SHOULDER IMPINGEMENT SYNDROME

Shoulder pain and dysfunction can have a variety of root causes. Chiropractors will directly or indirectly address shoulder problems since a large percentage are related to poor function and alignment of the cervical spine and upper thoracic spine preventing normal alignment of the shoulder girdle. However in this particular blog I want to talk about the more intrinsic presentation of shoulder pain and dysfunction, called shoulder impingement syndrome.

Shoulder impingement syndrome is actually a bit of a broader umbrella itself. In a nutshell, it describes a problem whereby the space above the ball of the head of the humerus and the bony bridge of the a acromioclavicular joint is narrowed, causing a pinching of the structures located in between, mostly some of the rotator cuff tendons and the bursa.

Shoulder impingement syndrome can fall into 2 categories, which sometimes overlap:

– static impingement syndrome describes a more or less permanent narrowing that is not affected by the movement and position of the arm. This happens when there is for example a bony outgrowth on the inferior aspect of the acromioclavicular joint, or some calcification of the tendon. The impingement will be the same regardless of the position of the arm. Those tend to be more difficult to resolve conservatively, since there are fewer ways to impact the problem. Thankfully it's a minority of the shoulder impingement presentations.

– Dynamic impingement syndrome describes an impingement that is the variable based on the position and movement of the arm. The vast majority of impingement syndromes are in the anterior aspect of the shoulder, sometimes lateral, and infrequently posterior. The main reason for the anterior dominance have to do with modern humans tendency to have very dominant anterior shoulder muscles pulling them in a rounded forward shoulder position, as well as the fact that the shape of the acromioclavicular joint tend to slope downward in the front of the shoulder, thereby predisposing more easily to impingement in the front.

Presentation of dynamic impingement syndrome often is anterior shoulder pain, sometimes radiating down the arm, when the arm is repetitively moving above the head or to decide, especially if additional weight is held, more pain when the shoulders slumped forward, or if this pressure to the anterior arm such as when sleeping on that side. Shoulder impingement syndrome is often found in combination with other shoulder problems such as acromioclavicular bony spurs, anterior frozen shoulder.

Resolving a shoulder impingement syndrome requires to look at all the modifiable factors that can be corrected to improve the clearance of the humeral head in relationship to the acromion especially when the arm is lifted forward or to the side:

– alignment of the neck and upper back in relationship to the shoulder blades. Anterior neck postures, rounded mid back and shoulder blade well-positioned the humeral head forward, in an already narrow subacromial space.

– Muscular balance between the front and back of the shoulder, which often goes with the anterior neck and upper back posture. This will require some manual release of the anterior contracted musculature and some passive as well as active retraining of the posterior shoulder stabilizers.

– Chronic scar tissue in the bursa, rotator cuff tendons, and anterior joint capsules. Those can fixate the head of the humerus superior and anterior, effectively narrowing the subacromial space with little to no margin during arm flexion and abduction. Manual adjustments of the humeral head as well as very specific soft tissues scar releases important to resolve this.

– Scar tissue and myofascial adhesions in the muscle group known as "humeral depressors", which are deep axillary muscles, in charge of pulling the head of the humerus down during arm flexion and abduction in order to create a little more space for the rest of the rotator cuff tendons. I find that to be often the missing part of the treatment plan to resolve long-standing shoulder impingement syndrome when people have already been working with physical rehab.

– Revisiting some of the patient's chronic triggers from the activities: sleeping position on the side without adequate support of the cervical spine can set up a cycle of chronic recurrent shoulder pain. Technology has been a huge problem, especially as computer use requires less keyboarding and more computer mouse usage, with the arm chronically rotating anterior. Ergonomic modification of the placement and type of computer mouse can be really helpful.

WHAT CAN GO WRONG WHEN YOU FALL ON YOUR ARM

https://www.youtube.com/shorts/kKP5KtWSxVw

We've seen so many of these injuries this week that I decided to record a short video with the help of my staff to review all the things that can go wrong when you fall on your arm. I thought it was an important educational material to have available since so many people fall and develop problems that they do not connect to the original incident. Especially since the area of symptoms may be far away from the point of impact on their hand and wrist.

Where the injury exactly will occur along the kinetic chain from the hand to the neck depends on a variety of factors, some of it having to do with the angle, and the speed of reaction and trying to break the fall. I've seen some patients develop along acute cervical disc herniations from the side to side during when they're caught off guard during the fall and the neck experiences a form of lateral whiplash. Probably more common are the areas along the shoulder girdle. I especially find that the sternal clavicular joint, at the end of the anterior kinetic chain, can be a source of continued misery and destabilization along the anterior neck and chest, often overlooked and even more often undertreated.

SHOULDER PAIN AND SIDE SLEEPING

https://www.youtube.com/watch?v=7Qrcm2jk6CM

A very overdue simple hack blog about shoulder pain in the side sleeping position. I think a lot of people understand the problem with sleeping on the painful shoulder, but not as many people understand that the top shoulder can also be a problem due to side sleeping position.

WHAT ARE THE SCALENE MUSCLES AND WHY DO THEY MATTER ?

It's a question that came up a couple of times this week, always an omen that it's time to blog about it.

The scalenes are a group of 3 muscles, small, but mighty. They are located in the front of the neck, attaching to the anterior lateral aspect of the vertebra and traveling downwards, with one group attaching all the way to the 1st rib just behind and below the clavicle. They are involved in fine motion of the cervical spine such as rotation and lateral bending.

The scalenes are important in many regards:

– as 1 of the primary middle layer of the anterior neck muscles, they are easily injured with rapid extension injuries to the neck which can happen during motor vehicle accidents, falling backwards, and sports. Without involving any additional neurovascular compression, which I'm going to touch on below, the scalenes stem cells can be the source of significant chronic posttraumatic pain, anterior neck posture, and vague radiating pain in the throat and anterior chest

– probably 1 of the most significant contribution of the scalene muscle group is the ability to cause compression over the neurovascular bundle, which is the combination of nerves and arteries and veins that travel between the anterior and middle scalene, just above and then behind the 1st rib, into the arm. This will often result in a sensation of vague pain, tingling, prickly achy sensation in the upper extremity, which does not seem to follow a single nerve root pattern from the cervical spine because the brachial plexus bundle of nerve is comprised of several cervical nerve roots.

https://www.bwclinic.com/blog/2024/11/21/what-are-the-scalene-muscles-and-why-do-they-matter-

SCROLLING TENDINITIS (DE QUERVAIN'S TENOSYNOVITIS)

https://www.youtube.com/shorts/GCtCfrTNej8

I have seen several of these cases recently which then again prompts me to get behind the camera and record a short educational video. Wrist tendinitis can be caused by multiple types of activities, but the increasing number of repetitive strain injuries associated with the use of smart phones, especially single hand phone handling that relies on thumb scrolling, seems to be an increasing percentage. The thumb extensor tendon loops underneath a dorsal wrist ligament called the retinaculum, and the friction of the tendon underneath the retinaculum creates pretty significant inflammation and scarring over time, leading to pinpoint pain on the inside of the wrist during activities that involve wrist extension, holding and picking up objects, and rapidly moving your hand towards the outside of your wrist. When it's becoming an entrenched problem, we have to treat it obviously, but the proverbial ounce of prevention goes a long way in this case. Making sure you scroll with the opposite hand of your phone holding hand will virtually eliminate a lot of left-sided wrist tendinitis, which means that occasionally you have to put on your cup of coffee to use your right index to scroll. Better yet, get off your smart phone and start doing something more beneficial for yourself.

Tennis Elbow ( even if you don't play tennis)

"Tennis elbow" is a term that actually encompasses a variety of different pathologies affecting the lateral elbow, and has been described by 1 of my savvy patient as "the most unglamorous yet truly painful and brutally persistent" condition of the upper extremity. You never really know how much you use your lateral elbow until you find yourself unable to do simple tasks such as picking up a cup of coffee without wincing in pain. You're not even thinking about playing tennis at that point...

In medical terminology, conditions of the lateral elbow are often referred to as "lateral epicondylitis". A catch all term for repetitive strain injuries of various soft tissues of the lateral elbow. The reality is a little more nuanced, since that piece of real estate is dense in many structures: wrist and finger extensor tendons, lateral collateral ligament, supinator muscles, lateral myofascial edges of the triceps, radial head, radial head bursa, and traversing branch of the radial nerve. The mechanisms of trauma can be repetitive overuse injuries, or can actually be triggered by an initial single trauma such as pulling too hard on a stuck object, setting the cycle for continued reinjury with normal use.

Traditional treatment of lateral epicondylitis involves a combination of supportive measures such as heat, ice, resting from aggravating activities, and light bracing with activities. It will work for some people, but the truth about tennis elbow is that it can be persistent for a really long time and not respond to those first-tier approaches.

One of the reasons for the poor response of tennis elbow cases to traditional approaches is that tennis elbow is often the proverbial "singing canary" for mechanical and myofascial problems upstream. In order for the elbow to properly do its job, especially during repetitive activities, it needs normal stability of the scapula on the upper thoracic spine and the external rotators of the shoulders. If both of these mechanisms fail to function properly, the elbow flexors and extensors will be working harder during normal activities. And eventually get injured.

When patient presents with persistent poorly healing tennis elbow symptoms with normal treatment,we will need to look at the following silent upstream problems:

– global position of the shoulder girdle, especially with a lot of rounded shoulders and protraction, and poor function of the shoulder blade muscles. Patients will often have "winging" of the scapula either when sitting or when using their arm.

– Alignment and function of the upper thoracic spine, for silence spinal functional lesions, especially those that cause continued flexion and loss of normal rotational joint play.

– Mechanical problems of the cervical spine that cause some low-grade irritation of the C5 and C6 nerve roots, since they are responsible for firing the stabilizing muscles on the inside of the blade, which are essential to offload elbow muscles during arm activities.

The bottom line is that an elbow pain is sometimes not just an elbow pain. Even with upstream problems, which will require chiropractic and myofascial interventions to the neck, upper back and shoulder blade, the elbow problem may have become a separate entity that needs co-treating in order to fully recover. Local treatments involve soft tissue therapies that help break up scar tissue, and improve blood flow to the affected areas that are often very fibrous, stabilizing kinesiotaping, active range of motion retraining etc. Ultrasound therapy can often be extremely useful short-term as well as infrared therapy as a home therapy. There are lots of options available, and there is no reason to wince every time you pick up your well-deserved morning cup of coffee.

( photo courtesy of Racool studio)

CAN I HAVE A PINCHED NERVE IN MY SHOULDER ?

It’s another 1 of those questions I field almost every day, and for which I finally decided to write a reference blog to direct patients to.

The short answer is yes, and the devil is in the complicated details. Patients will often ask that question when they're presenting with a type of shoulder pain that feels very "nerve like", and have been told that there is no pinched nerve in the cervical spine to account for the pain. It's important to note that a large proportion of shoulder pain can indeed be referred nerve pinching pain from the cervical spine.

If you want to get clinical, and if you consider the shoulder a broad area from the lower neck into the upper arm, from the clavicle to the shoulder blade, the number of peripheral nerves you can entrap is surprisingly high, but in this blog entry I wanted to focus on four neurological structures that are subject to impingement from functional shoulder disorders (misalignment, trauma, muscular imbalances especially): the brachial plexus, the suprascapular nerve, the long thoracic nerve, and the axillary nerve. As you can see from the various images, they are distributed in various parts of the shoulder girdle close to neuromusculoskeletal structures such as the shoulder joint, the clavicle, and various deep muscles of the shoulder. Of these 4 structures, the brachial plexus receives the lion share of the peripheral shoulder entrapment syndromes, because of the length of its path from the lower cervical spine into the upper arm, and the number of structures it has to traverse. It also gives rises to several of the secondary peripheral nerves. Incidentally almost all of the peripheral nerves travel alongside with correlating vascular structures, meaning that peripheral nerve entrapment syndromes also are often jointly vascular entrapment syndrome (with symptoms associated with decreased blood flow to an area). Developing shoulder entrapment syndrome can be both acute and chronic, often the result of long-standing postural shifting of the shoulder, as well as one trauma or acute sprains. Ultimately treating the underlying mechanism of nerve entrapment is the best way to address them.

Home soft tissue treatment for symptoms of carpal tunnel

We finally got around to recording the instructional video for patients using the Armaid tool to control symptoms of carpal tunnel associated with repetitive soft tissue strain of the upper extremity. It's going to be much more effective if we can have a 15 minutes set up time in the office, to make sure that each patient can properly locate the trigger zones, since everyone's primary area of soft tissue entrapment can be a little bit different.

https://studio.youtube.com/video/6dR7TZnJtnM/edit