Understanding Shoulder Pain and How to Return to Living

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Published on: September 26, 2017

By Meredith Griffin PT, DPT

Shoulder pain is a very common issue. Every day in the clinic, I see at least one patient with complaints of shoulder pain and the only other diagnosis I see more frequently is low back pain. Shoulder pain can be brought on by a variety of causes, including over use, trauma, and aging. Veterinarians, especially ET practitioners, are highly susceptible to the former of the three. Despite the cause, the progression of therapy is generally the same.

The most common issue with shoulder pain is weakness of the rotator cuff. The rotator cuff is a group of 4 mus- cles: supraspinatus, infraspinatus, subscapularis, and teres minor. These 4 small muscles are responsible for ensuring prop- er biomechanics when ever you do any movements with your arm. The larger muscles surrounding the shoulder are responsible for the power that our shoulders are able to produce to be able to lift, push, pull, and all other strenuous activities.

The shoulder motion is the combination of mobility at 4 different joints: sternoclavicular jt, acromioclavicular jt, glenohumeral jt, and  scapulothoracic jt. The scapulothoracic jt is the most unique of the 4, in that it is not the typical articulation of two bones but rather the sliding of the scapula around the rib cage. This is a highly important due to its participation in maintaining proper biomechanics when reaching over head. The only things that control this motion are the muscles that attach the scapula to the trunk. When working with a patient who has complaints of shoulder pain, there is considerable time spent on strengthening these muscles to maintain proper biomechanics and alignment during shoulder use.

The other primary joint is the glenohumeral jt. This is the articulation of the humerus with the scapula (Figure 1). Around this joint is a fibrous capsule and multiple ligaments to help provide inert stability. These structures are responsible for preventing shoulder dislocations and abhorrent movement. These tissues are able to lengthen or shorten with the proper stresses and influences. All of these components are examined and af- fected by therapy exercises.

The progression of exercises and return to function is pain free movement in the following order: passive range of motion, active assistive range of motion, active range of motion, and resisted range of motion. See figures 2-5 for descriptions and examples.

When a patient has achieved pain free AROM, progression to resuming functional use of the arm can begin. There is always some variation to this and treatment should be tailored to each specific patient. If progression toward functional movements is done too soon dysfunctional movement patterns, pain, and biomechanical abnormalities can result, leading to further limitations. Progression through these stages is best dne under the direction of a licensed physical therapist, as stalling at different stages can have a variety of reasons. Lack of ability to use the shoulder motion to its full extent can result in shortening of the shoulder capsule and ligaments and inevitable loss of motion. Stretching of the shoulder capsule and ligaments is best done by a physical therapist, as they are able to control the biomechanics of surrounding structures and ensure that the stretching forces are applied to the proper structures. Exercises and amount of resistance is also determined by the physical therapist based on how the patient is able to move.

The benefit of having a common issue like shoulder pain is that we know much about the mechanics, what exercises are effective, and how to progress patients, potentially avoiding surgery and further disability. Shoulder pain can be highly limiting especially for those who are required to use their shoulders for daily work tasks. The most effective way to address and manage shoulder pain is with rapid and aggressive treatment, re- turning the patient back to their daily activities as quickly as possible. If you have been suffering with any kind of shoulder pain and are unsure of the proper course of management, contact a physical therapy clinic for an evaluation. Physical therapists are trained to assess and determine if skilled therapy is appropriate, or if you require a referral to a different care provider.

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