The Shoulder

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Clicking, crunchy noises?
Often patients complain of a clicking shoulder. The age at which the clicking began, whether they eventually became aware of it after an injury, and whether it's a painful click are all factors we consider when evaluating a clicking shoulder.

Under 25, clicking is probably more related to an instability problem than in later years in which loose bodies and a thickened bursa are frequent causes. A painful click represents some type of pathology. A painless click indicates internal imbalances in the shoulder with the joint, muscles, tendons and ligaments.

The clicking can also be caused by a loose body (some type of extra material in the shoulder) and these are usually visualized by radiography. 

The above causes of a click may also cause a palpable and audible crepitus (crunchy noise) at the same time.

A tear in the glenoid labrum can also cause a clicking shoulder. The labrum is a fibrous structure joined to the glenoid fossa (the socket of the shoulder blade which faces the ball of the shoulder bone). Its function is to deepen the concavity of the glenoid fossa (see picture to left), act as the origin for the some shoulder ligaments, and has a role in resisting forward movement of the ball of the shoulder (humeral head).

Often we are asked, Is it normal for my shoulder(s) to click? I have no pain associated with it.

The answer is: No, it is not normal, there is some type of underlying issue and with continued use can lead to future problems.

A complex structure: 
3 Bones, 3 Joints which attach it to the neck, mid back, elbow, arm and hand, 5 Ligaments, over 30 Muscles,
4 Bursa, 3 capsules.

75% of North Americans will experience shoulder problems requiring care at some point. In 2003, approximately 15.7 million people in North America sought care for shoulder problems.

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Forward Shoulders/Forward Neck

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Probably one of the most common postural distortions we see is the forward head, forward shoulders posture. This distortion often appears in teenagers and progresses to old age. This forward head/forward shoulders places stress on the neck joints—leading to early arthritis, shoulders, causes nerves to be pinched, the jaw muscles can be tight and can lead to tension headaches/ migraines.

This causes the chest to descend with the shoulder blade (scapula) shifting forward around the rib cage. In this position, the humerus rotates inward and the head and neck are brought forward.

This can be examined and worked on!

Scapulo-thoracic motion—often overlooked!

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The muscles and joints of the shoulder allow it to move through a remarkable range of motion, making it the most mobile joint in the body!

The six motions in performs are: flexion (bringing forward), extension (to go backwards), adduction (to bring together), abduction (to bring apart), medial rotation (inward), lateral rotation (outward).

One most often over looked movements of the shoulder, which is key to resolving shoulder problems is known as: Scapulo-thoracic motion. The Scapulo-thoracic motion is between the shoulder blade (scapula) and the thorax wall). The Scapulo-thoracic motion is a critical element for normal shoulder motion. During normal Scapulo-thoracic motion the shoulder moves 2/3 and the scapula 1/3 of the motion. When someone has a shoulder problem the mechanics are normally changed. 

This change is that the shoulder starts to move only 1/3 and the scapula 1/3. This places pressure/force on the scapula, thoracic shoulder problems spine, muscles in these areas and the tops of the shoulder. There would be tension in the tops of the shoulders due to over-use of other muscle groups.

A Shoulder Aggravating a Neck that Aggravates a Shoulder
The title of this article looks odd, usually when we attempt to find the source of pain in a shoulder; we also evaluate the cervical spine.

If motion testing of the cervical spine does not refer pain to the shoulder, and motion testing of the shoulder reduplicates the patient's shoulder pain, we would probably as- pain is localized in the shoulder.

It is very important to evaluate the neck as well, because muscles from the neck insert into the shoulder blade.

These muscles can shorten, causing rotation of the neck vertebrae and restrictions in the neck vertebrae can result.

Also the nerves from the neck supply the sensory sensation to the shoulder. So shoulder dis-comfort can often be referred from the neck due to nerve related issues. Many people who have their shoulder treated do not have full resolution of the shoulder because the neck and upper back are not evaluated and treated with their shoulder condition. It will often get better, but not be quite 100%.

Pregnancy

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What happens to the body during pregnancy?

Pregnancy is a time of rapid biological change. All bodily organs and systems are affected by the growth of the fetus and this brings with it alterations in body mass, a subsequent change in the centre of gravity and stretching and weakening of abdominal muscles.

Within the early period of pregnancy the woman will feel tired much more quickly and will often experience nausea. Be-cause the enlarging abdomen shifts the centre of gravity forward, the body compensates by increasing the curve in the lower back. This is known as “sway back.”

By the second and third trimester there is an increase in the hormones estrogen and relaxing which begin to affect the musculoskeletal system, causing softening of ligaments and increased joint laxity. During this phase of pregnancy the pelvic joints are relaxed and capable of greater movement. This allows greater rotation in the sacroiliac joint and allows alteration in the diameter of the pelvis at childbirth.

Breech Presentations 

One of the developments in chiropractic prenatal care has been a method of correcting breech presentations in which the baby isn’t positioned properly for birth. Chiropractic techniques are able to release stress on the pregnant pelvis and cause relaxation of the uterus so that the baby will turn naturally. Studies have demonstrated a high success rate in turning babies in utero so they can be delivered successfully.

Source: Journal of Manipulative and Physiological Therapeutics, July/August 2002

Chiropractic Care for during Pregnancy

A common complaint that pregnant women have during pregnancy is back pain.

Chiropractors are specially trained to locate and correct problems that are causing back pain during pregnancy. It is a safe and effective method of care for both you and your baby. You will be positioned in a comfortable manner during your adjustments and no manipulations that place unneeded stress on the baby will be performed.

Additionally, some women report their labour is shorter and more comfortable after receiving adjustments during their pregnancy.

For more information on Chiropractic care and pregnancy, please see www.americanpregnancy.org/pregnancyhealth/chiropracticcare.html or www.chiropractic.on.ca/

Massage Therapy and Pregnancy

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The primary goal for massage during pregnancy is to promote both the baby and the mother’s health. This is done via relaxation techniques as well as those that support proper lymphatic drainage and joint stability. All Registered Massage Therapists in Ontario are properly trained to treat pregnant women.

During your massage, you will likely be positioned on your side with a variety of pillows, in order to best support the weight of the baby and take pressure off your ligaments and blood vessels. Many different parts of the body can be treated in this manner, including the back, hips, abdomen, shoulders and neck.

Massage is also excellent for postpartum care. It can aid in regaining proper posture and biomechanics of the body. It can also help with any remaining back or hip pain, something that is quite common in women who had difficult deliveries.

Please talk to any of our Registered Massage Therapists if you have any concerns about pregnancy massage.

Chiropractic & Massage for your Baby

Most children develop within the womb with healthy, properly aligned spines. However, spinal misalignment may occur due to birth trauma. As the baby grows, he or she may also develop spinal problems due to injury. Having the spine checked by a Doctor of Chiropractic during these developmental stages can prevent not only spinal subluxations but also many other problems that are related to them.

Chiropractic adjusting procedures are modified to fit a child’s specific and unique spinal condition. Using their hands and/or specialized instruments proper correction can be made to the problem area or areas.

Can babies also benefit from massage? Of course! Just like adults need positive touch, so do babies. Whether performed by a Registered Massage Therapist or by the parents, it helps the baby’s growth and development as well as with mood, feeding, digestion, and sleeping. If you would like to learn more about baby massage, please speak with your Massage Therapist.

Self-Care Tips for During Pregnancy

1. Pelvic Tilt – strengthens your abdominal and back muscles to decrease back strain and fatigue

Inhale through nose and tighten your stomach and buttock muscles.

Flatten the small of your back against the floor and allow your pelvis to tilt upward

Hold for a count of five as you exhale slowly

Relax, repeat 10 times

2. Keep your knees bent while lying on your back.

3. When sitting, do not cross your legs. This position decreases circulation.

4. When doing any task where you are standing for a prolonged period of time put one foot up on a step or stool. 

For example, if you are in the kitchen, open the cupboard door and place your foot on the bottom shelf. This will decrease the sway in your lower back and will relieve pressure.

5. Don’t lock your knees. Locking the knees can also increase pressure on your low back. Instead, stand with feet shoulder-width apart and flex your knees just a bit so that the thighs are holding the majority of your weight.

6. Mild to moderate exercise, such as walking or swimming, is a great way to keep fit during pregnancy. Just make sure to use caution with any flexibility exercises, as the increased laxity of your joints puts you at risk for injury.

Any questions about self-care or pregnancy in general?

Just ask any member of the Back To Health team!

Lower Back Pain

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LUMBAR FACET IRRITATION
Reach behind you and feel the centre of your back, just above the buttocks. This is your lumbar spine. Lumbar facet irritation usually is a painful condition affecting the joints. These are responsible for connecting the spine with protection, limiting excessive motion and preventing the vertebrae from locking together.

Patients suffering from lumbar facet irritation usually complain of a well localized low back pain, meaning they can pin-point the exact site of discomfort. The condition is closely related to lumbar facet syndrome—however, patients with the latter also feel referred pain in one hip, buttock or upper leg. Facet irritation often precedes facet syndrome, usually if someone had the irritation treated properly. The onset of lumbar facet irritation is often sudden, occurring after a misjudged movement or while recovering from a bent position. 

These activities may stretch the joint capsules (which protect and support the joints) or jam the facet joints, causing subluxations (restricted motion or abnormal positioning) in the spine and painful swelling. Other causes include poor posture, every day wear-and-tear and trauma to the low back.

Symptoms of facet irritation usually get worse when people sleep on their stomach, work with their arms above their head or rise from a sitting position. All these activities expose the joints to stress that they are not accustomed to, making them more vulnerable to injury and irritation.

Chiropractic is effective for lumbar facet irritation and syndrome. Chiropractors perform a procedure called spinal manipulative therapy, also known as an adjustment, which relieves pain and restores function to misaligned or malfunctioning joints.

Some Back Pain Statistics
• From 2000 to 2004 WorkSafeBC (Workers' Compensation Board) received over 107,000 claims for back strains.
• Back strains account for just over 25% of all WorkSafeBC (Workers' Compensation Board) claims.
• Roughly 30% to 40% of all workplace absences in Canada are due to back pain.
• Back injuries may be caused by a single instance of overexertion or develop as a result of repeated motion over time. Over two-thirds of back injuries are a result of overexer-tion.
• 60% to 90% of the population will experience low back pain in their lifetime.
• More than 90% of lower back pain cases have no specific cause (such as infection, osteoporosis, arthritis, etc
• In the health care industry, injuries due to patient handling (lifting, transferring, or repositioning) account for about 35% of all accepted time loss claims and for about 40% of claim costs.

Some common causes of stress and strain on the spine are:
• Lifting or exerting incorrectly
• Slouching in chairs
• Driving in a hunched position
• Poor posture
• Sleeping on a sagging mattress

Acute back pain is if an episode of pain lasts less than 3 months. Most back pain is acute and goes away with 4 to 6 weeks of treatment.

Recurrent back pain is if acute symptoms come back. Most people have at least one episode of recurrent low back pain.

Chronic back pain is if your back bothers you most of the time for longer than 3 months

Massage Therapy and Low Back Pain
Most people, in their life time, have experienced low back pain. It is one of the most common musculoskeletal disorders of today’s society. Many times, people will suffer through the discomfort, not really knowing that relief is just around the corner! Did you know that the Canadian Medical Association Journal published a study recently about low back pain and massage therapy? The conclusion was that of the people who completed the study, 63% of the people receiving comprehensive Massage Therapy reported NO PAIN after 1 month.

To read more about this study you can go to the Canadian Medical Association Journal web-site and look up the article published in the July 27th, 2000 edition.

Orthotic support for Low Back Pain
Whenever we stand, walk, or run, the lumbar spine and pelvis balance on the legs. If there are leg length inequalities, foot asymmetries, or postural misalignments exist, abnormal forces traveling up the kinematic chain will interfere with spinal (low back) function.

Most low back pain is due to some form of musculoskeletal weakness or failure. A very common source of these problems is imbalances (pronation-shifting inward) at the feet.

The feet make up the postural foundation for the body. Statistical evidence says that at birth most people have perfect feet. By age 20, 80% of humans have developed some type of problem (pronation). By age 40 nearly everyone has some kind of foot condition. Many foot problems eventually contribute to health concerns farther up the kinematic chain, especially generalized back pain.

A major factor in reducing excessive forces on the lumbar spine is often overlooked by health care professionals: the use of external supports (orthotics/heel lifts/ metatarsal pads) to decrease external forces.

Example: If a patient presents with excessive foot pronation/arch collapse, a torque force will produce internal rotation stresses to the leg, hip, pelvis and low back. The result is recurring subluxations and eventual ligament instability affecting the sacroiliac and lumbar spine joints. These forces can be decrease significantly with the use of semi-rigid, custom made orthotics.