shoulder - what to check

[Guest guest]

Here's some clinical thoughts on patterns in the shoulder, I thought I

would share it. Hope it helps you with some of your difficult patients.

I'd like to speak to common musculo-skeletal lesions found on physical

exam of the shoulder and surrounding regions, which can effect shoulder

function. Some of the effect on the shoulder can be assessed via

immediate ROM changes, some via changes in tenderness over areas in the

shoulder that are frequently tender, such as the biceps tendon, and the

deltoid insertion.

The shoulder is not just the scapulo-humeral joint. Motion assessment

must be done of the AC and sterno-clavicular joints. Another

functional joint is the scapular junction with the rib cage,which can

be assessed by checking motion in various directions at the coracoid

process. The neck and upper back can refer to the shoulder, and the

lower neck and upper thoracic segments must be evaluated. Frequently

missed fixations include the anterior aspect of the lower cervical

spine, where the segments can often lack anterior glide. Additional

important joints include the sterno-costal, and costo-chondral joints

in the front of the chest. These are clearly tender when restricted.

The muscular aspects are also important. Janda's upper crossed pattern

affects the shoulder. Does the patient have rounded shoulders and

anterior head carriage. This posture will affect the carriage of the

scapulo-humeral joint, tending toward impingement. This pattern would

include tight pecs, both major and minor, tight upper trap, tight

scalenes and SCM, tight levator scapulae and rhomboid, and weakness of

the deep neck flexors and middle and lower trapezius. This whole

pattern can be reinforced by improper activities, even in a well

muscled individual. Additional muscular patterns include weakness in

the teres minor and infraspinatous (external rotators of the shoudler),

and tightness of the latissimus and subscapularis. In a frozen

shoulder, or any condition where the patient lacks full abduction, the

subscapularis must be addressed, ideally with Leahy's active release

methods.

The shoulder is a classic site for visceral referral. Those who are

trained in visceral manipulation would be wise to check for liver and

gall bladder problems in relation to R shoulder pain, and stomach

problems, or gastro-esophogeal problems such as reflux, in a left

shoulder pain. I'm sure that the acupuncturists and naturopaths would

have other ways of assessing this connection.

I hope this flow chart of what to check is helpful for your difficult

shoulder patients.

Marc Heller DC

mheller@...