Put your shoulder to the wheel

Research shows that patients with underlying lung disease often present with the same symptoms as people with shoulder pain: pain with daily activities, difficulty sleeping on the shoulder, and increased pain in recent times. This is often seen as rotator cuff problems, which did not improve during therapy. Research has shown that there may also be another underlying problem, such as a lung top tumor, (neglected) pneumonia or lung operations from the past (Petchkrua, 2000) (Al Shammari, 2020) (Brindisino, 2020).
In addition to the fact that another pathology can be the cause of a shoulder problem, the problems also often appear after operations on the pulmonary system. Bando (2018) has shown that 40% of people who underwent surgery on the pulmonary system had ipsilateral shoulder complaints.
The study by Miranda (2015) looked at the effect on ROM, pain and disability of the shoulders after lung surgery. After lung surgery, bilateral shoulder impairment with reduced ROM, with greater impairment in the ipsilateral shoulder, was often found.
Despite the fact that a small percentage of patients report to the practice with the lung as the cause, it is important to always do an extensive history and thorough examination, so that ‘red’ flags are recognized and referrals can be made in time. If a relationship is found between lung and shoulder complaints without serious underlying pathologies, fascial stretches and hold-relax techniques are recommended (Bischof, 2017). (Nadi Blokhuis)

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Johnston (2021) looked at the biomechanical relationship between the shoulder and the spine. The aim of this cross-sectional study was to see the functional relationship between the range of motion (ROM) of the shoulder and the curvature of the spine.
This was done through a multivariate analysis involving 163 healthy, right-handed subjects. Measures contributing to the shoulder-spine relationship were shoulder flexion, internal and external rotation, trunk flexion and lumbar lordosis. The findings show that the examination of the shoulder should be interpreted in relation to the spine and vice versa, independent of the region in which the pain is located.
Another possible cause of shoulder and neck complaints is a dysfunction of the first rib. Mastromarchi (2020) investigated this via a Delphi survey, in which the opinion of a large number of experts was asked. He asked which methods were useful to diagnose a dysfunction. Consensus was reached on important aspects of first rib dysfunction, namely limited mobility, symptoms in the arm, and a possible sub-classification into two groups.
The main clinical findings were: painful and restricted neck movements and load-bearing capacity of the shoulder girdle; positive neural test of the arm; direct palpation of the first rib, neural structures, and the m. scaleni; pain and hypomobility of the first rib movements with improvement after mobilization.
The cervical rotation-lateral flexion test was considered useful but not widely used. There were doubts about the diagnostic accuracy and interpretation. These methods need further investigation to establish the reliability and validity of the tests.
Other biomechanical chains (from daily practice, J. ten Brink) that impose restrictions on the shoulder girdle are:
– absence of joint play (add/abduction) in the elbow restricts the elevation in the shoulder joint.
– limitation of pronation results in limitation of elevation and abduction in the shoulder joint.
Often the left and right restrictions are present to varying degrees, and therefore also limit the rotations of the cervical spine and thoracic spine (and sometimes lumbar spine/pelvis), partly due to the direct influence on the lattissimus dorsi m.

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The laparoscopy is a procedure in which a surgeon uses a camera (laparoscope) to examine the abdominal organs. The layers of the peritoneum are separated to allow safe insertion of the equipment and good visibility. This is often done by using a gas, carbon dioxide. This is called a pneumoperitoneum. The phrenic nerve is probably stimulated and this leads to referred pain to the shoulder area postoperatively.
Kaloo (2019) describes multiple ethologies. It is thought that the carbon dioxide is locally converted to dihydrogen carbonate. The pH decreases and this would lead to irritation of the phrenic nerve and shoulder-tip pain (STP). During the pneumoperitoneum there could also be a lot of stretch at the level of the tendon of the diaphragm. It is sensory strongly innervated by the phrenic nerve. Because the tendon leaf is stiff, it is unlikely that damage will occur due to stretch. However, increased intra-abdominal pressure does increase the incidence of STP.
The laparoscopy could cause micro- and/or macroscopic damage to the fascia. This leads to a local inflammatory reaction. The application of gas could also possibly influence the suction effect between the liver and the diaphragm. This creates a traction on the liver ligaments. This could lead to STP. This hypothesis is not substantiated, but according to Kaloo (2019) it is supported by the fact that STP complaints often increase during movement and sitting up.
Choi (2016) refutes this. During the first few days, pain around the incision points and local visceral pain are often experienced during movement. Shoulder pain experienced at rest does not increase with movement (Choi, 2016). The shoulder pain seems to be caused more by neurological stimulation than by biomechanical influences. Could this mean that in practice we have more of a neurological influence to the shoulder by acting on the visceral fascia? (Joost Veldhuizen)

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The diagnosis of Frozen Shoulder (FS) is given on the basis of clinical examination, exclusion of other pathologies and also the absence of glenohumeral abnormalities radiographically. There are three stages: the freezing phase, the frozen phase and the thawing phase. We also know that the recovery time is 12-42 months.
The pathophysiology of FS is complex and largely unknown. There appears to be an abnormality in the volume of the glenohumeral joint. Normally this is 15-20ml, but with FS it turns out to be less than 5ml. It would also seem that the lig. coracohumerale may play a role in the development of FS.
FS appears to be more likely to occur if there was already chronic inflammation and elevation of pro-inflammatory cytokines. This includes people with Diabetes Mellitus (DM), cardiovascular disorders or thyroid problems. FS occurs in 2-5% of the entire population and 10-30% of diabetics. Studies have also shown that depression may play a role in its development.
No scientific evidence has yet been found that the menopause in women plays a role in the development of FS, but this group appears to be more sensitive to general musculoskeletal pain. Literature studies show that men and women are equally likely to have FS, that it is often the non-dominant shoulder and that in 17% it eventually develops on the other side.
There are still many questions about the effectiveness of treatment methods for FS. Treating FS by mobilizing the shoulder with mechanical stress in the pain threshold is even detrimental in the recovery process. This is in contrast to mechanical stress within the pain threshold. Intra-articular injections of corticosteroids have also been shown to be useful, especially in the early stages of the development of FS. This has an effect on the inflammatory processes but not on the fibrotic changes. When injecting corticosteroids around the lig. coracohumerale may be more effective than when the injection is placed posteriorly in the glenohumeral joint.
In the literature study by Kraal et. although it is suggested that the use of nasal spray containing calcitonin may be effective in treating FS. A deficiency of calcitonin can also be seen in people with osteoporosis or a thyroid disorder, among others. (Liesbeth van den Berg – van Esch)

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Ottiger-Boettger (2020) investigated whether the neurodynamic testing (stretch of the nerve) provides a clear clinical picture of neuropathy. Her conclusion is that this is quite mixed up. There can be negative tests and damage, or vice versa. Nevertheless, she considers the probability that patients with positive neurodynamic tests do have nerve damage is high (however, she does not indicate how high). In addition to the pain that occurs, there may also be loss of sensation, even on the heterolateral side. This indicates how central the problem is.

However, nociception is not yet an unambiguous concept. There may be local tissue stimulation or overstimulation higher up in the pain system (central sensitization). Ingraham (2019) even argues that this should be referred to as a third category: primary pain, in which it is purely a matter of the phenomenon of pain and not of damage to tissue or nerves. In addition, there are of course also the “referred pains” within nociception.

Fernández-López (2020) investigated with a literature study whether there can also be nociception in shoulder pain from the Nervus Phrenicus (C3-C5) to the arm: the so-called visceral pains. First of all, she indicates that there is a high incidence of shoulder pain after abdominal or chest surgery, even up to 95%. According to her, several studies have shown that the Nervus Phrenicus often anastomoses with the different parts of the brachial plexus. The Nervus Phrenicus contains, in addition to motor, many sensory fibers of the pericardium, pleura and peritoneum. Irritation of these structures then causes shoulder pain.

Bordoni (2020) has extensively researched and reported on the Phrenicus to further clarify the neurological model within osteopathy. His first finding is that the nervous and lymphatic systems are a two-way street. Poor mobility of the neuron already stimulates a lymph node, which in turn promotes inflammation. Neuron mobility can also affect fascial mobility, for example in the brachial plexus. Bordoni describes not only the peripheral nerves but also the ganglia and their influence on the vascularization of the head. In short, this article is a must read for every osteopath and offers many explanations for the relationship between pain and regional problems.

In conclusion, it can be said that shoulder problems are again a multivariable issue. By examining the presentation of the various pains, the osteopath can differentiate whether it is a neuropathy or nociception/neurogenic (often also visceral/referred) pain. This differentiation is important for us to provide insight into which subpopulation of shoulder complaints osteopathy is useful for. This way we can effectively get on someone’s nerves.

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