Treating Shoulder Pain: Effective Techniques and Patient Types

Shoulder dysfunction treatment often involves addressing muscle imbalances and joint restrictions for improved range of motion.

### Osteopathy Shoulder Treatment Techniques
* 🗓️ Osteopathic shoulder treatment faces challenges due to the complex interplay of muscles (**pecs, deltoids, biceps, trapezius, rhomboids, triceps**) and the shoulder joint itself, including the humerus, glenoid socket, clavicle, and ribs.
* 🤔 Practitioners must differentiate between conditions requiring referral (e.g., rotator cuff tears) and those treatable with osteopathic manipulation.
* 💪  A simple example focuses on the **coracobrachialis muscle**. Its contraction can pull the humerus upward, reducing the space in the glenohumeral joint and hindering smooth shoulder abduction.
* 🤝 Gentle inhibition techniques, involving manual contact and induced motion, can effectively address muscle contractions and improve range of motion.  This is done by sliding a hand into the gap behind the patient's arm and gently engaging the muscle, with the other hand guiding movement.
* 🤸  This approach yields visible improvements, unlike some back pain treatments where relief might be delayed. Patients often experience immediate, noticeable improvement in range of motion.
* ⚠️  Orthopedic testing is crucial for identifying rotator cuff injuries, guiding treatment decisions, and determining when referral is necessary.  Treatment within a safe range of motion is emphasized to avoid further injury.  Referral within 6 weeks is advised to avoid scar tissue formation if surgery is required.
* ⏱️  Chronic shoulder pain (lasting 5-10 years) often involves additional complexities, including the influence of the **lung lobes** and their interaction with the rib cage and shoulder.
* 🫁  Addressing lung lobe shifts, even in millimeters, can significantly enhance treatment outcomes for long-term shoulder issues. This involves considering the force vector and tension in the lung field, and using visceral work to address any observed shifts.

Treating the shoulder as a practitioner, what are you expecting? You're expecting a patient that comes in restricted with

very little range of motion. Are you expecting in one treatment to be able to get them up to here, or maybe to get them

all the way up to that full range of motion? Or is that unreasonable? What are we expecting? Maybe the patient's got a

rotator cuff tear, and we aren't going to be able to get any kind of range, and we need to be referring them off for

treatment. So it can be a challenge to work out what's going on for the patient; there's so many moving parts. I mean, look

at all these muscles to start with, and they all need to be working together: the pecs, the deltoid, biceps, and of course

through the back here, all the way through trapezius, rhomboids, etc., etc., triceps. If those are not balanced and

working together, then you are not going to get function in the shoulder and arm. Now we take off that layer and go a

little bit deeper, and you've obviously got the joint as well. And there's issues with the joint, then you're going to have

issues with the shoulder. So what is happening deep in this socket? What is happening with the position of the humerus

in the glenoid socket? How is the clavicle affecting this? What about all the ribs? So there's a whole bunch of

stuff here, even before we start talking about scapular stabilization, influence of the latissimus muscle coming up the

back there. So a lot of stuff going on. So I get why this challenges practitioners, but shoulders can be so much fun to work

with. And if you are able to identify which are the ones you need to refer off because you think you've got a rotator

cuff tear, and then which are the ones you can actually get in and work on, then you can get some great changes. And I'll show you

A simple example here. Look at this shoulder motion here; this is showing shoulder abduction, obviously, and the

muscle that we've got highlighted here is the coracobrachialis. Now what we'll do

here, if we just zoom in a little bit here and we see that coracobrachialis. Now you can get in and work very easily

on this coracobrachialis and, obviously, other muscles around there. Now, if that muscle contracts, the biceps contract,

then what is it going to do? Let's say the person has had the arm has been in an outstretched position like this, and

they fell on it—boom! Well, you're going to get this protection; you're going to get obvious influence of the joint, but

you're also going to get the muscle contract to try to protect that area. And so what then happens is, let's say we're

back in that resting position. This coracobrachialis contracts, then what it's going to do, it's going to drag this humerus up;

it's going to drag this humerus upwards, and what you're going to see is that this humerus socket here starts to jam

in the socket. So this space here reduces. Now, obviously, we're talking about anatomy here, so it's not going to

close all the way up here. You know, these are subtleties we're talking about here. We're going to talk about a movement of

this humeral head into a position that's not optimal. And then what happens is that as this bone starts to move, as we

start to move up into this abduction, what happens is that this part of the humerus here, it starts to jam

it, and it can't actually get in and work and move the way it wants to because, if we zoom in and look at this humeral

head, as we move the arm into abduction, the humeral head does not go up. I mean, it

Does relatively, you look at the whole body moving, the scapula moving, but what is happening is that as that arm bone comes

up, humerus goes up, then what's happening is this humerus actually needs to shift a little bit. And when we drag it all the

way up into that position, in terms of the actual position in relation to the socket, it's actually come downwards, so

there's this lever motion going on. Now what happens is if that humeral head is a little bit further up, then you can't do

that; it can't do that beautiful motion in that socket; it can't get that motion. Let's see if we can get a good view in

here. Yeah, look at that! Look at that roll through there. Let's see if we can get it even better. Oh, better is the enemy of

good. Here we go. This is the one we want. So watch this here as it's—watch the humeral head, not the arm—so it's sliding,

sliding, sliding, sliding, sliding, sliding all the way through that. Now if that muscle here, the coracobrachialis, is

contracted, then as it tries to do that, it can't get that smoothness, and instead it jams in and you get this clunkiness,

and the person—and the person reports this inability to move the arm up, or they report poor quality in terms of

that motion, because obviously it's not just about this muscle. You think about that muscle contracting that and then

pulling the humeral head out of position, then what's going to happen here with the pec muscle? That's going to be

influenced. We come around the back, we look at the latissimus muscle, we look at all the other muscles here that

are acting in conjunction, working together, and you get this clunkiness of this movement. So we either get this

restriction in motion where we can't come all the way up, or we can get the full—well, not full range—good range, but

It just feels like it jams; it feels like it drags, and the patient reports that this whole area just doesn't feel

right. So that's a coracobrachialis. Now, what happens if we add in the bicep here?

Well, the same thing can happen with this bicep. It can influence what is happening at this joint, and sometimes you see these

patients that kind of walk around with that little internal rotation, and this elbow is slightly flexed because this is

contracted. It's influencing the elbow joint, but it also influences what goes on all the way through that socket there and

particularly, also obviously, in that motion of that shoulder. And the great thing about shoulders is that you will find a lot of patients coming in with

shoulder dysfunction where, if you work on these bicep muscles and if you work on the coraco-

brachialis, and you do that with—you just slide your hand into this gap here. So we—we come in behind the patient here and

you slide your hand in and work on those muscles. You can work on the triceps as well using inhibition. So we're not using

rocket science type of technique here; we're using gentle inhibition. I come in and I gently engage that muscle, a little

bit of compression, and wait for it to melt a little bit. What I'll also do is use both my hands for the technique, so

what I'll actually do is my one hand will come in here, so the fingers of my left hand, for example, will come in

around the humerus here, and I'll be contacting the coracobrachialis. And we'll talk about how you contact that and what

you contact that in a minute, but we contact through their gentle inhibition, and then my right hand will take hold of

their arm, and I'll induce a little bit of motion. So I'll move this back and forth, back and forth, as my fingers of my

Left hand is sliding in and engaging on that carbar, engaging on that bicep whilst I'm getting a little bit of

motion here. Now what I can do sometimes is actually bring this up even higher, so we start to have a little bit more

motion through that; more effectiveness in terms of the range and the stretch through that muscle that you're working

on. So, simple technique like this; not rocket science, but it almost is rocket science because it's such an effective

technique. It allows you to normalize the coracoid breakout, normalize the biceps breakout, and then what you'll

actually find is you'll retest and you've had motion here. So the patient's got a—he's getting pain at this kind of

range, and suddenly you bring them up to here and they're like, 'What?' They just look at you like stunned, and they they

will sing your praises. The roof! That you've got to go and see this person is amazing. What have you done? You worked on these

muscles. It wasn't particularly, you know, difficult technique; what it was was just knowing the areas to work on and knowing the

areas which are going to make an effective change. And so working like shoulders like that can make a huge

difference for patients and a huge difference for your practice because people love it and they see the visible change. Sometimes with back pain it's

like you treat someone, they get relief. Sometimes you treat them, they don't get relief for 3 or 4 days, 5 days; they're

like, 'Oh well, it wasn't really the path I saw; it was going to come good

anyway.' It's not like this with shoulders. They come in, they're like, 'Oh, what's your problem? I can't move my arm more than

here.' You take them out at the end of treatment; they can move it up to here. They see that; they are stunned and they

Love it. Now, of course, not all shoulder injuries will respond as quickly as that, and you have to identify the ones that

won't. How? By doing your orthopedic testing. Now we see orthopedic testing. People will bring the arm up into here

and you're testing this range. Well, that's pretty hard if they can't get it up to that range. So what you do? Well, you take

them into this kind of range. What can they do in this range here? Okay, well you might do a little bit of testing; you

might get them to push up against you, and if that's incredibly painful, then you're not going to go any more than

that. But that doesn't mean you can't work on the coracobrachialis; you can't work on these muscles through this area here.

Why? Because you're in this range anyway. Either the arm is still and you're working on it, or you're working with

that little bit of movement I showed you. And then we'll retest, and then we go, okay, now we can get a bit

further. Interesting. Okay, you might not rotator cuff test again because you don't want to aggravate them too much.

You might then work a little bit more through here, work through the pecs, and see if you can get a bit more motion. Now if

you can come up to here, say here, yes, we'll do a rotated cuff, and we might get a better idea of what's happening

because you might have these muscles contracting down; you might have the coracobrachialis in trouble and the other muscles

in trouble and still have a rotator cuff test. So please listen to it; make sure you do your rotator cuff test; make sure

you are safe to treat. All that stuff I showed you is safe to treat. Why? Because you've got it in this range of motion

here; you're not taking it up and stressing it into an area which is going to damage it further. And if you have any

doubts about them having a rotator cuff injury, you refer them off. Why? Because within 6 weeks, that will start to fill in with scar

tissue. Because you want to refer them off, it's going to take a few weeks to get a referral and get them to see an

orthopedic person. So if they're going to get surgery, you want that surgery before it starts filling in with scar tissue.

But notwithstanding that, doesn't mean you can't work with it in that range, through that area, start to get

change, a bit more slack now. We can work on it a bit more, etc., etc. Now, of course, there's lots you can do in terms of the

joint as well. I'm not going to go into this. I've got a whole course that talks about shoulders and treating shoulders,

50 videos long, so you know that's something that we can't cover just in one video. But I want to talk about

those easy wins that we talked about; working on the muscles, also being safe, talk about these rotator cuff injuries and

making sure we screen for those. And then I want to move on and talk about the third type of patient, and that's the

type of patient that is long-term. What I mean by that is not necessarily long-term—you've got to treat them long-term—but

Osteopathy Treatment Techniques: Treating the Shoulder

Kindred Academy

Initial Expectations and Challenges in Shoulder Treatment

Patients often present with restricted range of motion.

Determining realistic treatment goals is crucial; full range of motion might not be achievable in one session.

Conditions like rotator cuff tears may require referral to specialists.

The complexity of the shoulder involves numerous interacting muscles (pecs, deltoids, biceps, trapezius, rhomboids, triceps).

Joint issues significantly impact shoulder function.

Coracobrachialis Muscle and Humeral Head Movement

Shoulder abduction is demonstrated, highlighting the coracobrachialis muscle.

Working on the coracobrachialis and surrounding muscles can improve shoulder function.

Muscle contraction protects the injured area, potentially leading to humeral head jamming in the socket.

Humeral head movement during abduction is analyzed; it doesn't simply move upwards.

Smooth humeral head movement is ideal; coracobrachialis contraction can disrupt this smoothness.

Treatment Techniques and Patient Outcomes

Biceps involvement mirrors the coracobrachialis impact on the joint.

Gentle inhibition techniques are applied to the biceps and coracobrachialis muscles.

The described technique normalizes muscle function, leading to improved range of motion.

Shoulder treatment often yields immediate, visible results, unlike some back pain treatments.

Orthopedic Testing and Safe Treatment Practices

Orthopedic testing helps identify cases requiring referral.

Treatment can be adapted to the patient's limited range of motion.

Prioritize safety; avoid aggravating the injury during treatment.

Refer patients with suspected rotator cuff injuries promptly to prevent scar tissue formation.

Chronic Shoulder Dysfunction and Respiratory System Involvement

Long-term shoulder injuries may involve the chest wall and respiratory system.

Chronic shoulder problems can lead to various compensations throughout the body.

Lung involvement can be a factor in long-standing shoulder injuries.

Lung lobe shifts can contribute to stubborn chronic shoulder pain.

Addressing lung lobe compensations can improve treatment outcomes.