The Clinical Coach: Lateral Shoulder Pain

Happy Friday!

I sure hope you’ve had an amazing week, and I hope you are kicking butts and taking names!

This newsletter as you may have seen by the title is about lateral shoulder pain.

Why? Because that is part of the goal of this newsletter - to give you the best information in business, fitness and rehabilitation. And one thing I haven’t done as of this issue is talk much about the fitness and rehab areas respectively.

If you want more business issues, let me know - send me your questions.

Why are we talking about lateral shoulder pain?

For one, it’s been brought up to my attention as the most miss-diagnosed shoulder pain in clinical practice. So I wanted to clarify a few things in regards of managing and treating lateral shoulder pain in the general population.

Below you’ll find a table of contents so you can skip around to the pertinent areas you need, and you can always come back to read the whole thing later.

If you have any questions, as always feel free to send me an email.

Now let’s dive in.

Basic Anatomy & Definition

What is lateral shoulder pain?

Lateral shoulder pain has been described as deep, achy and in some instances as a sharp pin point pain in the area of the middle deltoid. Hence, why so many have miss-diagnosed this as a deltoid strain. As I have mentioned to all of our CDNP’s, middle deltoid injuries are relatively rare.

True middle deltoid injuries do happen, but most of the time happen in association to a large rotator cuff tear. As of today, it is estimated that a non-traumatic middle deltoid injury occurs in about 0.3 to 7% of shoulder injuries. That in fact is a small percentage, but it is not zero.

What muscles and structures should you be assessing during your examination?

• Middle Deltoid Muscle (it’s the area of pain)

• Posterior Deltoid Muscle

• Infraspinatus Muscle

• Supraspinatus Muscle

• Teres Major and Minor Muscle

• Brachialis Muscle (lateral proximal insertion)

• Superior Lateral Brachial Cutaneous Nerve (should make you think posterior shoulder)

• Subdeltoid Bursae

• Deltoid tuberosity

The assessment for these structures should involve observation and palpation. Keep in mind that 90% of your history taking, should give you your top two differential diagnosis, and give you an idea of which structures are most likely involved.

Functional Anatomy

For the purpose of this newsletter our focus is on the functional anatomy that is most likely to have an impact in lateral shoulder pain, not the full kinetic chain.

In each functional movement I am highlighting in bold the muscles that have been seen to contribute to lateral shoulder pain during these movement in patients that I have had the pleasure of working with. This is not a definitive list, but should give you a new perspective.

• Flexion - Defined as bringing the upper extremity anterior in the sagittal plane. The main flexors of the shoulder are the anterior delt, coracobrachialis and pectoralis major.

• Extension - Defined as bringing the upper extremity posterior in the sagittal plane. The main extensors of the shoulder are the posterior deltoid, latissiums dorsi, and teres major.

• Internal Rotation - Defined as rotation towards midline along a vertical axis. Can be performed with the arm at 0 degrees from the body or at 90 degrees from the body. The main internal rotators are the subscapularis, pectoralis major, latissiums dorsi, teres major, and the anterior aspect of the deltoid.

• External Rotation - Defined as rotation away from midline along a vertical axis. Can be performed with the arm at 0 degrees from the body or at 90 degrees from the body. The main external rotators are infraspinatus, teres minor.

• Horizontal Adduction - Defined as bringing the arm across the body in the transverse plane. The main horizontal adductor is the pectoralis major.

• Horizontal Abduction - Defined as bringing the arm away from midline in the transverse plane. The main horizontal abductor muscles are the rhomboids, supraspinatus, infraspinatus, posterior delt, and teres major.

• Vertical Abduction - Defined as bringing the upper extremity away from midline in the coronal plane. Primary vertical abductors are the supraspinatus, middle deltoid, trapezius, and serratus anterior.

• Vertical Adduction - Defined as bringing the upper extremity towards midline in a coronal plane. Primary vertical adductor are the pectoralis major, latissimus dorsi, serratus anterior and teres major.

What about functional movements like planking, and throwing?

Throwing is a full kinetic movement. While we do assess throwing mechanics in a large variety of our patients, it does not seem to provide a “better” assessment of the painful shoulder as the patient’s mechanics are already compromised due to pain. I prefer to assess dynamic movements like throwing once 60% of the pain has been managed successfully and the patient is able to throw/dynamically move with confidence.

Functional assessments like the push-up, plank, presses and DNS positions are helpful to get an idea which exercises/movement are going to be 1) helpful in their rehab and 2) easiest for your patient to complete at home and progress with confidence. We’ll be talking about them in the next sections.

Orthopedic Examinations and MMT

There are few orthopedic examinations specific for lateral shoulder pain that point to a specific structure. In most cases, we utilize the following orthopedic examinations to rule out serious pathologies:

• Crank’s test (labral/SLAP tear)

• Speed’s test (bicipital tendinopathy)

• Cross-body adduction test (AC Joint pathology)

• Hawkin’s Kennedy (impingement/RCT injury)

  • It’s important to note that rotator cuff tendon (RCT) pathology is one of the most common pathologies for lateral shoulder pain.

Some of the most commonly used manual muscle tests that tend to reproduce lateral shoulder pain (MMT) have been:

• Infraspinatus/Teres minor (active or resisted ext. rotation)

• Supraspinatus (empty can test long lever)

• Brachialis (resisted elbow flexion with thumb pointing to the ceiling)

• Middle deltoid (vertical abduction at 20-80 degrees)

When we have positive findings with any of these MMT, we begin by treating these muscles to improve their function directly. Introducing proper mechanics of the shoulder including thoracic spine mobility and scapular mobility are always part of the treatment plan.

PRO Tip: Don’t be surprised if after a couple of treatments (weeks) function, mobility and your objective findings have improved overall, but the patient still feels pain in the lateral shoulder upon palpation. This means there is still sensitivity present and you may need to be more localized in your passive treatment.

Functional Examinations

Throwing

Throwing is a full kinetic motion that starts at the feet, involves rotation and flexion of the spine and other various structures at various velocities. For this reason we don’t introduce, or assess throwing mechanics until the patient’s pain and function have improved 60% or better.

Because throwing requires the acceleration and deceleration of the scapulo-humeral and scapulo-thoracic complex we chose to discuss throwing dynamics once the patient is able to complete concentric, eccentric and isometric movements with confidence and with any increase in pain lasting less than a day. Preferably less than a couple of hours.

Not every throw is the same. Pitching is much different than throwing a football. In most instances it is smart, and I highly recommend, to refer out your patient to a throwing coach who will be able to work with you and your patient to improve their throwing mechanics for their specific sport. If you are working with general population,

Push-up

Proper push-up position is one of the simplest dynamic movements for the scapulo-humeral and scapulo-thoracic complex. In the painful shoulder, patients will often shift away from the painful shoulder. This shouldn’t deter you from having them in your patient’s rehab program.

Eccentric push-ups, and isometric at various depths have proven to be efficient at relieving and improving tendon-based pain from muscles like the infraspinatus, and teres major.

90% of our patients with lateral shoulder pain have some type of push-up in their rehab program. Be it counter push-ups, or short lever isometric push up holds. The key is finding the position where your patient is able to exert as much force as possible while maintaining proper shoulder mechanics.

Plank

Ah the most hated exercises in the planet. Essentially a static pushup position from either the elbows or wrists.

I don’t typically use planks as McGill cues them, or as seen in every single Instagram or YouTube video. I have patient’s place their elbows just slightly forward from their shoulders. This allows them to engage the external rotators of the shoulder, in addition to the serratus anterior and latissimus dorsi. Providing the patients with a more shoulder focused plank. If you are familiar with DNS prone 3, it’s a similar setup, but with hips in the air.

It’s important to note that every single one of my patients learns how to brace properly to meet the demands of the exercise/movement they are participating in.

Treatment

By now you should have a very good idea of the which muscles are most likely to recreate lateral shoulder pain in your patient. In 90% of the case your external rotators will be the most likely structures, followed by the supraspinatus tendon, brachialis, and middle deltoid.

How do we treat these muscles?

I am as much of a fan of the active approach as the next rehab chiro, but a combination of passive and active care provides patients with what they want and what they need making them more compliant with their rehab.

Passive approach:

It’s no surprise that I am going to tell you that the first thing I’ll do is needle these muscles. Dry needling has been a part of my practice since I was in school and after I graduated it’s been a main passive treatment that I use for shoulder pain and other injuries and pains in my office. By needling the infraspinatus and teres major patients have seen a reduction in pain almost 50% faster than those whom I’ve had to treat with other IASTM.

*There are patients who are not treated with needles for personal reasons or contraindications. 

It doesn’t mean that IASTM, Pin and stretch, ART, or other manual therapies won’t help your patient. I’ve just seen faster results with dry needling in my office.

When I do need to utilize other passive modalities, IASTM, Pin & Stretch and oscillatory therapy are the ones I end up using. I will use tools before I use my thumbs as I have already seen some of the early effects of overuse.

Active approach:

At one point in my practice I was using DNS movements about 80% of the time. Overtime I’ve found myself utilizing different exercises that are easier for my patients to perform at home, and can be progressed to meet their goals easier. I still use a few DNS exercises in the office for both acute and chronic issues, but its a handful of movements now.

At the office I have the following pieces of exercise equipment:

• 10lb DB (pair)

• 15lb DB (pair)

• 30lb KB (pair)

• 50lb KB (pair)

• Light, and medium weight bands (one of each)

• Yoga Mat

• Bench

With these I can load, overload and progress a variety of exercises that target tissues and movements that become part of my patients rehab program.

My approach involves providing patients with a dedicated progressive strength and conditioning program broken down into four phases:

• Pain Management Phase

• Strength Phase

• Conditioning Phase

• GPP Phase

Each phase has specific goals that are outlined for the patient at the beginning of each phase. This ensures the patient understands the goals of the phase and the expectations of it.

This is presented to the patient as a program with in-person visits pre-scheduled after the first visit.

Conclusion

By now you should have a very good idea of the which muscles are most likely to recreate lateral shoulder pain in your patient. In 90% of the case your external rotators will be the most likely structures, followed by the supraspinatus tendon, brachialis, and middle deltoid.

How you choose to treat these tissues and which movements to focus, will depend on your patient’s goals, wants and needs as well as your experience developing a program that will meet them where they are and will progress them accordingly.

If you found this issue helpful, send me an e-mail and let me know. If you find that there’s something missing, or you’d like me to dive into deeper areas, let me know too.

Until our next issue!

In health and strength,

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