Clinical Chiropractic: The Shoulder and Arm
We would all like to thank Dr. Richard C. Schafer, DC, PhD, FICC for his lifetime commitment to the profession. In the future we will continue to add materials from RC’s copyrighted books for your use.
This is Chapter 7 from RC’s best-selling book:
“Clinical Chiropractic: Upper Body Complaints”
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CHAPTER 7: THE SHOULDER AND ARM
Shoulder pain can be deceiving. As in so many musculoskeletal disorders, consideration of pain in the shoulder should not give priority to sudden trauma whether it be of intrinsic or extrinsic origin. Thorough investigation of the history may reveal that trauma did not initiate the first attack or that an injury was just a precipitating event that revealed an underlying degenerative disorder. Besides trauma, shoulder pain may have an inflammatory, a neurologic, a psychologic, a vascular, a metabolic, a neoplastic, a degenerative, a congenital, an autoimmune, or a toxic origin. See Table 7.1.
The Complexities in Treating Shoulder Complaints
Many practitioners would be happy if another patient with a shoulder complaint did not enter their offices. There are five major reasons for this:
- The shallow shoulder joint is highly unstable. Its stability is provided by muscles rather than the strong ligament straps provided in most other joints. This makes recurring disorders common. The answer is therapeutic exercise, but many patients soon get bored with such regimens and the prescribed exercises are stopped long before adequate strength is acquired. Thus thorough counseling and monitoring are required.
- The shoulder area is unique in its wide extremes in range of motion. There is abduction, adduction, downward rotation, upward rotation, and depression in the shoulder girdle. The shoulder (glenohumeral joint) expresses abduction, adduction, elevation, extension, external rotation, flexion, horizontal abduction, horizontal adduction, and internal rotation. Thus, a thorough knowledge of shoulder kinematics, neurology, angiology, myology, and kinesiology is required for proper treatment to be applied.
- Cases presenting with what initially appears to be the result of minor trauma are often misdiagnosed. The shoulder and arm are common sites of referred pain from the cervical spine, lungs, heart, mediastinum, diaphragm, liver, and gallbladder. Sometimes a lesion in the wrist or elbow will refer pain to the shoulder. As tenderness also can be referred, a thorough diagnostic workup is required in almost all cases of shoulder pain, tenderness, paresthesia, and weakness. This must incorporate a thorough knowledge of referred pain patterns and reflexology.
- The sternoclavicular, acromioclavicular, glenohumeral, and scapulo-thoracic joints form the shoulder girdle complex. A primary disorder in one articulation invariably has its effects on all other joints in this complex kinematic chain. Functionally, the cervical and upper thoracic spine are also part of this complex. Thus attention must be directed to multiple joints and the interconnecting biomechanical, neurologic, and myologic implications. If the underlying cause is a joint fixation, it is rarely the site of complaint. Rather, compensating hypermobile link(s) will be the first be express symptoms of overstress. Thus, knowledge of normal versus abnormal kinematics and motion palpation techniques for each of the many joints in the complex is required. Of course, intra-articular fixation is not the only cause of inhibited joint motion. Joint arthritis, calcification, spasm, contractures, dislocation, subluxation, paralysis, scar tissue, and tumors must be ruled out.
- There may be unavoidable occupational stress in the clinical picture that is aggravating the condition and delaying healing. How should the patient react when a doctor says “avoid overhead work” and the patient makes his living as a painter or pipefitter of ceiling sprinkler systems? Temporary rest can be provided but not permanent relief from such occupational stress. It may have taken the patient many years of apprenticeship to reach his present status. This is not easily put aside.
With the patient’s associated symptoms at hand, the examiner can use inductive and deductive reasoning to arrive at a logical diagnosis. For example, the age of the patient may be an aid as some shoulder conditions have a high incidence in infants while others are more common to the elderly. Roentgenography is often a help in identifying bone and joint swelling, congenital deformities, and tumor and tumor-like conditions. The existence of soft tissue pain or swelling also aids differential diagnosis. In further differentiation, there are some lesions that produce both neck and shoulder pain, certain disorders that produce pain predominantly in the shoulder, and some that typically produce shoulder pain with radiation into the arm. Nerve compression syndromes also have their unique characteristics. See Tables 7.2 and 7.3.
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