Why Does My Shoulder Hurt?
Shoulder injuries are arguably some of the most commonly misdiagnosed structural problems. So why are they misdiagnosed, and how does correct diagnosis change the outcome? The single biggest issue regarding shoulder problems is limited understanding of the anatomy of a very complicated joint. On top of this, it has neurological links to certain organs and is frequently involved in emotional issues too. In this short article we look at the most common causes. Let's break it down as follows:
There are three 'joints' in the shoulder. 'Joints' is in inverted commas because one of those isn't really a joint at all. Firstly there is the ball and socket, where the humerus (upper arm bone) joins the scapula (shoulder blade), the second holds the scapula against the back of the rib cage, and the third joins the scapula to the collarbone (clavicle). Each has its own set of problems.
For a Ball and Socket type joint, the shoulder has an amazing range of movement. This is achieved primarily by having a very shallow socket, in fact it's hardly a socket at all. The ball of the humerus sits in a small cartilaginous ring on the scapula, and is enveloped by the joint capsule and a layer of ligaments. Outside of this are the muscle tendons. It is very common for people who have dislocated their shoulder to damage this cartilage ring, tearing it away from the joint capsule. Such injuries are rarely the same afterwards because scar tissue builds up at the junction of those tissues altering the mechanics of the joint, often leading to early arthritis. A more common finding is for the ball to sit eccentrically within the cartilage ring after injury or illness.
There are nine muscles which span the ball and socket, and these are broken down into several muscle bundles. Weakness or hypertonicity (muscle that won't relax) in any one of those bundles, tends to pull the ball off centre. Clearly now when trying to move that joint, instead of the ball sliding smoothly within its socket, it tries to roll over the cartilage ring. This causes pain, which leads to a tightening of more muscles, gradually restricting the movement of the joint as a whole.
The joint with the Clavicle, the acromio-clavicular joint, introduces certain characteristic structural complications. The other end of the collarbone attaches to the sternum, which bio-mechanically is often led by the sacrum, and therefore frequently influenced by spinal distortions. Hence a fall on your bottom as a child might predict a shoulder problem in later life. The sternum has connections to scalene muscles in the neck, through the upper ribs, which are neurologically associated with the sinuses in the head. So allergic rhinitis, coughs and colds, chest infections and food intolerances may also cause shoulder pains through the sternal-clavicular-scapula complex.
A normal range of movement in the shoulder enables you to move the arm to the vertical above your head, with a straight elbow. The big take away here is that only 50% of that movement comes from the ball and socket. In order to lift a straight arm above the horizontal, the scapula must be able to rotate on the thorax, and this is where the majority of problems start.
The Scapula is held against the back of the rib cage by another seven muscles (again divided into several bundles) and at their origins they attach to the spine, mostly; Pectoralis minor comes down onto the chest and Omahyoid actually comes up into the throat, to the hyoid bone. Muscles are controlled by neurological signals from the brain and spinal cord. Poor posture, structural degeneration, old injuries or underlying disease have a significant influence on the nerve and blood supply to these muscles. Some muscles may become relatively weak, some may become hypertonic (tight). The product of which limits the normal range of movement of the scapula preventing the arm from being raised easily above the horizontal. In this scenario it is common for the rotator cuff (so often blamed for shoulder problems) or one of the other muscles spanning the joint, to get strained as the user tries to push through the restricted movement.
When your posture is good and upright, the scapula/ball & socket complex can move freely. It is normal for these joints to have limited movement backwards, because as you push a straight arm backwards the inside edge of the scapula cannot go beyond the vertebrae. But try rounding your shoulders and lifting your arms vertically over your head. You can't. That's because by rounding the shoulders the plane of movement of the scapula has been changed from vertical to inclining forwards. With rounded shoulders, by trying to lift the arms vertically, you are in fact pushing them backwards relative to the spine. With the same posture, raise your arms not vertically, but in front a bit, and you find you can do this more easily.
The vast majority of shoulder related injuries occur because the shape, flexibility and health of the thoracic spine and neck, prevents free scapula movement, leading to real strain of the rotator cuff muscles. Rounding shoulders presents another problem too because the humerus doesn't just drop, it rotates internally, turning the palms of the hands inwards, introducing yet another component of muscle tension imbalance to the shoulder complex. One problem stems from another, with the spinal issues being primary.
The effects of old injuries. If you have ever fallen off your bike or been in a road accident or crashed on your skis, it is highly likely you will have developed patterns of compensation. If those patterns have never been corrected with treatment they will probably still exist, influencing the shape and function of your spine and neck. Shoulder problems rarely improve long-term if those underlying issues are not addressed first. We love to brush off these little tumbles as "nothing", but they are cumulative. If you ever had a whiplash injury or broke your collarbone, it is 100% guaranteed they will have a knock on effect to your shoulder. If you ever fell onto your hand, elbow, or shoulder, those too are pretty well guaranteed to have caused spinal disturbance. If you know you have a history of injury, get yourself treated before everything gets stiff and arthritic!
Being aware of the problem. If you see yourself in this situation, concentrate on spinal mobility, and be aware of your posture. Round shouldered postures are very common because so many people spend their lives working at computers or worse still laptops. If this is the case, spend some time correcting your work-station setup. First adjust your seat height, with knees below the level of your hips. (feet on the floor). Then adjust the desk height so your arms rest easily on the desk, neither high nor low. Position the screen a little below the horizontal from your eyes. Face the screen directly, not to one side, and tilt the screen so the top and bottom edges are the same distance from your eyes. You should be able to sit comfortably with both the keyboard and mouse within easy reach. If you work on a laptop for long hours, get a separate keyboard and put the laptop on a pile of books to bring it more level with your eyes.
When trying to correct your posture, don't just pull your shoulders back like you're in the army. That will make it worse. Instead, think yourself taller. Keep your head level and imagine someone is gently pulling you up from the top of your head. Allow sunken spinal curves to straighten up a bit, with ease.
Breathing exercise are a really good way to help restore a more normal range of movement to the chest, ribs and thoracic spine. One of the most effective methods you can use is proposed by Wim Hof. He has plenty of material available online to teach you how to do that.
Do be aware of those miracle cure videos on You Tube. They might work for some, but for most, these procedures on their own will not be enough to correct the compensations of old injuries or address other underlying issues as described below.
It is taught in first aid courses a warning sign of imminent heart attack is sometimes pain in the left shoulder or down the left arm. This happens because of a certain shared neurology between the heart and shoulder musculature. A similar situation arises with liver or gallbladder complaints, only this time in the right shoulder. Heart, liver, lungs, stomach, gallbladder, thyroid all have an association with muscles around the shoulders. Functional issues or disease involving those organs have an influence on shoulder muscle function. This may be something to consider if shoulder pains are not responding to physical treatment. Consult a Kinesiologist to assess them if you are in the situation.
We hear people say sometimes they are "carrying the weight of the world on their shoulders". It's an idiom which perfectly conveys the idea of how we carry all our worries. Emotional issues become physical, they are psycho-somatic. Compare the posture and bounce in a happy person relative to someone depressed. The first thing to note in the latter is usually the sunken round shouldered posture. In this shape they are in the same situation as the desk-bound individual we talked of earlier. It is common to see also in the depressive, a poor diet dictating nutritional deficiency and struggling organ function. Hence in this group we see an element of all three components leading to shoulder pain. In addition, stress interferes with blood flow reducing the speed of repair of all tissues, and finally, outside of the clinical perspective, tissues resonating in harmony with bad thoughts may never heal, maintained by unresolved emotional conflicts.
Shoulder pains can be some of the most challenging complaints to treat because of the complexity of the joint and their associations. They are frequently the site of emotionally driven issues. There are ways to deal with all the aspects described here, but they definitely need a well trained eye to identify the underlying cause.
Article by David Wells 2021
As always, information in this article comes not just from medical training but also from observation of symptoms and treatment protocols after 20 years of clinical experience. If you want to learn more about this topic, my new book Finding Awesome, Proven Step to Extraordinary Health is available on Amazon