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Dynamic Chiropractic – May 20, 2009, Vol. 27, Issue 11

Shoulder Pain: The Missing Link

By Perry Nickelston, DC, FMS, SFMA

Case scenario: A 35-year-old female patient named "Jane" walks into your office with chronic, intermittent shoulder pain. History reveals prior treatments including physical therapy, cortisone injections, chiropractic and massage.

MRI shows mild osteoarthritis with no indication of internal derangement. She has been diagnosed with impingement syndrome. Patient experienced temporary mild to moderate relief with all therapies. What do you do? What are you going to do differently than all of the other health care providers, including other chiropractors? How will you think outside of the box?

Clearly, this case warrants a different approach from traditional symptomatic treatment and assessment methods. The definition of insanity is doing the same thing over and over expecting a different result. So, don't do what everyone else has done! Change the way you evaluate to find the missing link, and you will see dramatic positive clinical outcomes and patient satisfaction. Shoulder injuries are very common and invariably the most difficult to treat, since they are the most mobile joints in the body. Here is an assessment of the primary missing link I find in patients just like our "Jane" case above.

The Missing Link

What is the missing link? There is a lack of thoracic spine and rib-cage mobility. The thoracic spine and rib cage are commonly neglected in the injury management of spinal and peripheral joint injuries, even though thoracic mobility and ideal posture are vital to injury prevention and recovery. Lack of thoracic mobility forces your body to function in ways it was not designed for. Lack of thoracic mobility also forces your lower back and/or neck to compensate for stability. Both increase risks of injury.

Kyphosis and decreased thoracic rotational ability prevents the scapula from tilting back when raising the arms. This narrows the subacromial space, increasing risks of shoulder impingement. Frequent impingement causes rotator-cuff injuries over time. And external rotations or typical rotator-cuff exercises won't help without addressing thoracic mobility.1

How does this lack of mobility occur? Energy leaks and improper movement patterns. Energy leaks can result from weak links. A weak link identifies physical limitations such as poor endurance, faulty coordination, lack of flexibility and inadequate movement patterns; it does not simply mean muscle weakness.

The term energy leak indicates poor efficiency as well as stress. Gray Cook, MSPT, OCS, CSCS says, "An energy leak occurs when all of the energy generated to perform a certain task or movement does not go specifically into that task or movement. It may cause unnecessary work or movement in another part of the body placing greater stress on certain muscles and tendons. It may create unnatural motion of the spine or limbs, placing greater stress on joints and ligaments."

Movement patterns result from habits, activities, hand or leg dominance, and previous injuries. Even if an injury is completely rehabilitated, a temporary compensation during recovery may still be present. The brain does not recognize individual muscle activity. Instead, it looks at movement patterns and creates coordination between all the muscles needed for the desired activity. This coordination is known as a motor program. Isolated muscle development does not play a primary role in movement patterns.2

So, why would you evaluate the most mobile joint in the body (shoulder) with isolated examinations and therapies? You can assume that the shoulder on patient Jane has been evaluated to the point of the ridiculous by now, but how many people have really looked at the thoracic and rib cage area? Don't assume that just because they had previous chiropractic care, there is proper thoracic mobility. Isolated adjustments to vertebrae will not be enough to address all of the intrinsic stabilizers (multifidus and rotators) of the spine.

Evaluating Thoracic Involvement

How do you determine the extent of thoracic involvement and mobility? Here are several ways to evaluate mobility and my preferred methods of increasing full thoracic motion. First and foremost, you must remember not to chase pain. We are looking for the most dysfunctional non-painful pattern of movement. Dysfunctional will describe movements that are limited or restricted in some way, demonstrating a lack of mobility, stability or symmetry within a given movement pattern. Asymmetries from the left side to the right side are a vital clue in putting together the puzzle. Can the patient do the same activity equally on both sides?

  • Multi-segmental flexion: This test looks at flexion in the hips, spine and muscles of the lower back. Have the patient stand with feet together and toes pointed forward. Have them bend from the hips forward and try to touch the ends of their fingers to the tips of their toes, without bending their knees. Look for limited toe touch without pain. The myofascial system of the body connects the upper and lower torso and is the key factor in shoulder malfunction. Therefore, we must evaluate the entire pattern.

  • Multi-segmental extension: This test looks at normal extension in the shoulders, hips and spine. Have the patient stand with feet together and toes pointing forward. Have them raise their arms directly above their head with the arms extended, trying to get their elbows in line with their ears. Have them bend backward as far as possible, making sure that their hips go forward and their arms go backward. Look for limited extension without pain.

  • Multi-segmental rotation: This test looks for normal rotational mobility in the neck, trunk, pelvis, hips, knees and feet. Have the patient stand with feet together, toes pointing forward, and arms out to their sides. Have them rotate their entire body as far as possible to both the right and left. Look for limited rotation without pain.

  • Apley (MREP / LRFP): This is a quick test for total range of motion in the shoulder, with a tie-in to pectoral tightness and thoracic mobility. Medial rotation, extension and adduction (MREP) should reach the inferior angle of the scapula on the opposite side. Lateral rotation, flexion and abduction (LRFP) should reach the scapula on the opposite side. Compare the distance achieved bilaterally.3

Treatment Protocols

This program is based on opening up the thoracic cage and affecting the connective-tissue myofascial structures. Notice these are all active therapies. Proper mobility in fascia is vital to the overall improvement. Instruct the patient to breath from the diaphragm.

Thoracic spine soft-tissue work. Have the patient lie back on the floor and put a foam roller under their thoracic spine. Have the patient hug themselves so their shoulder blades shift to the side, keeping their feet flat and glutes off the floor. Patient should roll back and forth, staying away from the neck and lower back, and lean on the left and right sides to exert more pressure. This should be done on a daily basis. For patients who can't tolerate the foam roller, use "the stick" as a replacement therapy.

Thoracic spine soft-tissue work with tennis balls. Same exercise as the first one, but using two tennis balls inside a sock or wrapped in athletic tape. Patient performs sit-ups with the thoracic spine between the two tennis balls. Head goes against the floor on each rep. Crossed-arm grip. Elbows up. Move the tennis balls up every three reps. Stay away from the lower back and neck.

Thoracic extension with foam roller. Patient stays on the floor with the foam roller under their thoracic spine. Glutes remain on the floor, hands behind the head, elbows pulled together. Patient should drop their head and let their upper back stretch. The goal is to "arch" the thoracic spine at the thoracolumbar junction. Position should be held for a few seconds.

Side-lying rotations. Patient lies on the right side, left hip and knee flexed at 90 degrees. Right leg straight. Rest the patient's left leg on a cushion or foam roller so they can't rotate their lower back. Patient should push the right hand straight up while bracing the abs, left hand on the floor with the hand palm up, and bring the left hand to the right hand while rotating the hands out. Instruct patient to hold the position for two seconds and then come back down. Perform 10 reps both sides. This exercise improves thoracic extension and rotation while improving chest flexibility. Make sure the patient moves from the thoracic spine, not from the lower back, and pushes the abs out from start to finish.

Threading the needle. A very effective yoga pose. Have the patient start on all fours with hands directly under shoulders, and knees directly under hips, and then slide the left hand forward a few inches along the floor. Patient should then lift the right hand and turn it over so the palm faces up, and turn fingertips to point to the left. Then they should slide their right arm along the floor as far as they can between the left hand and left knee, and lower their right ear and shoulder to the floor. If this is too difficult, patient can lower the right forearm to the floor and turn their head to look over the left shoulder. Instruct patient to take three to 10 breaths and then repeat the entire movement on opposite side.

Believe it or not, the patient may sometimes notice an immediate improvement with better range of motion and decreased symptoms. I suggest a 10-visit program with supervision. Most therapy programs are developed and implemented without all of the necessary information, leaving more to chance with failed results. You need a complete road map for reaching the target of successful healing. Consider this the critical starting point on the path to your final destination.


  1. Norkin C, Levangie P. Joint Structure and Function. Philadelphia: FA Davis Company, 1992.
  2. Cook G. Athletic Body in Balance. Illinois: Human Kinetics, 2003.
  3. Cook G. Selective Functional Movement Assessment: An Integrated Model. Gulf Breeze, Fla: 2008.

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