Shoulder Pain

The problem is pinpointing the correct diagnosis. A prescription might read: “physical therapy three times per week for shoulder pain.” But physical therapists will have different notions as to what should be done. For example, exercises for a rotator cuff tear are contraindicated if the problem is a separation of the clavicle from the acromion, which we call “separated shoulder.”

What is usually completely neglected is any evaluation of the rib cage as a cause of shoulder complaints.

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The nature of being a chiropractor is that I rarely see the successful outcomes from orthopedic and physical therapy interventions; I see the failed ones. A common feature of failed outcomes is the misalignment of the upper part of the rib cage in relation to the sternum. If the rib cage and the sternum are misaligned, there has to be a displacement pattern of those ribs from the joints that attach to the vertebrae of the thoracic spine. Patients with this type of displacement experience pain with a variety of symptoms; pain can be felt in the mid-back region between the scapulas, or it can penetrate all the way through the body. Symptoms can include burning, stabbing pain with breathing and coughing or dull achiness in the region. Pain can accompany motion of the shoulder or arm or it can be a consistent tearing sensation down the back of the arm. Pain can be felt deep in the shoulder and/or it can radiate out. In addition, a rib cage displacement makes some sleeping positions very difficult. Most of the time if shoulder pain is worsened at night, I find significant involvement of the rib cage.

Now I believe the orthopedic community will go to their graves denying any relationship between the rib cage and the shoulder. But a simple evaluation of the muscular attachments will show that there are some major muscle groups that share attachments to the shoulder and arm as well as the rib cage. The pectoralis major muscle attaches at the chest wall junction of the ribs to the sternum and goes to the humerus underneath the deltoids and biceps. Any disturbance of the joints connecting the sternum and the ribs will cause the pectoralis to tighten in order to preserve the body’s integrity. This rigidity can result in a feeling of distress in the chest itself but more commonly results in pain deep in the shoulder where the pectoralis major attaches to the humerus. The reason for this shoulder pain is that a tightening of the pectoralis causes a rotation of the humerus internally. This rotation will change the bicipital tendon action and will change the position of the humerus inside the rotator cuff, which generally causes a chronic low-grade inflammation inside the rotator cuff. Common complaints are of a deep ache in the shoulder with sharp pains caused by certain positions, usually extending the arm away from the body. Reaching above the shoulder can also be provocative but that pain pattern is more likely to be caused by a separation of the clavicle from the acromion process (a separated shoulder).

Another feature of rib cage displacement is the involvement of another muscle group called serratus anterior, which attaches on the side of the rib cage.

The serratus anterior is very visible in developed weightlifters; it is the big muscle that gives a ripple effect on the side of the chest and wraps to the front of the scapula. If the ribs are out of alignment this serratus anterior muscle will tighten along with the pectoralis, causing the scapula to pull away from the midline, which results in a winged appearance. Both these muscles tighten for the same reason: they are attempting to hold the ribs and chest together. How problematical the winged scapula become depends on the degree of rib displacement. However, the displacement of the shoulder blade away from the midline coupled with the internal rotation of the humerus, changes the position of the entire shoulder and arm in neutral positions. This rotation, in turn, causes problems with normal activities, such as reaching for a seat belt or lifting groceries. It is a very painful and bothersome condition and will persist as long as the ribs stay out of place.

The advanced imaging done for the shoulder can be excellent in determining whether there is a rotator cuff injury, damage to the bones, or possibly cysts. However, many people receive normal MRI reports when they are in terrible pain; this occurs because the MRI often does not pick up the rib cage displacement. It can be very vexing. One condition of rib displacement that is seen by the MRI is an “impingement syndrome,” which is the orthopedist’s term for the shoulder blade being out of place with the humerus internally rotated. Because there is compression of the medial and inside tissues of the rotator cuff, the orthopedist’s solution is to surgically “release” them; I have seen reports that say they have cut the “unnecessary ligaments” of the shoulder. I do not think the body contains any unnecessary ligaments. It is hard for me to characterize this position except as ridiculous and I have not seen any positive outcomes from these impingement syndrome surgeries.

The shoulder girdle is an amazing apparatus that allows us to do wonderful things.

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However the traumas we experience, such as accidents while restrained by a seat belt, falls onto concrete from dismounting a bike abruptly, are actually very disruptive to all the soft tissue connected to the shoulder area. Soft tissue injuries are sometimes minimized but most of the body is comprised of soft tissue, including the nerves, arteries, and veins. Damage to these tissues can result in permanent impairment. Cartilage within the shoulder girdle, whether part of the rotator cuff or the joint structures of the clavicle, is an important structure that, once damaged, might never fully recover. This can lead to chronic pain and impairment of motion.

The management of these injuries is very difficult because the shoulder affects many everyday activities, such as entering a car, reaching in the back seat, lifting packages from the passenger seat, getting dressed, grooming, and sleeping positions. These normal motions need to be modified or stopped for a while so recovery is possible. Patients balk when they are given instructions on how to manage an injury because they think they are doomed forever, but it is only for a period of time to allow the structures to heal.

As I state in other sections of this website: inflammation and healing cannot happen at the same time in the same tissues.

Following injury it is necessary to reduce the inflammation as quickly as possible so healing can begin – laser therapy is excellent for this purpose, and it relieves pain as well. If routine activities keep an injured structure inflamed, then healing will never be complete and the result is chronic inflammatory processes characterized, years later, as arthritis. This type of arthritis caused by chronic inflammation is called osteoarthritis, or degenerative arthritis. The best approach is to do chiropractic adjustments of the shoulder, manage the inflammation with ice and laser therapy, restrict some activities, and sometimes prescribe a brace.

Shoulder exercises should only start after the inflammation has receded. After a trauma I like to see anywhere from seven to ten days of joint rest and no signs of edema and/or significant tenderness before we start an exercise program. Some people find this an interminable period of time but a week is not an exceedingly long time to let tissues rest following an injury. There are a number of exercise regimens for the various types of shoulder injuries but a correct and specific diagnosis is necessary to know what exercises are compatible with recovery.

To summarize, the three major problems concerning shoulder pain are:

1. failure to correctly diagnose the source of the shoulder pain;

2. failure to prescribe the proper protocols to let the injury recover; and

3. failure to designate the proper exercises necessary for these tissues to resume their integrity and function.