It can be a challenging area to work on, and certainly an area of the body where I have made the most mistakes in my career.
It is the most mobile, yet least stable joint, yes the shoulder is complex (pun intended).
Whether I was misinterpreting what I thought was happening, not using the right test, or maybe just plain old not listening properly to the patient, treating the shoulder can sometimes get a bit confusing.
There is a long list of possible injuries that could take place, dislocations, separations, labral tears, mobility issues, and of course the ever so scary term: frozen shoulder.
I mean, prior to being an RMT (in my old career), I was used to seeing and dealing with those traumatic injuries and knew exactly what to do when it came to a dislocation or separation, I would just sling the shoulder, pack the person up and send them on their way in an ambulance, but was never involved in helping the injury after that.
So how was I going to properly treat all of these other things and actually narrow down what was affecting a person?
Well, as it turns out, there are some guidelines we can look to.
Management In “Primary Care”
When looking at much of the research on different pathologies there is a lot of reference to how something should be handled in “primary care”.
This is generally thought of as your main entry point into healthcare, where you see a doctor, they diagnose an issue, and then refer you out to a specialist, or prescribe medication, etc.
Unfortunately, at this time massage therapy isn’t typically classified in this realm (however we are starting to see Massage Therapists in hospital settings in the U.S. which is a GREAT start), but it is possible for us to get referral of a patient from a doctor. In fact, many extended health insurance companies here in Canada require a doctors referral before they will reimburse a patient for massage therapy.
So, it is important for us to know what is being done at the primary care level, so we can understand why a patient is being referred to us.
According to one systematic review, shoulder pain is the third most common reason a patient experiences musculoskeletal consultation in primary care with 1% of adults experiencing new shoulder pain each year. The first thing that should happen is ruling out any red flags (many of which are similar to the red flags of low back pain we have reviewed before on this blog):
- History of cancer, unexplained deformity, mass, or swelling (possible tumor).
- Red skin, fever, (possible systemic infections).
- Trauma, epileptic seizure, electrocution, loss of rotation ability (possible dislocation).
- Trauma resulting in acute disabling pain, significant weakness, positive drop arm test (possible rotator cuff issues).
- Sensory or motor deficit (possible neurological lesion)
Anytime things like this are seen, it’s most likely the patient will be referred for blood work or imaging to rule out any of the above.
Once the above are ruled out, the four most common reasons for shoulder pain and disability are:
- Rotator Cuff disorders (impingement, tears, tendinopathies).
- Glenohumeral disorders (adhesive capsulitis aka frozen shoulder, arthritis).
- Acromioclavicular joint disease (osteoarthritis, separation).
- Referred neck pain.
These are the types of conditions which would most likely be referred out to other practitioners, as conservative management is being recognized as the most beneficial. However, patients may be referred for surgery if:
- Pain and disability last more than six, months after conservative management have taken place.
- History of instability, or acute, severe post-traumatic A/C pain.
- Uncertainty in the condition, or red flags present.
However, with long waits for surgery and consultations, there is a good chance we could see someone for pain management and rehab long before surgery ever takes place, and of course for post-surgical help as well. This makes it important to know there are more favourable results when there is only mild trauma (an A/C separation usually only gets surgery with fourth-degree and up, first to third-degree is typically just rehab), overuse before the onset of pain, or acute onset. The outcomes aren’t as great with increased age, severe or recurrent symptoms and females (not sure why as jobs like hairdressing, construction, and lifting heavy loads are labeled as high-risk occupations).
So, now that we know all of this, the question is, what can we do?
The Massage Therapists Role In Shoulder Pain
Looking through research on the clinical guidelines of the treatment of shoulder pain, there are a few modalities mentioned that are supposedly successful, but I would venture to say they have more to do with our therapeutic relationship and interaction with the patient than it does the actual modality.
The one thing that consistently comes up is patient education.
Regardless of the diagnosis given, education and acknowledgment of biopsychosocial aspects are a crucial part of pain management whether it’s the shoulder or any other part of the body.
You may be thinking, “well, how can we educate a patient on this”?
There are various ways and probably one of the biggest is educating them on the diagnosis and what it means to them. Some of the names like: “impingement, frozen shoulder, arthritis, tears, tendinopathy” is simply enough to strike fear into the patient, causing them to catastrophize the diagnosis due to the name alone.
You will probably hear them say things like: “my friend, sp0use, relative, etc had this and never got better”. I’m sure we’ve all had patients say this to us several times in our career. Providing reassurance to them, showing how they can and will get better, even with this ominous-sounding diagnosis is a big influencer in the biopsychosocial aspects of pain. Helping them understand how their friend/relatives outcome is not the same as theirs and there are steps we can take to prevent the same outcome is crucial. This also requires some work on our part, to educate ourselves on the best treatments and outcomes for each of these diagnosis. We can continue to use whatever our favourite techniques are, but there are certainly some additions that need to be made (since your treatment style is probably what has them coming to you in the first place).
In the coming weeks we will dig deeper into the interventions we can use to improve and educate our patients on each shoulder issue. Hopefully then we can even help prevent some surgeries while pushing more toward conservative care with better outcomes.