Shoulder pain/

Rotator cuff syndrome

The primary shoulder pain syndromes involve one or more of half a dozen muscles in the shoulder, some of which belong to the so called rotator cuff.

The acromio clavicular, or AC, joint is often involved, preventing full movement between the collarbone and the shoulder. It readily becomes fixated in shoulder syndromes, probably the reason that it is the second most likely joint, after the thumb, to become arthritic. More about immobilization arthritis later.

The underlying cause of many arm pain syndromes including the shoulder often lies in the cervical spine, or the first rib, also known as a thoracic outlet syndrome which affects both the artery and the nerves to the arm. Raising it above the head starves the limb of blood and nerve supply, increasing the tingling.

Rotator cuff syndrome

It behooves the chiropractor to carefully examine the shoulder to determine if the pain is a referred nerve pain, or a shoulder condition, perhaps muscular, or even a torn ligament. And if there's a history of breast or lung cancer, the cervical spine and shoulder are prime targets for metastasis. 

Shoulder pain usually starts after minor trauma or an unaccustomed activity. Using a heavy drill, painting the ceiling, or lifting an unexpectedly heavy suitcase; the key is a little warm up, and that usually doesn't happen when we've never had problems before.

But, if you've previously suffered from shoulder pain, then it behoves us to do a few loosening up exercises for the neck and shoulders before beginning odd jobs.

I have a large garden, and yesterday involved a couple hours with a heavy chainsaw removing two invader species. It's hard work, and yes, fairly dangerous work. Large trees are widow makers. I wear eye protection, gloves and heavy trousers, and a few warm up rotator cuff strengthening exercises did the trick, not unlike the preparation for a game of tennis.

The rotator cuff syndrome is a painful and debilitating condition giving pain with every movement of the arm, particularly lifting it above your head, and dressing and undressing. Fortunately not many cars still have window winders, that used to be torture. But changing gear is often painful. More further down this page. Untreated, it often leads on to frozen shoulder.

Rotator Cuff 

This is the name given to a group of four muscles that act to stabilize the upper arm. 

They allow you to raise your arm, turn it and move it into many different positions, each carefully controlled and coordinated, as in throwing a ball accurately, for example.

Unlike the hip though, the socket is very shallow to allow for a greater range of motion. This makes the joint more vulnerable to injury, leading to pain, strains and tears.

Complete rupture is uncommon, most usually after a cortisone injection. More commonly, calcium deposits in and around the joint, an ultimately a frozen shoulder may occur. 

Rotator cuff muscle tears cause pain and weakness in the shoulder. Usually it starts as a small strain with heavy lifting, or not warming up properly before tennis, for example, or a fall on the outstretched arm.

This may be followed some weeks or months later by a partial tear if the initial minor injury was not correctly addressed. The shoulder will be painful, but you can still move the arm in a normal range of motion. Obviously, the larger the tear, the more weakness and the more pain the injury will cause.

You may become aware that certain movements become painful and possibly slightly restricted. Reaching behind your buttock to remove a back pocket wallet, or loosen the bra may become difficult. Raising your arm to brush your hair may hurt.

Complete rupture is fairly rare, often occurring after cortisone injections, which should be considered only after chiropractic (or other) conservative treatment has been exhaustively tried without success.

Regular stretching before activity is the key to the healthy functioning of the shoulder muscles and joints. Otherwise wear and tear, or degeneration, of the muscles and tendons occur. Tearing of the rotator cuff tendons is an especially painful injury. A torn rotator-cuff creates a very weak shoulder. Most of the time patients with torn rotator cuff are in late middle age. But rotator cuffs tears can happen at any age.

Upper arm pain and the so called frozen shoulder often involve these four key muscles.

They are the

1. Subscapularis (which lies UNDER the shoulder blade),
2. Supraspinatus (which lies ABOVE the spine of the shoulder blade),
3. Infraspinatus (which lies BELOW the spine of the shoulder blade) and
4. Teres Minor (which attaches to the side of the shoulder blade.
   To these four muscles we will add the
5. Biceps muscle for simplicity, since it also a common offender and cause of shoulder pain.

What causes Rotator Cuff Syndrome?

Rotator cuff muscle tears can occur from a single traumatic injury, for example a fall on the outstretched arm, causing immediate severe shoulder pain. If a fracture, or torn ligaments occurs at the same time, then of course the rotator cuff injury may be missed, and the treatment of the fracture, obviously immobilisation, may unavoidably be the very worst treatment for the muscle injury. It can't be helped. Just rehabilitation of the shoulder, once it comes out of the sling, will be further prolonged and more difficult.

Most tears, however, are the result of overuse of these muscles and tendons over a period of years, starting with a minor injury that is not adequately cared for. People who are especially at risk are those who engage in repetitive overhead sports such as tennis and weight lifting.

This nasty shoulder syndrome frequently starts after a whiplash injury, usually many years earlier and long forgotten. It is indeed difficult to prove the link. Progressive irritation of the nerves by arthritis or a subluxation in the neck may weaken the shoulder muscles and makes them vulnerable to sprains and strains.

For unknown reasons, smokers are more prone to right shoulder pain.

A frank tear usually doesn't occur unless the muscle is already weakened by some other problem, either in the neck and sometimes in the acromioclavicular joint.

Rotator Cuff Strengthening

This process is an integral part of the treatment of every injury, otherwise the body part will remain weak and prone to further, and often worse, problems.

This is is the name given to a group of four that act to stabilize the arm. Pain and the so called adhesive capsulitis often involve one or more of these key muscles.

These shoulder muscles allow you to raise your arm, turn it and move it into many different positions, each carefully controlled and coordinated, as in hitting a golf ball accurately, for example.

Unlike the hip joint though, the shoulder socket is very shallow to allow for a greater range of motion. This makes the upper arm more vulnerable to injury, leading to pain, strains and tears. 

Since the shoulder is non weight bearing, as are the hip and knee, it is much less prone to arthritis. An exception here is the AC joint, between the acromion and the clavicle. This joint that connects the collarbone to the shoulder blade is often injured in falls and, should it not be correctly managed with rotator cuff strengthening, it tends to becomes prone toimmobilisation degenerative changes of the hyaline cartilage.

The acromioclavicular is second most arthritic joint in the body, after the thumb.

They are the

• Subscapularis (which lies UNDER the shoulder blade), the
• Supraspinatus (which lies ABOVE the spine of the shoulder blade), the
• Infraspinatus (which lies UNDER the spine of the shoulder blade) and the
• Teres Minor. To these four muscles we will add the
• Biceps muscle for simplicity, since it also a common offender that needs strengthening.

Acromioclavicular joint

See if you can follow the thin clavicle, collarbone, at the top of the picture to where it joins with the shoulder blade, scapula, at theacromion. This acromio clavicular joint with its ligament is key to shoulder mobility. Chiropractic adjustment of the ac joint is very important.

The shoulder muscles are energised by nerves emerging from the lower neck. An old neck pain injury often lies at the root of shoulder pain. Have you perhaps been involved in a car accident or an old sporting injury?

The so called rotator cuff syndrome is a complex condition involving four shoulder joints, together with their capsules and ligaments, the shoulder muscles and their tendons, their nerve supply and the acromio clavicular joint.

In these shoulder syndromes, the muscles after being strained adhere to each other and the roof of the fossa which is formed by the acromio clavicular joint.

A sports oriented chiropractor will not only adjust your neck but focus on these peripheral sites of injury, the four shoulder joints, and a complete set of rotator cuff strengthening exercises. 

Rotator Cuff Strengthening

The simplistic and safest rotator cuff strengthening exercises are theisometric exercises. A very good place to start, as Julie Andrews would say! Sound of Music ... (Sorry, a bit crazy this morning!) When you read you begin with A-B-C, when you sing ... when you strengthen your shoulder you begin with STRETCH-ISOMETRICS-DYNAMICS) These isometric exercises mean that the shoulder doesn't move! Here are six little exercises to start with. Whilst sitting in a chair, place your elbow against your side with the elbow at 90 degrees, and your hand straight in front of you. Using your other hand,

1. grasp your wrist with the good hand, and press straight across, inwards, with your injured arm. Without movement! Against resistance from the good arm.
2. Adjusting the fingers slightly, in the same position, now pull outwards, again without movement.
3. Now pull your elbow straight against your chest.
4. Reaching across, grasp the elbow of the painful shoulder, with your good hand. Now attempt to pull your painful arm away from the body, against the resistance of your fingers; without movement. Gently, because you're not eligible for the Olympics.
5. Now press your elbow backwards against your chair.
6. Lastly, make a fist with your sore arm. Keeping the elbow at your side, push straight forwards against the good hand, again without any movement.

Do about five to ten repetitions each and every time you take a tea break. Start slowly, particularly if these movements are painful; there is no rush.

Isometrics are more effective that dynamic exercises in the initial phase after injury when it comes to rotator cuff strengthening, but you must do it in different positions. When these six are painless, then do them with the shoulder flexed at forty five degrees, say, and then ninety.

Strengthening exercises with movement should then follow. Once you can do the isometrics without pain, then progress using this inexpensive apparatus. It's a simple affair with a small pulley,  and a cord with a handle at each end. Fix it in the door jamb, and pull away, changing the position.

WEIGHT TRAINING

Once you can do that without pain, then it's time to move your ROTATOR CUFF STRENGTHENING on to light weights. Holding any tin can of around 400 g (1 lb) in your hand, start moving the arm in these same directions. Always start with stretching and do it at least twice a day.

A used bicycle tube is excellent for Rotator Cuff strengthening. Hook it over some fixed point, and start doing gentle exercises against the resistance of the tube. Inwards, outwards, forwards ... you can use your imagination, but follow a routine, gradually expanding it as you feel the shoulder getting stronger.

Warm up routine of golfer Padraig Harrington

Whilst none of us amateurs would consider a routine like this before playing sport, if you are a professional sportsman, where fine-tuning makes a profound difference at the finish line, then you may wish to think about Padraig Harrington's preparation before a round of golf.

Padraig was missing four to five tournaments per year due to injury. So he hired chiropractor Dr Dale Richardson to go on tour with him. Now he misses no tournaments. This is the routine that his DC has given him.

1. On arising in the morning, 45 minutes of stretching, stabilizing and core muscle exercise as a warm up for the day.
2. Take a warm shower.
3. Enjoy a hearty breakfast of his own choosing.
4. Thereafter follows twenty minutes with Dr Richardson checking that all the joints and muscles needed by a professional golfer, every one in the body, are working correctly; then more stretching.
5. An hour at the range hitting shots to warm up further.
6. Four to five hours on the golf course.
7. This is followed by another hour with Dr Richardson giving treatment and cool down procedures.
8. Gym work in the late afternoon for ultimate strength and endurance needed by any professional sportsman. 

For a professional sportsman, Harrington's words are interesting.

One thing I know from my own experience is that my body needs constant attention, even when I take a few weeks holiday; because I can see even though I would be injury free for say a month, I can feel tightness and pain building up. I never used to pay much attention to  those early signs; it wasn't long before that translated into bogeys on the golf course.

The basic principles here are:

• Stretching, warmup and checking that muscles and joints are working correctly. 
• After sport stretching and cool down apply whether you are going to spend the day gardening, preparing for a game of squash, or even just going for a hike.