If you’ve ever experienced a painful shoulder that’s holding your back from sport, you’ll be very aware of how intrusive it can be. Shoulder symptoms can also prove to be a source of frustration for the clinician, and this may stem from the wish anatomically locate the particular ‘pathology’ or ‘lesion’.
The reality is, that trying to pin down a patient’s symptoms to a single ‘structural’ abnormality isn’t very helpful.
Many of the traditional clinical tests we use to assess shoulders are supposed to help us pick out pick out the offending ‘lesion’ through the use of a ‘present or absent’ positive test ,as if we were running the patient through a mystical hands-on MRI scanner.
The trouble is, the sensitivity and specificity of many of our traditional impingement or rotator cuff tests are, frankly, poor.
We shouldn’t really be surprised at is, when we consider how amazingly complex shoulder anatomy is. None of the tendons, ligaments or bursae are isolated, and any one of them can generate pain. It’s difficult to see how an orthopaedic test could there for be very accurate at calling out the culprit. In addition, just as in the case of lumbar spines, we regularly see ‘lesions’ flagged up on MRI, that aren’t hurting anyone. Literally.
Whilst it’s of course possible to sustain a significant trauma to a shoulder (e.g. a violent dislocation, or a fracture of the greater tuberosity from a fall whilst skiing), most of the time when someone present with shoulder pain, it’s usually arrives in a non-traumatic manner, and with certain functional movements.
Shoulders are wedded to thoracic spines, with cervical spines as neighbours – and that’s just the beginning of the anatomical relationship web. To make an efficient movement, which is both pain-free and strong, all components need to play together. Nicely.
So where to start in our journey of treating the painful shoulder?
Thankfully, there are now suggested routes to follow, laid out by clever shoulder cartographers. For example, Dr Jeremy Lewis has some great methodology suggestions as to how-to-go-about-it. Lewis JS. Rotator cuff tendinopathy: a model for the continuum of pathology and related management. British Journal of Sports Medicine. 2010;44(13):918-23.
If you’re not familiar with his ‘Shoulder Symptom Modification Procedure’, it’s a clinician friendly (yep, even Doctors can follow it) step-by-step approach, beginning with looking at a patient’s thoracic spine first.
Let’s face it, so many of us have lousy thoracic function, so it’s an easy place to win points. If you can change a patient’s pain when throwing or carrying out a press-up, by altering his or her thoracic kyphosis (e.g. with tape), it makes sense to focus your rehab there.
Still not making progress? Next you get to move to improving the starting position of the scapula, and finally, you can tackle humeral head positioning. It’s by no means the only approach to treating shoulder symptoms, but I personally like it because it helps to gain patient’s buy-in where rehab is concerned. If they can feel real time the difference a new positioning can make, they become more willing to do the exercises need to achieve that movement in sport.
If I sound like a devotee to the process, it’s because shoulder pain (from personal experience), is really, really boring. Back then, I’d have been far more enthusiastic about performing my exercises (rather than playing catapults with my green Thera-band), if my therapist had been able to show me, real time, how I could change my pain.
I wonder how many more patients could benefit, from a change in our beliefs about how best to treat shoulders?