The shoulder joint. Anatomy, pathology, soft tissues and mobilisation.

The 'scary' stuff: The anatomy and pathology of the shoulder joint as
illustrated by the late, great Frank Netter.

It has been my experience that non-surgical Shoulder joint problems are quite common and can be amenable to a manipulation approach. They range from the acute, sudden swelling of a bursa to long standing cases of frozen shoulder which need a lot of soft tissue work and mobilisation. The illustrations above of pathological states reflect a minority of these cases. The assumption is that you need surgery to fix such painful levels of pathology. The proper and diligent use of the vast array of mobilsation techniques can often mean that the patient will be able to avoid surgery.

In acute and very swollen cases, especially where the patient cannot sleep due to the pain is where I make the decision after trying traditional cooling applications that a Cortisone jab is a good bet to calm the whole thing down. This jab must be administered by someone who is intimate with the process and knows where to place the jabs contents. They must take great care not to hit bone or tear tissue by accidentaly move the needle sideways. They must administer it in a gradual fashion.

Click on the thumbnails to enlarge the images, then click the bottom right to enlarge to the maximum.

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Anti-inflammatories are useful if the condition is inflammed, swollen, hot and angry so long as your stomach and intestines can tolerate them. If you find they don't work within 24 hours then they probably won't at all. This is often due to the assumption that everything painful is inflammed. This is not the case.

The major predisposing factors are shortening of the Pectoralis minor, Infraspinatus, Subscapularis and the Teres group. The deep fibres of Biceps are usually involved as well. These tight muscles effectively 'hold' the head of the Humerus too far forwards in the socket and at the same time 'tether' the Humerus such that it cannot be lifted to its full potential range. There is frequently an extension of the irritation pattern into the same side of the lower neck muscles. The lesioned state can, in turn. irritate the nerve supply to the area, thus amplifying the level of perceived pain.

This state of postural shortening of muscle groups can often persist for years such as in musicians who started playing as children. The long term effects of playing the Oboe, for example, where the arms are 'pinned' to the sides of the ribcage and the pectoralis minor is very tight and short in the front can be very deleterious.This has the effect of preventing external rotation and elevation of the arm.

The movement of the scapula at its articulation with the acromion process is a big factor in overall loss of movement. For every three degrees of movement at the shoulder joint there is one degree given by the acromio-clavcular joint and stern-clavicular joint. Persistent subluxations, usually a raised acromial head, can be traumatised easily leading to inflammation and its possible spread into adjacent tissues.

A raised upper ribcage on the same side will predispose the shoulder mechanism to harm due to the eccentric axis of circumduction then assumed by the mechanism. It is a bit like having a flat tyre and the effect on the axis of steering and suspension, not good.

The main task is to establish which soft tissues are involved and where they are tight and short, to soften and lengthen them using deep (but not painful) massage and long lever stretches. One must be careful not to over stimulate the areas with over-exuberant manual technique.

The condition can blow up or magically melt away. It can frustrate you as a therapist due to its wide variety of combinations but it is worth the effort and worry when the patients can give you a full salute at the end.

Thats all for now...