Chiropractic management of shoulder pain and dysfunction of myofascial origin using ischemic compression techniques

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Chiropractic management of shoulder pain and dysfunction of myofascial origin using ischemic compression techniques
The Canadian Chiropractic Association
Guy Hains, DC, Private practice, 2930 CŸte Richelieu, Trois-RiviÀres-Ouest, Canada.

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Shoulder pain and dysfunction is a chief complaint commonly presenting to a chiropractorÌs office. The purpose of this article is to review the most common etiologies of shoulder pain, focusing on those conditions of a myofascial origin. In addition to a review of the literature, the author draws upon his own clinical experience to describe a method to diagnose and manage, patients with shoulder pain of myofascial origin using ischemic compression techniques. This hands-on therapeutic approach conveys several benefits including: positive therapeutic outcomes; a favorable safety profile and; it is minimally strenuous on the doctor and well tolerated by the patient.

(JCCA 2002; 46(3):192Ò200)

KEY WORDS: shoulder pain, dysfunction, myofascial pain syndromes, ischemic compression, chiropractic.

Introduction
Shoulder pain and dysfunction is a common chief complaint prompting a patient to seek out chiropractic care. According to the Job Analysis of Chiropractors 2000, upper extremity pain and injury account for 8.6% of the chief complaints among chiropractic patients (this number does not include those patients with upper extremity pain as a secondary complaint).1 Moreover, after low back pain, shoulder pain is the second most common cause of occupational injury claims.2 These statistics are not surprising when one reviews the anatomical structure of the shoulder. Being a multiaxial joint capable of complex movements, the shoulder is prone to a vast number of different pathologies. These include adhesive capsulitis (Îfrozen shoulderÌ), any number of arthritides (osteoarthritis, rheumatoid arthritis, polymyalgia rheumatica, etc.), several inflammatory conditions, and impingement syndromes of different etiological sites.3 Of all the different pathologies affecting the shoulder, impingement syndromes are the most common, especially those involving the rotator cuff tendons.4Ò6 Several recent studies have shown that these conditions can be successfully managed with conservative therapies, including chiropractic care.7Ò11 Foremost among these therapies are mobilization and ischemic compression techniques.

In addition to a review of the relevant anatomy of the shoulder, the author provides a review of the relevant literature, as well as drawing upon his own clinical experience with respect to the successful management of patients with shoulder pain and dysfunction. It is the authorÌs intent to provide the reader with a therapeutic model focussing on ischemic compression for the management of those patients presenting with shoulder pain of myofascial origin.

Anatomy review
The shoulder is a complex, ball and socket synovial joint, comprised of the humerus, scapula and the clavicle. The labrum is a ring of fibrocartilage that surrounds and deepens the glenoid cavity of the scapula. The resting position of the glenohumeral joint is 55Ì of abduction and 30Ì of horizontal adduction.12,13 When relaxed, the humerus sits in the upper part of the glenoid cavity; with contraction of the rotator cuff muscle, it is pulled down in the lower aspect of the glenoid cavity. It is this Îdropping downÌ that permits abduction (Figure 1). There are three joints that are intimately involved with shoulder mechanics, permitting its multiaxial movements. These are the sternoclavicular joint, the acromioclavicular joint and the glenohumeral joint.12,13 In addition, although not a true joint, the scapulothoracic ÎjointÌ functions to allow maximal shoulder motions, particularly abduction.12,13 What makes the shoulder unique among all the joints of the body is that its support, stability and integrity depend on muscles rather than bones or ligaments.13

Several large muscles influence the stability and movement of the shoulder joint. For example, the tendon of the long head of the biceps muscle originates from the upper edge of the glenoid cavity, traverses anterior to the head of the humerus along the bicipital groove and inserts into the radial head.12 Other important muscles involved with normal shoulder mechanics are the deltoid, trapezius, levator
scapulae, pectoralis and rhomboid muscles.12 However, recent studies have shown that it is the group of muscles known as the rotator cuff that is most commonly involved in myofascial pathologies of the shoulder.4Ò6,14,15 The rotator cuff muscle group is comprised of the supraspinatus, infraspinatus, teres minor and subscapularis muscles (the SITS muscles). Each muscle originates on different aspects of the scapula, and crosses the glenohumeral joint. The supraspinatus, infraspinatus, and teres minor each inserts into the greater tubercles of the humerus, whereas the subscapularis muscle inserts into the lesser tubercle of the
humerus.12 In addition to initiating most shoulder motions, the SITS muscles also serve to stabilize the glenohumeral joint.13 The subacromial bursa is located between the tendons of the rotator cuff muscles and acromion, providing a frictionless surface upon which the tendons can glide during shoulder motions.12,13

According to Kalb,14 ninety-five percent of all cases of shoulder pain are attributable to the tendons of the rotator cuff becoming impinged between the greater tuberosity of the humerus and the anterior edge of the acromion, especially during motions that position the arm above the head. Thus, impingement syndromes are the most frequent types of shoulder pathology, and are often the result of the cumulative effect of the rotator cuff tendons constantly passing under the acromion hood.14

Clinical presentation
In a recent article, Norregaard et al.15 suggested that there is terminology chaos within the field of shoulder pathologies, and even trained clinicians may disagree about the diagnosis when examining the same patient. Clinical conditions involving the rotator cuff muscles may interchangeably be referred to as rotator cuff tendonitis, supraspinatus tendonitis, impingement syndromes and subacromial pain syndrome. These authors go on to state that, since many of the orthopedic tests used to examine the shoulder are only cursorily validated, there is no consensus on clinical criteria. This had led to the use of different clinical criteria among those epidemiological studies conducted in this area.15

A patient experiencing an impingement syndrome usually presents with pain in the anterolateral region of the deltoid, which then radiates to the lateral upper arm.4,10 The pain typically does not radiate below the elbow. The pain is often worse at night, and is aggravated if the patient positions the arm over his or her head.4,10 Other pathognomonic signs of an impingement syndrome include crepitus, tenderness of the supraspinatus tendon, and a Îpainful arcÌ experienced between 60 to 120 degrees of abduction, although the painful arc may also be observed in cases
of subacromial bursitis.11Ò14 However, the drop-arm or CodmanÌs test is positive only in cases of rotator cuff injury. For this test, the patient is asked to slowly lower his or her arm from a position of 90Ì of abduction. A positive sign is indicated if the patient is unable to slowly lower the arm to the side of their body, or if he or she experiences severe pain while attempting to do so.13 Other orthopedic tests that are often pain producing for patients with impingement syndromes are the Hawkins-Kennedy test (arm flexed to 90Ì and forcibly medially rotated) and the Neer test (arm forcibly elevated through forward flexion).13
According to Neer,16 there are three consecutive pathological stages associated with an impingement syndrome. These are: (i) inflammation, edema and hemorrhage of the tendon, (ii) fibrosing and thickening of the sub-acromial tissue, accompanied by partial tearing of the supraspinatus tendon and (iii) tearing of the rotator cuff and osteophyte formation.

Since the 1980s, a number of authors have discussed the importance of myofascial pain syndromes (MPS).17Ò25 Within health care circles, MPS is now recognized as a
leading cause of musculoskeletal pathologies, and it should be suspected in any patient suffering from chronic pain.17 The most characteristic symptom of MPS is the presence of palpable nodules sensitive to digital pressure. Typically, the patient exhibits a jump sign if a sensitive nodule is palpated.15 These nodules, which represent focal, hypersensitive points within a muscle, are referred to as trigger points (TPs).21,23 When compressed, they give rise to a characteristic pattern of referred pain distant from the point of contact. The pain is diffuse and often radiates to an area representing the symptomatic site.25 In almost all cases, digital pressure on the painful point will reproduce the symptoms of the chief complaint, or even worsen the level of reported pain. The area of maximum tenderness, often approximately 1 square centimeter in size, is referred to as a tender spot (TS).23 In other words, tender spots differ from trigger points in that the former are defined as discrete areas of soft tissue that are painful to
about 4 kg of palpatory pressure, whereas the latter are defined as hyperirritable spots located within a taut band of skeletal muscle that are painful to compression and give rise to characteristic referred pain patterns and autonomic
symptoms.23 However, it should be noted that even experts find it difficult to distinguish between trigger points and tender points and no reliable diagnostic criteria have been established for myofascial pain syndromes.15

Both tender spots and trigger points may exist in muscle tendon, ligament, fascia or fibrous articular capsule.25 Differential diagnoses Contrary to popular belief, partial or complete tearing of the rotator cuff is often asymptomatic.26 For example, Sher26 reported that, of 96 asymptomatic patients examined using MRI imagery, 15% had complete tearing of the rotator cuff, with an additional 20% showing signs of partial tearing. In that study, the frequency of tearing increased
with the age of the patient. Of the 46 patients examined over the age of 60 years, 28% had a complete tear of the rotator cuff, and 26% had partial tears. These findings led Sher to conclude that tears of the rotator cuff often are compatible with normal painless use of the shoulder.26

The symptomatic characteristics of biceps tendonitis are pain and inflammation of the tendon of the long head of the biceps. The pain is felt along the anterolateral aspect of the shoulder. The biceps tendon will often be painful as it travels along the bicipital groove of the humerus.10 Neer G Hains
J Can Chiropr Assoc 2002; 46(3) 195 recently reported that one-third of patients suffering from impingement syndromes demonstrated bicipital tendon anomalies pre-operatively.16 Both YergusonÌs test (resisted forearm supination with elbow flexed to 90Ì) and SpeedÌs test (resisted shoulder forward flexion) are often positive.13 The author has found that bicipital tendonitis is a common finding among patients in private practice. For example, of 25 patients randomly selected who were experiencing shoulder pain, 21 displayed signs of bicipital tendon hyperirritability.

Other pathologies commonly found in the shoulder involve the muscles or tendons of supraspinatus and subscapularis. These can be differentiated by the Empty can
test (resisted abduction with arm at 90Ì abduction and medial rotation) and Lift-off sign (patient asked to lift hand off his or her lower back) respectively.13 Another common condition affecting the shoulder is adhesive capsulitis (frozen shoulder).11,27Ò30 Adhesive capsulitis is characterized by severe limitations of all shoulder motions with both active and passive movements.
27,28 It is this limitation of passive motion that differentiates adhesive capsulitis from impingement syndromes. The etiology of frozen shoulder is often idiopathic, 4 but may be subsequent to trauma, periods of emotional stress, surgery, and other medical pathologies (diabetes, thyroid disease, myocardial infarction, cerebrovascular accident, and so on).30 Plain film x-rays are typically unremarkable.30 Paradoxically, according to Kozin,27 upon examination, the capsule demonstrates neither inflammation nor adhesions. Although the natural
history of adhesive capsulitis is for it to resolve on its own without treatment, this may take anywhere from 6 months to 2 years amd some patients may suffer residual discomforts for even longer.28

Some experts have cited shoulder joint calcification as a possible cause of shoulder pain.31 However, in a study of patients with shoulder bone calcification, Welfing reported that of 925 symptomatic shoulder cases, 63 patients (6.8%) had some evidence of calcification.31 By contrast, in another study of 200 asymptomatic patients, 7.5% had calcific deposits in the shoulder. This led the investigators to conclude that the frequency of shoulder calcification is virtually identical in both symptomatic and asymptomtic patients.31

Lastly, shoulder pain may originate from the spine or the viscera. Shoulder pain of cervicogenic origin is suspected in cases where neck movements (flexion, extension, rotation and lateral flexion) reproduce the chief complaint. 13,32 Conversely, shoulder pain originating from the shoulder seldom radiates to the neck. Furthermore, shoulder pain may stem from the thoracic or lumbar spine33 and
pathologies of the gall bladder (cholecystitis) have been known to refer pain to the shoulder.34

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References
1 Christensen MG. Job Analysis of Chiropractic. National Board of Chiropractic Examiners 2000. Greeley, Co. p 78Ò79.

2 McDermott FT. Repetitive strain injury: a review of current understanding. Med J Australia 1986; 144:196Ò200.

3 Souza TA. Differential diagnosis and management for the chiropractor: Protocols and algorithms. 2nd Ed. Aspen Pub. Gaithersburg, Maryland. 2001;165Ò168, 179Ò189.

4 Curtis AS, Wilson P. Shoulder pain in the work place. Orthopedic Clinics of North America 1996; 27:763Ò781.

5 Farber JF, Singleton SB, Hawkins RJ. Rototor cuff disease: Diagnosing a common cause of shoulder pain. J Musculoskeletal Med 1998; 15:15Ò25.

6 Bergman TF, Conley RN, Davidson WT. Grand Rounds: Right shoulder pain in a 73 year old man. JNMS 1997; 5:74Ò81.

7 Leahy MP, Mock LE. Myofascial release technique and mechanical compromise of peripheral nerves of the upper extremity. Chiropractic Technique 1992;6(4):139Ò150.

8 Roubal PJ, Dobritt D, Placzek JD. Glenohumeral gliding manipulation following interscalene brachial plexus block in patients with adhesive capsulitis. JOSPT
1996; 24(2):66Ò76.

9 Hanten WP, Olson SL, Butts NL, Nowicki AL. Effectiveness of a home program of
ischemic pressure followed by sustained stretch for treatment of myofascial trigger points. Physical Therapy 2000; 80(10):997Ò1003.

10 Daigneault J, Cooney LM. Shoulder pain in older people. J Am Geriatr Soc 1998; 46:1144Ò1151.

11 Green S, Buchbinder R, Glazier R, Forbes A. Systematic review of randomized controlled trials of intervention for painful shoulder: selection criteria, outcome assessment, and efficacy. BMJ 1998; 316:354Ò360.

12 Moore KL, Dalley AF. Clinically Oriented Anatomy. 4th ed. Lippincott, Williams and Wilkins. Baltimore, MA. 1999:664Ò830.

13 Magee DJ. Orthopedic Physical Assessment. Third Ed. WB Saunders Co. Philadelphia, PA. 1997:175Ò246. Figure 7 Chiropractic management 200 J Can Chiropr Assoc 2002; 46(3)

14 Kalb RL. Evaluation and treatment of shoulder pain. Hospital Practice 1998; 119Ò122.

15 Norregaard J, Jacobsen S, Kristensen JH. A narrative review on classification of pain conditions of the upper extremity. Scand J Rehab Med 1998; 31:153Ò164.

16 Neer CS. Anterior acromioplasty for the clinic impingement syndrome in the shoulder. J Bone Joint Surgery 1972; 54:41Ò50.

17 Imamura M, Fischer M, Imamura S. Treatment of myofascial pain components of plantar fascitis speeds up recovery: documentation by algometry. J Musculoskeletal
Pain 1998; 6:91Ò110.

18 Simons DG. Clinical and etiological update of myofascial pain from trigger points. JMPT 1996; 4:93Ò121.

19 Duarte M. Primary fibromyalgia syndrome and myofascial pain syndrome: clinical features and criteria for diagnosis. Chiropractic Technique 1989; 1(3):97Ò100.

20 Goldenberg D. Fibromyalgia, chronic fatigue and myofascial pain syndromes. Current opinion. Rheumatology 1992; 4:247Ò257.

21 Fischer A. Algometry in diagnosis of musculoskeletal pain evaluation of treatment outcomes: An update. Musculoskeletal Pain 1998; 6:5Ò32.

22 Russell IJ. The reliability of algometry in the assessment of patients with fibromyalgia syndrome. J Musculoskeletal Pain 1998; 6:139Ò152.

23 Schneider M. Tender points/ fibromyalgia vs. trigger points/ myofascial pain syndromes. A need for clarity in terminology and differential diagnosis. JMPT 1995;
18:398Ò406.

24 Hains G, Hains R. Combined ischemic compression and spinal manipulation in the treatment of fibromyalgia. JMPT 2000; 24:225Ò230.

25 Travel JG, Simons DG. Myofascial pain and dysfunction: The trigger points manual. Williams and Wilkins, Baltimore.1983. Vol 1:2

26 Sher JS, Uribe JW, Posada A et al. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surgery 1995; 77A:10Ò15.

27 Kozin F. Two unique shoulder disorders, adhesive capsulitis and reflex symptomatic dystrophy syndrome. Post-Graduate Med 1986; 73:207Ò216.

28 Polkington BS. Chiropractic treatment of frozen shoulder syndrome utilizing mechanical force manually assisted short lever adjusting procedures. JMPT 1994; 18:105Ò115.

29 Pearsal AW, Speer KP. Frozen shoulder syndrome: diagnostic and treatment strategies in the primary care setting. Med and Science in Sports and Exercise 1998; 30:S33Ò39.

30 Kazemi M. Adhesive capsulitis: a case report. J Can Chiropr Assoc 2000; 44(3):169Ò176.

31 Welfing J, Kahn MF, Desroy M et al. Les calcifications de lÌepaule. Revue du Rhumatisme 1965; 32:325Ò334.

32 Ginn KA, Herbert RD, Khoum W, Lee R. A randomized, controlled clinical trial of a treatment of shoulder pain. Physical Ther 1997; 77:802Ò809.

33 Young JL, Herring SA, Press JM, Casazza BA. The influence of the spine on the shoulder in the throwing athlete. J Back Musculoskeletal Rehab 1996; 7:5Ò17.

34 Seidel HM, Ball JW, Dains JE. Benedict GW. MosbyÌs guide to physical examination. 4th ed. St. Louis, MI. 1999:546

35 Hawk C, Byrd L, Jansen RD et al. Use of complementary health care practices among chiropractors in the United States. Altern Ther Heatlh Med 1999; 5(1):56Ò62.