Wisdom Wednesday: The Shoulder

Shoulder pain is a very common clinical complaint, second only to low back pain in frequency. Research indicates that most of us tear our rotator cuff (the group of muscles that support the shoulder joint) sometime in our lives and most of us actually forget the injury.

I guess I’m not like most people because I vividly remember tearing both my right and left rotator cuff even though the first injury was 45 years ago.

The shoulder joint is very complex. It is a little like the hip joint but is designed with much greater range of motion but can’t tolerate constant weight bearing. There are no ligaments in the joint proper. Ligaments attach bone-to-bone. So the head of the humerus (upper arm) is suspended from the glenoid fossa (shoulder socket) by a series of tendons attached to the rotator cuff muscles.

Think of the humerus as the gondola on a hot air balloon. As long as all the cables (tendons and muscles) are even in strength and tension, the balloon sits level. However, shorten or break even one of those cables and the gondola will lurch to one side. When the humerus is riding unevenly in the socket, inflammation and subsequent degeneration occur.

To complicate matters, when the shoulder is lifted above level, the clavicle (collar bone) and scapula (wing bone) both elevate to change the shape of the joint allowing even greater range of motion.

The four rotator cuff muscles are the supraspinatus, infraspinatus, teres minor, and subscapularis. Each one acts to strengthen and facilitate motion in the shoulder but all have their unique evaluation and treatment issues.

Wisdom Wednesday: Visceral Referred Pain

Visceral referred pain (VRP) is an important concept in the evaluation and treatment of patients. In brief, it is a location on the skin of referred pain from an internal organ. Virtually all organs have VRP locations. Even though you may not realize it, you are familiar with some of them.

When someone is having coronary insufficiency or a heart attack, their heart does not hurt. The referred pain (angina) is generally into the left arm but can also include the left chest, mid-back and into the jaw and teeth. In appendicitis, the pain is referred to the skin over the pancreas. Gallbladder problems often refer pain into the right shoulder. When the kidneys are inflamed (think kidney stone) the pain is referred down the sides into the outer aspect of the thighs.

We use these VRPs initially as diagnostic tools. When a new patient comes in with right shoulder pain, the gallbladder is in the differential diagnosis. If they also note right sided abdominal pain late at night, especially after a heavy evening meal, gallbladder moves to the top of the list. Treating the right shoulder as a mechanical issue with manipulation and therapy will often provide good temporary relief. However, the pain will always return if the gallbladder is the real issue.

VRPs are also used in muscle testing challenges. Pinching a VRP stimulates the nociceptors (pain receptors in the nervous system) and stimulates the sympathetic system (fight or flight). Rubbing a VRP stimulates the parasympathetic system (increases digestion, calms everything else).

Challenging a VRP helps locate the source of a health issue. It can also be used to temporarily negate a reflex. If, for example, I find a histamine response to wheat sensitivity has an active VRP to the small intestine, I can stimulate the VRP, temporarily shutting the reflex off. This allows me to move forward in the QA (Quintessential Applications) protocol. Otherwise, I would have to wait weeks or even months until the histamine issue was resolved to test further.