Treating Shoulder Pain and Dorsalgia of Myofascial Origin

Shoulder pain is a common musculoskeletal complaint, with nearly 50 percent of the population suffering at least one episode annually.¹ Upper extremity pain and injury account for 8.6 percent of the chief complaint among chiropractic patients.² Recent data indicates that trigger points are treated by 91 percent of chiropractors, and ischemic compression of trigger points is one of the most popular treatment methods used by chiropractors to treat myofascial pain.²

Recent Research

In a randomized clinical trial conducted by the present author,³ 59 patients suffering from chronic tendinitis (average duration: four-and-a-half years) each received 15 treatments of ischemic compression therapy on trigger points(TrPs) localized mostly at the deltoid muscle, the supraspinatus muscle, the acromion process, the coracoid apophysis and the subscapularis muscle. Then they completed two standard questionnaires.

After 15 treatments, the experimental group (41 patients) reported 62 percent amelioration on the Spadi questionnaire versus 18 percent for the control group (18 patients). The control group also had received 15 treatments of ischemic compression therapy, but on trigger points located on cervical and upper dorsal muscles.

A second questionnaire was used to assess patients' perceived amelioration using a scale from 0-100 percent. Results showed 75 percent amelioration for the experimental group versus 29 percent for the control group. Six months later, perceived amelioration was 66 percent for the experimental group; 85 percent reported an evident amelioration within the first six treatments.

Patients in the experimental group were treated exclusively by ischemic compression (eight seconds of pressure, one thumb on the other) on the trigger points located on the ligaments, tendons and muscles of the symptomatic shoulder. Trigger points are pressure-sensitive, palpable nodules that reproduce the chief complaint.⁴

When a thumb pressure is applied on the trigger point, the patient recognizes the produced pain as an important source of their problem. Because of that hyper-irritability, the chiropractor has to be very careful at the beginning of treatment. Pressure should be gradually augmented to the patient's tolerance level and kept without moving until the end of the eight seconds. That treatment is repeated on each trigger point at each visit until their complete elimination.

Treatment Protocol

1. With the patient in pronation, the hand of the symptomatic shoulder is placed on the back of the patient's head. To keep their shoulder completely relaxed, the therapist's thigh holds the patient's arm in place. The supraspinatus muscle (at the back of the clavicle), the deltoid muscle (anterior, posterior and lateral) and the infraspinatus muscle must be examined attentively for the presence of trigger points.
2. Next, with the patient supine, arm stretched along their body, apply firm pressure to the acromion process and at the coracoid apophysis to find the trigger points, if present. Examination of the axilla is also done with the patient supine, hand under their head.

In around 10 percent of cases, I find trigger points in the armpits, which have a relation with shoulder pain. The TrPs are treated at each visit until their complete elimination.

Other Variables to Consider

Often the patient has a diagnosis of partial or complete tear of the rotator cuff. This could appear to be an important cause of the shoulder problem, but a trial by Sher⁵ showed that after 60 years of age, 26 percent of subjects had a partial tear and 28 percent had a complete tear (a hole all through the rotator cuff) without symptoms.

Research by Welfing⁶ showed that in 925 symptomatic patients, 6.5 percent had a calcium deposit. In 200 others, asymptomatic this time, there was a deposit in 7 percent. In another study,⁷ the authors concluded that the relationship between calcium deposits and shoulder pain is unclear.

Imaging such as radiography, arthrography, computed tomographic scanning, and magnetic resonance imaging should be reserved for difficult cases in which the diagnosis is insufficiently clear and conservative measures have not been successful.⁸

In a group of 349 patient with shoulder pain treated by 11 general practitioners, surgery was performed on four patients only in the following year.⁹

The natural history of shoulder pain is frequently considered self-limiting. However, a three-year follow-up report found that 54 percent of patients had persistent pain, whereas 90 percent had chronic disability.¹⁰ In a systematic review of 31 clinical trials, conducted to evaluate the effectiveness of various therapeutic interventions for shoulder pain, only subacromial cortisone injections were found to be more effective than placebo to increase abduction.¹¹ There are no randomized clinical trials of surgical interventions for shoulder pain.¹¹

The complex anatomical and functional structure of the shoulder joint often complicates diagnosis and clinical management of the shoulder lesion. This has resulted in much confusion and a lack of consensus regarding the classification and diagnosis criteria of shoulder disorders.^1,9,11

In my experience, if the patient can raise laterally (abduct) the symptomatic arm above their head, we talk of tendinitis. If the pain is sharp at any movement and has been there for a week or so, we talk normally of bursitis. Most of the time in the latter case, the pain will go away by itself within a week. If the pain is sharp at any movement, and has been there for months, we talk of capsulitis. The first cause of most chronic shoulder pain is the presence of trigger points. Even the worst cases can be treated by ischemic compression therapy.

In these cases, the patient kneels perpendicular to the table, forehead on the asymptomatic arm. The hand of the painful arm is then put on the back of the patient's head. The practitioner holds the arm in place with their thigh, and can then treat the trigger points localized in the deltoid and the supraspinatus muscles.

In a small percentage of shoulder pain, the cause may be partly vertebrogenic. An examination of the neck, flexion and rotation, will cause a neurological irradiation to the shoulder.

If there are many trigger points to treat, three- to four-second pressure should be used, instead of the height habitually used on each TrP, because there is a limit to which a patient can support pain. The patient will be happy to feel that you are treating the good places, but we have to be very attentive to their reaction and inquire, particularly at the beginning of treatment, if the pain is bearable.

In very chronic cases, 15 to 20 visits may be necessary. Ideally, the treatments should be repeated until there are no more trigger points.

Trigger Points and Dorsalgia

Dorsalgia is present in 11.5 percent of patients who see a chiropractor.¹² The following technique, which can replace or be added to the vertebral adjustment, is very efficacious and can be used with patients of any age.

With the patient prone, firm pressure with the thumbs (one on the other) is applied on the lateral aspect of the spinous processes at a 45-degree angle with the chiropractor perpendicular to the patient. When that pressure causes pain, the hyper-irritable vertebrae should be treated. This examination must be delicate because the spinous processes of the involved area may be very sensitive. The most important region to be examined is the one pinpointed by the patient.

Treatment is like the examination, except in the final eight seconds, without moving, 2-3 vertebrae may be treated at the same time. The pressure has to be painful, but bearable, at the patient's tolerance. The more vertebrae involved, the less time the pressure should be applied (2-3 seconds), because there is a limit to how much pain can be endured at each visit.

Normally there is an evident amelioration within 5-6 treatments. The patient will recognize the pain provoked by the pressure as an important source of their problem and will be ready to follow the necessary treatments in order to get rid of the irritation.

TrPs may also be located at the level of the transverse processes, the rhomboid muscle, the upper crest of the scapula, and the supraspinatus muscle located behind the clavicle, and are best reached with the patient's hand behind their head.

Keep in mind that the infraspinatus muscle is very tense in most chronic dorsalgias. The best way to treat this muscle is with the patient prone, arm on the involved side folded and kept close to the body by the thigh of the practitioner. Thumbtip pressure is applied from lateral to medial on the lateral aspect of the scapula. This is often very painful, but the TrP in the infraspinatus has to be dealt with in order to get rid of the dorsal problem.

If all the involved areas are treated, amelioration is often felt at the first few treatments, but all irritations should be eliminated.

Strengthening the Dorsal Muscles

Many patients with chronic dorsal problems overwork, or their work is repetitive and lasts too long for their musculature. It is possible to strengthen the dorsal muscles considerably with simple exercises. The following exercises can be prescribed to all patients who want to at least double the strength of their dorsal muscles.

1. With the patient standing and holding dumbbells (1 kg for women; 2 kgs for men), they cross their arms horizontally and stretch backward as far as possible. This exercise is repeated until the patient starts to experience fatigue.
2. The second exercise is done with the same dumbbells, but this time, the patient should stretch out their arms, making an arc forward from upward (over the head) to downward as far back as possible. This exercise is repeated until the patient fatigues.

Normally, these two exercises are repeated once a day at the beginning, 10 to 15 repetitions at the maximum. The aim should be at least 50 repetitions daily, which can take a few months. The patient's dorsal region will then be much stronger, and the weight used can be increased if desired. In my experience, these strength gains will persist, at least to some extent, 2-3 years later – even if the patient stops doing the exercises after reaching their goal.

References

1. Brox JL. Shoulder pain. Best Pract Res Clin Rheumatol, 2003;1:33-56,
2. Christensen MG, Kollasch MW, Ward DA. Job Analysis of Chiropractic. National Board of Chiropractic Examiners, 2005, p. 98.
3. Hains G, Descarreaux M,Hains F. Chronic shoulder pain of myofascial origin. J Manipulative Physiol Ther, 2010;33:362-69.
4. Borg-Stein J, Stein J. Trigger points and tender points. Rheum Dis Clin North Am, 1996;22:305-23.
5. Sher JS, Uribe JW, Posada A et al. Abnormal findings on magnetic resonance images of asymptomatic shoulder. J Bone Joint Surg (U.S.), 1995;77A:19-15.
6. Welfling J, Kahn MF, Desroy M et al. Les calcification de l'epaule. Revue Rhumatisme, 1965;32:325-34.
7. Wang CJ, Ko JY, Chen HS. Treatment of calcific tendinitis of the shoulder wuth shoc wave therapy. Clinical Orthop, 2001;387: 83-89.
8. Daigneault J, Cooney LM. Shoulder pain in older people. J Am Geriatr Soc, 1998;46:1144-51.
9. Van der Windt DA, Koes BW, de Jong BA et al. Shoulder disorders in general practice: prognostic indicators of outcome. Br J Gen Pract, 1996;46:519-23.
10. Macfarlane GJ, Hunt IM, Silman AJ. Predictors of chronic shoulder pain: a population base prospective study. J Rheumatol, 1998;1612-15.
11. Green S, Buchbinder R, Glasier R, et al. Systematic review of randomized control trials of interventions for painful shoulder: selection criteria, outcome assessment, and efficacy. BMJ, 1998;316:354-60(12).
12. Christensen MG, et al., Op Cit, p. 75.