Painful shoulder?

A problem in the shoulder

Many patients will attend the clinic with shoulder pain as their main presentation. A number of problems can occur in the shoulder as it is a complex joint that we can put a lot of stress on.

Having ruled out the pain the patient has as definitely coming from the shoulder, and not referred from anywhere else such as the neck, we start to examine the different tissues and discover the source of the pain. 

 

 

As you can see from the picture there is a lot going on in the shoulder joint!

 

A very common problem is damage to part of your rotator cuff mechanism and that's what we will concentrate on in this blog.

 

Because the shoulder is such a mobile joint we have the normal supporting structures such as the ligaments and bony structure but there is a special set of muscles called the rotator cuff.  This cuff is made from four muscles that form a cuff around the shoulder joint therefore increasing its stability. 

 

Damage to these muscles can occur suddenly through an injury such as forcing your arm out to the side for example slipping on the stairs whilst holding onto the banisters. More often through these muscles become damaged slowly over time as part of the natural degenerative process.  Because the muscle on the top of the shoulder blade, the supraspinatus, has quite a poor blood supply this process tends to affect this muscle more so.  See the below image.

 

 

 

 

Treatment can help depending on the severity of the damage.  Often night pain is common and patients describe a throbbing pain that keeps them awake.

 

A lot of the rehabilitation with shoulder problems comes down to the same word again...posture!

 

If these muscles are under stress because of something you do then the damage will not get better.  Often sleeping position can be the culprit where people place their hands under the pillow or over the head.  

 

Rehabilitation often consists of graded exercises to strengthen the muscle to allow return to function once again.



Degenerative Disc Disease

Having attended the NSpine 2013 conference last week we came away with a mass of updated information regarding low back pain, surgical techniques, new research and procedures available to our patients.  It was fantastic to be listening to the same speakers as some of the most highly regarded surgeons in the world.

A lot of the talks focussed on degenerative disc disease (DDD) which is what this blog will be about.

Discs can degenerate for a number of reasons but unfortunately there is a strong genetic link. You are at higher risk of low back pain if you have a family history of DDD.

In DDD, it is thought that the discs dehydrate leading to a reduction in pressure in the discs.  This allows the disc to be more vulnerable to stress, therefore creating tears in the annulus. As a result rotation is very poorly controlled in the damaged segment. In turn this means the facet and capsule, that is attached to the facet hypertrophies, (becomes larger).  The next stage is then osteophyte formation which is the bodies attempt to re-stabilise the area. 

As part of this process if there is enough material in the centre of the disc and it 'leaks' out through theses tears this material can press on a nerve root leading to nerve compression.

All in all this can present clinically as low back pain with or without leg symptoms. It can be a chronic problem where people have pain for many years. 

One option to help DDD maybe surgery where the spinal consultants perform a fusion. (see image below).  Here they remove the interverbral disc and take a piece of bone, normally from your iliac crest/'hip' bone to use instead.  They place this part of bone where the disc was and use a system of screws and metalwork to hold it in place.  The end result is a 'fused' segment or segments depending on how many discs are affected.  The range of movement is lost at that segment but nearly normal mobility remains due to the movement in the rest of the spine and hips.

 

 

This unfortunately has only a 60% success rate with one in four patients having some remaining pain and/or disability after.  Often and particularly depending on the patients general health, the surgeons would prefer not to operate as the function, indicated by daily activities the person performs, one year after surgery is equal to the group of patients who had only conservative management ie./ manual therapy. 

Stress-the cause of pain?

We are often asked if the source of a patient's problem could be stress related?

The word 'stress' is open to interpretation and is often assumed to be negative whereas in actual fact some stress is essential to daily life or we would have no urgency to complete any tasks. 

In this context assuming the word 'stress' means 'excessive pressure or worry' then how do you get physical problems as a result?

All emotional states are reflected in the position and posture we adopt.  Think of the classic Charlie Chaplin surprised face. 

When an individual is stressed the typical posture they adopt is elevation of the shoulders.  The jaw can get tighter overloading the muscles around the jaw joint and those that run along the side of the neck.
Because a lot of the muscles that move the shoulders come from the neck, the tension in the shoulders transfers into the neck. Muscles then become fatigued causing pain themselves.  The picture is further aggravated by compressing the vertebrae potentially irritating the facet joints.  Headaches can then develop.

As part of the stress picture, breathing patterns alter leading to upper rib breathing taking over from diaphragmatic breathing.  This overworks the muscles at the front and side of the neck.

If this pattern is maintained for a while the muscles can change and symptoms can continue even after the stressor has eased. 

Try taking deep breaths to help stretch the diaphragm and relax the muscles.