THE SHOULDER A NEW FUNCTIONAL AND STRUCTURAL APPROACH TO THE SCAPULAR GIRDLE

Practice Published on Apr 24, 2021

Periarticular issues of the shoulder require all our attention since they involve a great number of factors.

The shoulder is an adaptive articulation which must always be considered in the context of the global lesion: spine, thorax, viscera, etc.

The shoulder is an intricate articular complex that must be investigated in great detail: bony parts, muscles, neurovascular pathways, periarticular soft tissues, etc.

The shoulder is a very mobile articulation which must not only be released but also stabilised: lines of force and articular diastases.

The shoulder is often under the influence of psychological and social factors that must be taken into account in the osteopathic approach.

 

Still viewed Osteopathy as the law of mind, matter and motion[1].

The approach to the scapular complex that we present in this article associates:

- functional evaluation (motion)

- specific treatment of the different osteopathic lesions (matter)

- psychosocial assessment of the shoulder issues (mind).

 

[1]  A.T. Still, Autobiography, 1897.

 

 

Functional evaluation of the shoulder

It is interesting to notice that, in much of the basic training, education is essentially based on gathering and exploring anatomopathological data.  In fact, we see in our clinic patients who have anatomopathological lesions with little or no pain[1] but also, patients without anatomical lesions who are however in great pain[2].

This is even more true in the case of the shoulder[3].

Current literature teaches us that a diagnosis based on anatomopathological data may not always be necessary, except in the search for red flags[4], to care for a population of patients presenting with shoulder pain unrelated to trauma.  We must therefore base our diagnosis on functional data to improve our therapeutic objectives and our results.

As osteopaths, our gateway in this functional health history, is observation, analysis and understanding of the movement of the scapular girdle using current data[5]. Indeed, the rotator cuff, by pre-activating just before movement, plays an important proprioceptive role, but also a stabilising role while providing a mobilising role during movement[6].

Furthermore, the orthopedic tests of the cuff are not that specific[7]; which comforts us in choosing a functional approach that, in other aspects, may complete our diagnosis:

highlighting motor strategies that are unclear and different due to a proprioceptive deficit that is characteristic for patients suffering from shoulder pain[8],

integration of muscular chains or kinematic chains influencing the movement of the scapular girdle through increasing or decreasing constraints[9],

integration of a physiological concept of positional and movement asymmetry so as not to distort our conclusions (Lehman G., 2017 ; concept Burnotte J.)

 

Functional evaluation as we understand it presents a number of benefits.

Better understanding the biomechanics and the kinematics of the shoulder to be able to categorise our patients suffering from a shoulder problem according to their major[10] and to better target our therapeutic objectives.

Establish a prognosis of the shoulder problem according to the good or bad risk factors.

See if the osteopathic treatment significantly improves the functional aspect of the shoulder[11].

Promote a therapeutic alliance with the patient and a cognitive restructuring based on the patient’s expectations.

Give simple advice and a few kinetic reprogramming exercises to optimise the result of the osteopathic treatment.

If needed, redirect the patient to a multidisciplinary therapeutic approach (physiotherapy, rheumatology, surgery, etc.) while preserving our specificity as an osteopath.

 

 

It must be noted that, even though the functional evaluation is necessary, it does not replace osteopathic diagnosis.  Osteopathic diagnosis is based on the osteopathic lesions present which may only be identified by specific tests.  We must not confuse finding the dysfunctions (functional evaluation) with finding of the osteopathic lesions (specific tests).

 

[1] Guermazi A. et al, Prevalence of abnormalities in knees detected by MRI in adults without knee osteoarthritis: population based observational study (Framingham Osteoarthritis Study), BMJ 2012; 345:e5339.

[2] Brinjikji W. et al, Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology, 36(4), 811-816. Doi:10.3174/ajnr.A4173, 2015.

[3] Teunis T. et al, A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age, Journal of shoulder and elbow surgery, Volume 23, Issue 12, p1913-1921, 2014

[4] Critical elements which would suggest a contraindication to osteopathic treatment.

[5] In particular the concept of dynamic stability of this girdle as well as of the rotator cuff, which is essential.

[6] Reed D. et al, Does changing the plane of abduction influence shoulder muscle recruitment patterns in healthy individuals? Man Ther. 2016 Feb; 21:63-8.

[7] Dean, B.J.F. et al, Why does my shoulder hurt? A review of the neuroanatomical and biochemical basis of shoulder pain. BJSM, 47(17), 2013.

- Dean B.J.F. et al, Are inflammatory cells increased in painful human tendinopathy? A systematic review Br J Sports Med; 50:216-220, 2016.

- Lewis J. et al, Rotator Cuff Tendinopathy: Navigating the Diagnosis- Management Conundrum. J Orthop Sports Phys Ther. Nov; 45(11):923-37, 2015.

- Lewis, J., Rotator cuff related shoulder pain: Assessment management and uncertainties. Manual Therapy, 23, pp.57–68, 2016.

- Hegedus E.J. & Cook, C.E. Return to play and physical performance tests: evidence-based rough guess or charade, BJSM, 49(20), 2017.

- Hegedus E.J. et al. Combining orthopedic special tests to improve diagnosis of shoulder pathology. Physical Therapy in Sport, 16(2), pp.87–92, 2015.

[8] Castelein B. et al, The influence of induced shoulder muscle pain on rotator cuff and scapulothoracic muscle activity during elevation of the arm. J Shoulder Elbow Surg. 2017 Mar; 26(3): 497-505.

[9] Kibler W. et al, Clinical implications of scapular dyskinesis in shoulder injury: the 2013 consensus statement from the “Scapular Summit”. BJSM, 47(14), pp.877–885, 2013.

- Roy J. et al, Impact of movement training on upper limb motor strategies in persons with shoulder impingement syndrome. Rehabilitation, Therapy & Technology, 11:1–11, 2009.

[10] Lewis J, Rotator cuff related shoulder pain: Assessment management and uncertainties. Manual Therapy, 23, pp.57–68, 2016.

[11] Thus the usefulness of performing a functional evaluation before and after the osteopathic treatment to appreciate the result of our corrections.

 

Osteopathic treatment of the shoulder

Here we propose an original approach based on the diagnosis and specific treatment of the scapular girdle with:

-  tension tests for the diagnosis of the lesions that are present,

-  inhibitory balance tests to determine the dominant lesions,

-  recoils to adjust in a specific manner each lesion that warrants it.

 

The major key points of the scapular girdle.

 

The examination of the shoulder is performed with the patient sitting (15 tests) then with the patient lying supine (9 tests).

Each test is performed rapidly by applying precise tension to the structures in question.

This examination is quick (a few minutes), non-invasive and comfortable for the patient, even with a fragile or painful shoulder.

Other tests may complete this evaluation as necessary.

 

Patient seated.

 

Test of the 1st rib

Test of the superior angle of the scapula (levator scapulae)

Test of the medial border of the scapula (rhomboid minor)

Test of the medial border of the scapula (rhomboid major)

Test of the inferior angle of the scapula (latissimus dorsi)

Test of the lateral border of the scapula (teres major)

Test of the lateral border of the scapula (teres minor)

Test if the quadrilateral space (axillary nerve)

Test of the head of the humerus

Test of the acromion

Test of the lateral extremity of the clavicle

Test of the spine of the scapula (supraspinatus and infraspinatus)

Test of the coracoid process (ligamentous and muscular cross)

Test of the labrum

Test of the medial extremity of the clavicle

Test of the lateral extremity of the clavicle

Patient lying supine.

 

Test of trapezius (accessory nerve)

Intraosseous test of the clavicle (supraclavicular nerves)

Test of the scapular notch (suprascapular nerve)

Test of the prescalene space (phrenic nerve, subclavian vein)

Test of the thoracic outlet (trunks of the brachial plexus, subclavian artery)

Test of the costoclavicular space (divisions of the brachial plexus, axillary arteries and veins)

Test of the subpectoral tunnel (cords of the brachial plexus, axillary arteries and veins)

Test of the tendon of the long head of biceps (rotator interval)

Test of the axilla (space between head of humerus and ribs, latissimus dorsi and pectoralis major)

 

Testing these 24 key points yields a precise diagnosis of the major fixations and gives a clear image of the lesional pattern affecting the shoulder.

The majority of tests presented here are related to acupuncture points the clinical indications of which go beyond the single framework of local shoulder pain[1].

Once the points in lesion have been determined, we proceed to the selection of those requiring specific adjustment, through inhibitory balance tests.

 

To correct the lesions, we preferentially use the recoil[2].

Concerning the treatment procedure, we propose two options therapists may choose from.

 

Targeted treatment.

For the targeting, we first treat by recoil the dominant lesion of the scapular complex, then after evaluating the remaining lesions, the second dominant, then the third, …. until all lesions that were affecting the shoulder are normalised.

Targeting has the advantage of approaching the shoulder in a prioritised manner and therefore is more etiologic than symptomatic.  Generally, and no matter how many lesions are present, 3 to 4 adjustments are sufficient to completely release the scapular girdle.

 

Combined treatment.

This method consists in adjusting the dominant lesion with another lesion of the scapular girdle.  The combined treatment has the advantage of capitalising on the anatomical or functional relationship that exists between two elements[3].

For example, from a dominant lesion of the coracoid process and depending on the other lesions found, we could associate:

- adjusting the coracoid process with the clavicle (trapezoid and conoid ligaments),

- adjusting the coracoid process with the acromion (coracoacromial ligament)

- adjusting the coracoid process with the scapula (scapulothoracic articulation)

In practice, the multiplicity of possible associations makes the combined treatment the best way to approach the complexity of lesional patterns of the shoulder.

 

 

[1] This relation between the osteopathic key points and the acupuncture points will be the topic of an upcoming  article.

[2] Even though we prefer to use the recoil exclusively, other techniques are of course possible. 

[3] The « mechanical link » concept takes on its full meaning here.

Combined treatment of a superior head of the humerus and the long head of biceps

At the end of the osteopathic treatment of the key points of the shoulder, we must come back to the functional evaluation to assess the result obtained: a clear and objective improvement of the range of motion as well as a decrease in pain on certain movements such as the active elevation of the arm are of course a good prognosis.[1]

 

[1] Awareness that certain movements that were limited and/or painful become immediately possible again is also a determining psychological factor for the patient, particularly in chronic issues.

 

Psychosocial assessment of shoulder issues

Shoulders express our ability to act and to support burdens.

A shoulder issue may indicate overexertion or difficulty in undertaking certain responsibilities.  With frozen shoulders, the burden is too heavy and there is inability to act.

The right shoulder is often linked to the management of our inner energy whereas the left shoulder corresponds to the management of what is external.

We must also take into account a possible relation of the right shoulder with the liver (anger) and on the left with the stomach (worries that are chewed over) or the heart (emotional burden).

Generally speaking, shoulder issues are often accompanied by a feeling of solitude, literal solitude of a person living alone or inner solitude of someone who bears their burden in silence.

Osteopathic treatment may greatly help the patient in releasing the emotional burden that affects them if the practitioner is able to perceive the emotional load that underlies the physical complaint.

In practice, sometimes all you need to do is asking questions to the person while keeping contact with the shoulder lesion in question.  It is surprising to see how a patient may easily confide in you as soon as you put your finger[1]  on their lesion when it turns out to be a somatic expression of psychological distress.  We must not at this point try to interpret or worse, judge what the person is saying but simply listen with benevolence.

To act simultaneously on both aspects of a psychosomatic lesion, the recoil is applied during a verbalisation phase, i.e. while letting the patient speak freely of their problem while the practitioner treats the point in lesion.  This way of connecting the pain (osteopathic lesion) to the person’s words has often given good results, both physically and psychologically. 

 

The approach to the shoulder proposed here presents the advantage of integrating a functional evaluation based on biomechanical data and a precise protocol of treatment of the critical points of the scapular girdle.

This original process must always be used in the context of the total lesion, i.e. the totality of the osteopathic lesions presented by the patient.

A psychosocial assessment of the distress of the person[2] may help in managing the shoulder problems. Nevertheless, we must keep in mind that we are not psychotherapists and that our treatments address the structure to be able to reach function and beyond.

 

[1] Both literally and figuratively.

[2] When appropriate and benevolent; this is not about suggesting to the patient that their shoulder issues are psychological, as some therapists sometimes imply.

 

 

Eric Prat DO

Thierry Gorraz DO

 

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