Osteopathic Considerations in Shoulder Pain - foma.org · Dermatomes . Gilroy . Atlas of Anatomy p330 . Gilroy Atlas of Anatomy p327 . ... • Magee, D. J. (2014) Orthopedic Physical

Osteopathic Considerations in Shoulder Pain

Kristen Brusky DO February 22, 2018

Overview

• Importance of pectoral girdle • Ligaments, ligaments…tensegrity • Bones, joints, muscles • Neurovasculature • Innervation…dermatomal and peripheral • Myofascial Pain Syndromes • It’s all connected!

3 Bones, 3+1 joints, 17 muscles

The 17 muscles are…

• Deltoid • Trapezius • Infraspinatus • Supraspinatus • Teres minor • Subscapularis • Levator scapulae • Omohyoid

• Rhomboid minor • Rhomboid major • Serratus Anterior • Latissimus • Teres Major • Triceps – long head • Biceps –long, short • Coracobrachialis • Pectoralis Minor

Pectoral Girdle

Clavicle

Allows Full ABduction

Acromioclavicular Joint

Scapulocostal (Pseudo) Joint

Scapula

Humerus

Labrum

http://3doptimalperformance.blogspot.com/2009/12/3-d-shoulder-rotator-cuff-impingement.html

http://3doptimalperformance.blogspot.com/2009/12/3-d-shoulder-rotator-cuff-impingement.html

Gilroy Atlas of Anatomy p268







Dermatomes




Gilroy Atlas of Anatomy p325, 346

To The Extremity and Beyond….

• Supraspinatus Syndrome • Deltoid Syndrome • Teres Major Syndrome • Scapulocostal Syndrome • Thoracic Outlet Syndrome • Adhesive Capsulitis

Supraspinatus Syndrome (M79.7) • Symptom Presentation:

exquisite tenderness superior border of the scapula. Pain on ROM and pain referred to the shoulder in a non dermatomal pattern.

• Mechanics: repetitive overhead trauma, a single injury, or chronic deconditioning of the agonist and antagonist muscle unit.

Supraspinatus Syndrome

• Predisposing factors: weekend warrior, poor posture while typing or watching television, prior injuries that result in abnormal muscle function

• Treatment: Trigger point

injection (TPI) with local anesthetic or saline. Use of pregabalin if no response to TPI.

• Adjunt therapies: PT, therapeutic heat and cold, transcutaneous nerve stimulation, and electrical stimulation

Deltoid Syndrome (M79.7) • Symptom Presentation:

trigger points in both the anterior and posterior deltoid fibers.

• Mechanics: Flexion-extension and lateral motion stretch injuries, repetitive lifting or impact injuries.

Deltoid Syndrome





Teres Major Syndrome (M79.7)

• Symptom Presentation: trigger points lateral to scapula. • Mechanics: Stretch or impact injuries sustained while

playing sports or MVAs in addition to falls onto the lateral scapula. Repetitive reaching up and behind

Teres Major Syndrome





Scapulocostal Syndrome (G56.80) • Symptom Presentation:

Unilateral pain and paresthesias at medial scapula. Referred pain from deltoid to dorsal hand. Decreased scapula ROM.

• Mechanics: repetitive reaching backward to retrieve items causing overuse of scapular stabilization muscles.

Scapulocostal Syndrome





Travelling Salesman’s Shoulder


What If no improvement after TPI?

• …tight muscles • …overstretched muscles • …weakness of other surrounding muscles • …cross pattern imbalance • …primary hypermobility of joint • …additional injury

Thoracic Outlet Syndrome (G54.0)

• Symptom Presentation: ache or paresthesias at neck with radiation into the shoulder

• Mechanics: compression of the neurovascular bundle due to cervical rib, hypertonicity of anterior and middle scalenes, somatic dysfunction of the clavicle or upper ribs, abnormal insertion of the pectoralis minor

Thoracic Outlet Syndrome

• Special tests – Adson’s (compression between the scalenes), Wright’s (compression under the pectoralis minor), Military posture (compression between clavicle and 1st rib).

• Treatment – OMT, PT, OT, gabapentin, carbamazepine (SE: aplastic anemia), pregabalin, baclofen, nerve block



Adhesive Capsulitis (M75.00)

• Symptom Presentation: aching anterior shoulder, grating/ popping and decreased PROM/ AROM typically after prolonged immobility and age over 40 years. Pain affects sleep.

• Worse with abduction, internal and external rotation. Extension is typically preserved.

• Mechanics: formation of fibrous adhesions.

Two Categories

Within Shoulder • Rotator Cuff

Tendinopathy • Subdeltoid Bursitis • Biceps Tendinopathy

Other Diseases • Stroke • Diabetes • Myocardial Infarction • Reflex Sympathetic

Dystrophy

Adhesive Capsulitis

• Prevention is the best treatment option; early mobilization after shoulder injury. Treatment – NSAIDs, COX-2 inhibitors, PT, rest, heat, corticosteroid injection, NSAIDs, rest, heat; OMT – Spencer technique, GH joint, upper thoracic

The 1 Connection….Fascia

Think about the fascia…

Gilroy Atlas of Anatomy p330, 331

3 Bones, 3+1 joints, 17 muscles

Pectoral Girdle

•To know all of a bone in its entirety would close both ends of an eternity. – A. T. Still MD

Resources • Abbasi, D. & Keener, J. Biceps Tendonitis. Retrieved from https://www.orthobullets.com/shoulder-and-

elbow/3045/biceps-tendonitis

• Armstrong, A. D. & Hubbard, M. C. (2016) Essentials of Musculoskeletal Care – 5th Ed. Rosemont, IL: American Academy of Orthopedic Surgeons

• Chung, K. W. & Chung, H. M. (2008) BRS Gross Anatomy – 6th Ed. Baltimore, MD: Lippincott Williams & Wilkins.

• DeStefano, L (2011) Greenman’s Principles of Manual Medicine – 4th Ed. Baltimore, MD: Lippincott Williams & Wilkins.

• DiGiovanna, E. L., Schiowitz, S. and Dowling, D. J. (2005) An Osteopathic Approach to Diagnosis and Treatment – 3rd Ed. Baltimore, MD: Lippincott Williams & Wilkins.

• Gilroy, A. M., MacPherson, B. R. and Ross, L. M. (2008) Atlas of Anatomy. New York, NY: Thieme Medical Publishers, Inc.

• Magee, D. J. (2014) Orthopedic Physical Assessment – 6th Ed. St. Louis, MO: Elsevier.

• Moore, K. L. & Dalley, A. F. (1999) Clinically Oriented Anatomy – 4th Ed. Baltimore, MD: Lippincott Williams & Wilkins.

• Myers, T. W. (2009) Anatomy Trains – 2nd Ed. China: Elsevier.

• Savarese, R. G. (2003) OMT Review – 3rd Ed. OMT Review.

• Simons, D. G., Travell, J. G. and Simons, L. S. (1999) Myofascial Pain and Dysfunction The Trigger Point Manual – 2nd Ed. Baltimore, MD: Williams & Wilkins.

• Waldman, S. D. (2012) Atlas of Common Pain Syndromes – 3rd Ed. Philadelphia, PA: Elsevier.

https://www.orthobullets.com/shoulder-and-elbow/3045/biceps-tendonitis

https://www.orthobullets.com/shoulder-and-elbow/3045/biceps-tendonitis

Osteopathic Considerations in Shoulder Pain - foma.org · Dermatomes . Gilroy . Atlas of Anatomy p330 . Gilroy Atlas of Anatomy p327 . ... • Magee, D. J. (2014) Orthopedic Physical

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