The shoulder is a joint of high acclaim. Isaac Newton “stood on the shoulders of giants.” We cry on our friends’ shoulders when disaster befalls us. They are the joints that allow us to perform complex manipulations of objects. Without a mobile shoulder joint what good is an opposable thumb? We could still play video games and conduct a text message conversation, but we could not hold an infant child or rebuild the World Trade Center.
At Symmetry Physical Therapy we see many people with shoulder dysfunction of various types. But before discussing how we approach assessment of these injuries, we should carefully define the shoulder joint. If I ask a patient who declares they have shoulder problems to point to their site of pain, they may touch the specific joint, but may also indicate their pectoral region, perhaps their shoulder blade (scapula), or even the exact center of their upper back. Instinctively, these people understand that there are intricate interconnections between these regions. And this intricacy merits thorough consideration by your physical therapist.
To be technical, the ‘shoulder’ is the place where the rounded end of the upper arm bone (humerus) meets with the shallow cup (glenoid) of the scapula. This is called the glenohumeral joint. However, this joint becomes more complex because the scapular side of it also interfaces with the rest of the body via multiple muscles – much like a floating dock held in place by multiple lines tied to anchors. The scapular muscles attach to the spine, ribs, pelvis, and upper arm. There is also an attachment of the outer part of the scapula (acromion) to the collarbone (clavicle). This is the only true bony connection of the arm to the central skeleton.
So when a patient has a complaint of “shoulder pain” there are many potential areas of concern. How do we determine what might be causing the pain? To begin investigating, we take a thorough medical history and inquire as to the mechanism of injury (MOI). The MOI may be traumatic, like a fall, or it may be a more cumulative repetitive strain or posture problem. We also want to know what activities or tasks are painful or difficult since the injury. In fact, we use questionnaires called “Outcome Measures” to get an objective baseline score of the patient’s function in their affected body region. The outcome measure that we use most commonly for the shoulder is the Quick DASH (short for Disabilities of Arm, Shoulder, and Hand).1 At various points during the course of physical therapy treatment we can gauge progress with these questionnaires, which allow the therapist and the patient to see how far they have progressed – often in a relatively short time.
After gathering adequate information to piece together a picture of the cause and the contributing factors to an injury or pain problem, we then perform a physical examination of the shoulder and the ‘shoulder girdle’ – including the scapula, clavicle, and associated spinal and ribcage structures. Physical examination includes assessing range of motion (ROM), which is essentially measuring the freedom of specific shoulder motions. Then we assess joint play, which is the very small “jostle” that is available directly at a joint. This provides valuable information about how the joint functions when the patient moves the arm, about the severity of injury, about the phase of healing, and about what tiny structures could be damaged and causing pain and dysfunction. Along with assessing joint play we may use special provocative tests to single out specific structures – to find what reproduces the patient’s specific pain.
During a shoulder examination we also assess muscular strength. We are looking for possible weakness and whether or not there is pain with resisted movement. We also observe the patient’s coordination while demonstrating their current strength. We want to know how the different body parts work together and in what sequence the muscles contract. Certain patterns of dysfunctional muscular coordination reveal themselves with specific injuries. For example, a patient with a rotator cuff tear may hike their scapula up using substitute muscles – shrugging to raise their arm overhead rather than performing the movement with a smooth pattern using rotation of the scapula along with elevation of the arm.
Finally, we also look for potential nerve involvement – screening the health of nerve tissue running between the neck and the arm. In a sense, the neck is the “fuse box” of the upper extremity. Major signal pathways branch off the spinal cord in the mid-to-lower neck and travel down arm and into the hand. These nerves can be irritated or entrapped, which can affect muscle strength or skin sensation in the shoulder, elbow, hand and fingers. Nerves are also pain producers – causing symptoms anywhere in the shoulder girdle and upper limb.
So back to the question of what might be causing shoulder pain? The answer might lie anywhere within the shoulder girdle, or also in the neck or upper back. The answer might involve ligaments, tendons, muscles, bones, joints, nerves, or some combination of several of these things. And the ‘cause of the cause’ of the pain might be related to a specific incident or injury, but could also involve posture, movement patterns, or underlying challenges to any of several body systems. It is our job as physical therapists to do the detective work of analyzing this complex joint, so that an effective treatment plan can be performed.
We use our shoulders for myriad life tasks, including useful idioms. After reading this we hope you will feel empowered to stop looking over your shoulder in fear of when you might have the next painful shoulder ‘twinge’ with a reach overhead or on donning a jacket. You don’t have to carry the weight of the world on those shoulders any longer once you have a skilled PT in your corner! Let’s stand shoulder to shoulder and give that nagging injury the cold shoulder. You have a good head on your shoulders, so when you find that you need excellent musculoskeletal healthcare, we invite you to contact us at Symmetry Physical Therapy so that we can help you to ‘shoulder’ the load of recovery!
- Macdermid JC, Khadilkar L, Birmingham TB, Athwal GS. Validity of the QuickDASH in Patients With Shoulder-Related Disorders Undergoing Surgery. J Orthop Sports Phys Ther. 2015;45(1):25-36.