I see lots of patients with shoulder pain. Sports players who can not reach overhead for their tennis swing. Or golfers who have a limited range of motion for their drives. Runners who do not have the extension to move their gait forward.
I also see people who have developed a frozen shoulder, which impacts every aspect of their lives, from tying up their hair, putting on clothes sleeping and driving etc.
Shoulder pain can impact the mundane and every day. It will impact you physically but also mentally. I understand completely.
This blog will examine:
I hope you find this blog post useful and you can call/message me to discuss how acupuncture could help you with your shoulder pain
Andrea
Acupuncturist in Hertfordshire
Shoulder pain: what muscles?
The primary muscles that support the shoulder are the rotator cuff muscles. These four muscles include the:
supraspinatus
infraspinatus
teres minor
subscapularis
Other muscles which I will talk about today include:
rhomboid
deltoid
trapezius
biceps brachii
coracobrachialis
teres major
latissimus dorsi
These muscles will each have their own action on your shoulder and what action impedes you during your daily life. Understanding this is helpful so that when you come for your acupuncture appointment when I ask when your pain is activated we can see what actions trigger that pain.
Internal (medial) rotation
When you cross your arm over your body
External (lateral) rotation
When you reach away from your body as if to hold someone from behind
Flexion
When you reach above and in front of your body
Extension
When you reach behind your body
Adduction
The movement of a limb towards the body
Abduction
Movement of limbs (arms, legs or fingers) moved away from your body's midline
Scapular elevation and retraction
Shrugging your shoulders
Shoulder girdle depression
Acupuncture for shoulder pain
When you come to your acupuncture appointment for shoulder pain, I am going to assess your range of motion and also discuss, with you, what movements trigger your pain and where.
I will also need to know what examinations you have previously had, including injections, x-rays, scans or physiotherapy. I will also examine for any red flags.
This will allow me to start my diagnosis and what areas I will be treating.
I will be using motor points, trigger points and acupuncture systems all with acupuncture needles. I will also use other necessary tools to work towards alleviating your pain. This will include gua sha, cupping therapy and electro-stimulation.
Let us look at each muscle and how this pain may show up for you.
Coracobrachialis
The coracobrachialis assists with flexion and adduction of the arm.
Often the pain will be felt on the front of the shoulder and it may also spread down the back concentrating over the triceps, back of the forearm and hand. It can also extend to the tip of the middle finger.
You may have trouble reaching behind the body and across the lower back e.g. if you are tucking your shirt in.
Deltoid
The deltoid will rotate, abduct, extend and externally rotate the shoulder.
With the deltoid, the pain will refer to the front and middle areas of the shoulder and to the side of the upper arm. The symptoms may appear after a traumatic incident e.g. when playing a contact sport, but can also be from repetitive strain.
You may find that you lack strength or inability to raise the arm to shoulder level.
Infraspinatus
Nicknamed the side sleepers nemesis as it can be triggered when lying on the opposite shoulder to the pain; the infraspinatus helps to externally rotate the shoulder.
Patients will report a deep ache on the front of the shoulder, deep in the joint. It can also spread down the side of the arm and lateral forearm and occasionally into the fingers.
You might find it difficult to reach behind to fasten your bra, reach into your back pocket or reach into the back of the car from the front, or brushing your hair. You will struggle to play overhead sports.
Latissimus dorsi
The latissimus dorsi works with the teres major and pectoralis to adduct, medially rotate and extend the arm.
You may struggle to pinpoint what activates your pain but it could be when reaching in front of your body when retrieving an object from a high shelf.
This pain could refer to the mid back but it can also run on the back of the shoulder, down the side of the arm, forearm and hand to the 4th and 5th finger (numbness and tingling).
Levator scapulae
The levator scapulae may produce a stiff neck where you are unable to turn your head but it also can refer pain to the scapular which will feel like a deep pain.
Rhomboid
The rhomboid muscles I think of the shrug muscles. They allow you to lift and abduct the scapula.
With rhomboid pain, you may typically feel a superficial ache between the shoulder blade and spine. Pain may be alleviated by rolling a tennis ball along that area, or getting someone to massage it.
Supraspinatus
The supraspinatus typically creates pain when lifting your arm up, for example, in overhead sports such as tennis or difficulty brushing your hair.
The pain will be felt side on the side of the deltoid which may refer to the elbow and forearm.
Subscapularis
Called the pseudo-frozen shoulder, the supraspinatus can create severe pain in the upper limb at rest and during motion. The pain will become increasingly painful and difficult to abduct beyond 45 degrees (or less)
Pain will be primarily felt on the back of the shoulder and it may refer to the scapula and down the back aspect of the arm to the elbow. It may also present as a strap-like band around the wrist
You may have decreased function when, for example, reaching back to throw a ball or reaching from the front seat to the back seat of a car.
Teres major
Teres Major will come into action on the backward swing of your walk, typing, handwriting and even turning the car steering wheel.
Pain will be typically aggravated by movement, which can be sharp on the back of the shoulder.
Teres minor
Teres Minor will externally rotate and assist with abduction.
The pain felt with injury to teres minor will be a deep pain felt on the back of the shoulder. It will not necessarily restrict the range of movement.
Trapezius
The trapezius muscle is a huge muscle spanning the back of the neck, the tops of the shoulders and into a v-shape on the upper and mid-back. It is therefore divided into upper, middle and lower.
For the purposes of shoulder pain, I am going to specifically discuss the middle and lower trapezius.
Middle trapezius: burning pain between the medial scapular border and the spinous process of C7-T3. It can also refer to an aching pain to the top of the shoulder by the acromion. People will likely complain when trying to put on their coats or are intolerant to wearing heavy one-sided bags
Lower trapezius: pain can be referred to the acromion and over the suprascapular region. They can also have a burning pain along the medial border of the scapula
Here are some muscles we should not overlook when it comes to shoulder pain.
Although these muscles have no primary role in shoulder movement, all of these muscles below can create pain referral which is felt on and around the shoulders.
Thus, I am always working on the assumption (and testing) to see if these are having an impact on your shoulder pain.
Biceps brachii: trigger points may refer upward over the anterior deltoid region of the shoulder and are occasionally located in the suprascapular region
The pain may be superficial in the front of the shoulder. and often increases during the elevation of the arm above the shoulder.
Triceps brachii: consisting of 3 parts I am going to look only at the long head.
Pain and tenderness can be felt upward over the back arm to the back of the shoulder; occasionally to the back of the head and sometimes down the dorsum of the arm, skipping the elbow
The pain is vague and hard to localise on the back of the shoulder and upper arm
Scales: whilst the scalenes stabilise the cervical spine against lateral movement and serve a primary role in respiration their pain referral can present with:
posterior shoulder pain, particularly along the border of the scapula
pain felt in the anterior shoulder region is described as tightness or grabbing
sleep may be disturbed and pain can only be alleviated by sleeping upright
numbness and tingling in the hand / dropping objects/puffiness of hand/fingers
The evidence for using acupuncture for shoulder pain
As an evidence-based acupuncturist, I am always reviewing studies based on acupuncture.
Acupuncture is now recommended by NICE (NICE gives evidence-based recommendations to the NHS) for chronic primary pain.
In a case report in 2014 for adhesive capsulitis (frozen shoulder) they found
After trigger point dry needling was introduced on the third visit, improvements in pain-free shoulder range of motion and functional outcome measures, assessed with the Shoulder Pain and Disability Index and the shortened form of the Disabilities of the Arm, Shoulder and Hand questionnaire, exceeded the minimal clinically important difference after 2 treatment sessions. At discharge, the patient had achieved significant improvements in shoulder range of motion in all planes, and outcome measures were significantly improved.
In a 2020 systematic review of acupuncture for the treatment of frozen shoulder, they found
acupuncture had shown to be a safe treatment with a significant effect in regard to reducing pain, improving shoulder function, and flexion ROM (range of motion) in the short term and midterm.
In 2004 randomised trial of acupuncture for shoulder pain they found
at the six-month follow-up, after treatment, the acupuncture group showed a significantly greater improvement in pain intensity compared with the control group [VAS mean difference 2.0 (95% CI 1.2–2.9)]
Safety
In order to be a viable healthcare choice, acupuncture must not only be effective but also be safe for patients, demonstrating a good balance of benefit to potential harm.
In a 2006 paper examining the safety of acupuncture, they found that
of 4,441,103 acupuncture treatments, the number of reported serious adverse events was 11
Who else can you see for shoulder pain?
There are many professions you can see for your shoulder pain. I work alongside amazing osteopaths and sports massage therapists who can support your treatment with me.
If you go to see your GP, here are the guidelines that will normally be offered to you.
Assessment including history, and examination - if suspected red flags then will follow a different path and will be sent for examinations including blood tests and x-rays
For the initial management of the pain
The prescription of analgesia, if appropriate.
Consideration of physiotherapy referral.
A corticosteroid injection may be considered for a person with shoulder pain, depending on the suspected cause and the severity of the symptoms.
Referral to secondary care should be considered if pain and function are not improving following conservative treatment for 3 months.
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