPress.
CHAPTER 7: THE SHOULDER AND ARM
Shoulder pain can be deceiving. As in so many musculoskeletal disorders, consideration of pain in the shoulder should not give priority to sudden trauma whether it be of intrinsic or extrinsic origin. Thorough investigation of the history may reveal that trauma did not initiate the first attack or that an injury was just a precipitating event that revealed an underlying degenerative disorder. Besides trauma, shoulder pain may have an inflammatory, a neurologic, a psychologic, a vascular, a metabolic, a neoplastic, a degenerative, a congenital, an autoimmune, or a toxic origin. See Table 7.1.
The Complexities in Treating Shoulder Complaints
Many practitioners would be happy if another patient with a shoulder complaint did not enter their offices. There are five major reasons for this:
- The shallow shoulder joint is highly unstable. Its stability is provided by muscles rather than the strong ligament straps provided in most other joints. This makes recurring disorders common. The answer is therapeutic exercise, but many patients soon get bored with such regimens and the prescribed exercises are stopped long before adequate strength is acquired. Thus thorough counseling and monitoring are required.
- The shoulder area is unique in its wide extremes in range of motion. There is abduction, adduction, downward rotation, upward rotation, and depression in the shoulder girdle. The shoulder (glenohumeral joint) expresses abduction, adduction, elevation, extension, external rotation, flexion, horizontal abduction, horizontal adduction, and internal rotation. Thus, a thorough knowledge of shoulder kinematics, neurology, angiology, myology, and kinesiology is required for proper treatment to be applied.
- Cases presenting with what initially appears to be the result of minor trauma are often misdiagnosed. The shoulder and arm are common sites of referred pain from the cervical spine, lungs, heart, mediastinum, diaphragm, liver, and gallbladder. Sometimes a lesion in the wrist or elbow will refer pain to the shoulder. As tenderness also can be referred, a thorough diagnostic workup is required in almost all cases of shoulder pain, tenderness, paresthesia, and weakness. This must incorporate a thorough knowledge of
referred pain patterns and reflexology.
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