What’s the number one area that the practitioners we work with say they struggle with? The shoulder!
And it’s no surprise, considering how complex this joint is - the fact that it’s actually FOUR joints says a lot! Then layer in the 25+ muscles, the brachial plexus, and all the blood vessels coming straight from the heart that pass through that area…and it’s no wonder that treating shoulder patients can be daunting!
While it’s super important to understand the complexity involved in the system that we are treating, our clinical decision making doesn’t have to be complicated or difficult!
We’ve developed a framework for looking at shoulder cases that can take these cases from being your most dreaded patients to ones that you feel confident treating. 👊
If you’ve downloaded our eBook, you’ll know our assessment framework has 4 key considerations: the metabolic system, psychoemotional/central nervous system, peripheral neurovascular system and biomechanical system (if you haven’t read this yet, you can grab a copy here)
One of the most important things to remember when treating shoulders is that in the vast majority of cases, being able to determine which FUNCTIONAL deficits are at play is much, much more important than assigning a STRUCTURAL diagnosis.
Of course, there are cases where we might suspect big structural pathologies that should be referred to a surgeon for consultation, but in most practice settings those are the exception, rather than the norm. The average patient you might see in an outpatient private practice setting might look something like this:
Bill is a 51 year old desk worker who leads a very active lifestyle. He either lifts weights or swims every day, and goes on multiple hiking trips to the mountains each year. He comes to you with a 2 month history of insidious onset shoulder pain. The area of pain is mostly at the front of the shoulder, but sometimes he feels it in the back of the shoulder or further down in the deltoids. The worst movements are raising the arm straight in front of him, but trying to reach out to the side is tough too. He stopped swimming 3 weeks ago because of the pain, and has had to modify his weightlifting routine - pushups are a no go for him at the moment.
Now, in school we are taught a LOT of special tests around the shoulder to diagnose a specific structural pathology - they could (and do) fill an entire book! We learn these special tests in school and diligently practice them for our board exams, but then when we get out into the real world and start using them on patients, things start to get fuzzy. For a lot of patients, these tests are ALL positive…kind of (how much pain is considered a positive finding??).
Does that mean they have multiple pathologies? 😭
We can see why our mentees struggle with these cases - and we’ve been there too! One of the most frustrating things is that the special tests have actually very poor psychometric properties, meaning that we don’t actually have great confidence in whether we are getting true positive or negative findings when we use them.
So then where are we supposed to start with these patients?
Here’s the secret: if you can do a good job of figuring out what kind of functional deficits your patient has, it's not really going to matter a lot whether you decide they have a rotator cuff tendonitis or a biceps tenosynovitis or a myofascial pain syndrome.
You just need to get all of the components of the shoulder girdle working the way they are supposed to work. That’s it! For the vast majority of cases, that’s all they need. The irritated tissue is simply a victim of the dysfunctional elements - clean up their functioning, and everything will settle down.
So you might be saying ok that sounds great in theory, but easier said than done 🙄. Don’t worry, we have a basic framework for you to follow for your shoulder assessments, and some clinical pearls to help you maximize your results. Let’s get started!
When it comes to shoulder cases, a great place to start is the scapula. As the transmitter of loads between the core/pelvic girdle and the arm, it serves a crucial role in shoulder function. In our experience, it would be exceedingly rare to have a patient with insidious-onset shoulder pain who DIDN’T have some form of scapular dysfunction.
So how do we evaluate this? Here are our favourite measures:
1. Observation:
Look at where your patients scapulae are located at rest (you need to get your patient standing up and with their shirt off in order to be able to see this best):
Watch what the scapulae do when your patient raises their arms overhead (we like to test this in both flexion and abduction, as you might see different scapular patterns with each movement, and it also gives us a sense of their active glenohumeral range of motion):
All of these findings can indicate scapular dysfunction!
1. Strength testing of serratus anterior
We like doing this in a seated position, where we ask our patient to protract the shoulder by punching forward. We then add a downward load through the arm in order to challenge the scapula’s ability to maintain its protracted position on the ribcage.
Tip: a patient might be really strong in their deltoids, so you won’t notice a drop in the arm as you apply pressure, but what you want to look out for is the position of the scapula on the ribcage: does it maintain its starting position, or does your patient have to retract/elevate/depress the scapula in order to manage the load? All of these strategies can indicate inability of one of the main scapular stabilizers to do its job…AND give you a clue as to what your patient’s preferred movement strategy is (hint: usually these overworked muscles will get angry, and require some manual work and/or acupuncture to settle down)
2. Hang test:
Getting patients to hang off a bar (or curl their fingers over the top of a doorframe and pull down if you don’t have a bar handy) can be a great way to evaluate scapular functioning. Some things to look for:
In Bill’s case, he presented with the affected scapula resting in a downwardly rotated and depressed position. As he raised his arms overhead, the affected side didn’t quite upwardly rotate as much as the unaffected side, and it elevated a LOT. During his serratus strength test, he was able to resist a good amount of load, but his scapula had to retract and elevate in order to do so.
The next thing we want to do in our assessment is palpate a few key tissues:
upper parascapular region: upper traps, levator scap, scalenes
anterior deltopectoral region: pec major/minor, ant delt, long head of biceps, subclavius
Why these areas in particular?
They tend to be most commonly involved in shoulder cases! SO many patients will have myofascial tension in the anterior deltopectoral region, and this will just throw EVERYTHING off - will make it harder for the scapular stabilizers to do their job, put strain on the neck, and make it harder for the rotator cuff to centrate the head of the humerus.
Abnormal palpation findings around the neck and upper parascapular region can be due to compensatory movement patterns as a sequelae of scapular dysfunction, OR they can be a primary problem (cervical dysfunction driving shoulder girdle dysfunction due to peripheral nerve involvement: remember, all the nerves that control everything in the shoulder come from the cervical spine!)
In Bill’s case, he was super tight through his pec minor, and had a significant myofascial trigger point in his levator scap on the affected side.
Now that we have a good idea of what’s happening at the scapula, and also done some active range of motion testing by having our patient raise their arms overhead, we can do some passive range of motion and strength testing (we like to do all these tests in sitting¹):
Check passive abduction and flexion, particularly if you noticed a deficit in these movements actively. This will help you determine whether there is an element of capsular restriction that might need manual therapy and/or acupuncture to loosen up
Check passive extension - this will give you another clue as to whether they have a myofascial restriction in the anterior deltopectoral region
Do strength testing of internal and external rotation, and abduction. This will give you an idea of which muscle groups need some strengthening work, but remember: if they have a significant scapular dysfunction, they aren’t going to be able to withstand very much load in any of these directions. That’s why restoring proper scapular functioning is so key!
In Bill’s case, he was a bit limited in passive abduction and extension more so than flexion, and his strength testing was quite good.
So you can start to see that with just a few simple tests, we’ve already gathered a LOT of information that will be useful for us to treat Bill effectively.
The key findings to focus on first here are:
myofascial tension in the anterior deltopectoral region, causing restrictions in abduction and extension range of motion (pro tip: these ROM tests now become your objective outcome measures for tracking progress!)
Poor scapular upward rotation and excessive elevation. We can hypothesize that the lack of upward rotation (a function of serratus anterior, upper traps, and lower traps) is being compensated for by the levator scap (to produce excessive elevation to make up for the lack of upward rotation). pro tip: this is why its super important to be VERY strong on your knowledge of which muscles and nerves do which movements! So that when you see a pattern of movement in your patient, you can quickly ascertain what’s working and what’s not working - this will help you come up with an actionable set of treatment targets on the spot.
So what do we do with Bill? Here’s our recommended approach:
To reduce myofascial tension in the anterior deltopectoral region:
use manual soft tissue techniques² and electroacupuncture to target the tissues that have the most significant placatory findings - pecs, anterior delts, subclavius
we also love using suction cups³ and and fascial scraping tools⁴ in this area
In addition to these passive treatments, Bill needs to do some homework in order to make a lasting change in these tissues. Adding a contract-relax component to a wall pec stretch is a great way to improve extensibility in these tissues. Supine chest flies on a narrow workout bench are also a fantastic option - you just have to make sure that the load is VERY small so that your patient can go to max range and get a good stretch through their pecs.
2. To improve scapular mechanics:
We want to set Bill up for success with his scapular exercises, so we are first going to stimulate his long thoracic nerve with either electroacupuncture or just using the Pointer Plus transcutaneously, and do some acupuncture and soft tissue release on his levator scap
A lot of the work of improving these scapular mechanics is going to be done at home by Bill, so we really have to make sure we communicate the importance of being consistent with his homework, AND we need to make sure that he’s competent in doing his exercises - no small feat when it comes to a tricky area like the scapula! We’ll start him off with some basic serratus activation in 4 point, and then progress to wall slides to help facilitate upward rotation⁵ (pro tip: the positioning of the thorax with this exercise is KEY. So often, practitioners will allow patients to get away with extending their spines and sticking their butts out with this exercise - this encourages scapular retraction and depression and completely contradicts the point of doing this exercises, which is to encourage upward rotation via the serratus and upper/lower)
So after a few sessions, Bill is progressing nicely with his scapular stability exercises (we’re moving him along into more loaded positions like incline plank and challenging him by removing one arm for support), and his shoulder is feeling much better. In the vast majority of cases, this is all you need to do in the short term!
Stay tuned for Part 2 - when things don’t go according to plan! 😱
¹ Want to learn more specific functional assessment measures? Check out Dr Mike Prebeg’s excellent Foundations in Neurofunctional Assessment course https://skillsinhand.com/
² We think Dr Alejandro Elorriaga’s Neurofunctional Soft Tissue Microconditioning is the best (www.mcmasteracupuncture.com), but Jim Bilotta’s Soft Tissue Release course is a fantastic intro (https://softtissuerelease.ca/)
³ ACE Massage Cupping (https://massagecupping.com/?gclid=Cj0KCQiA6vaqBhCbARIsACF9M6lyBNqqvPKczPPqpou4bgnvGhPSerxKpL6qdjXOw1nq_QOA26XOoHUaAjA3EALw_wcB) does a fantastic intro course, but this is a tool that is very appropriate to get a quick lesson from a mentor on and practice on yourself - it's not hard to learn the technique!
⁴ The Heskiers tool (www.heskiers.com) is by far the most ergonomic, but a low-budget version works just fine too - you can find Gua Sha tools for under 10$ at Chinese medicine retailers or Amazon
⁵ Want to learn how to effectively change your patients’ movement patterns? Check out Sally Belanger’s courses at Link Advanced Movement Mechanics https://linkamm.ca/link-education/