Under this heading may come a variety of conditions affecting one or
both shoulders causing much distress and, at times, total disability.
The conditions may be the result of direct injury to the joint,
systemic, or from spinal lesions. Anatomically the shoulder offers
frequent opportunity to injury as it has the greatest range of motion
of any joint, is least secure in its articulation, and is most
vulnerable from location. Once the shoulder has been dislocated it
is rarely back to normal functioning again as this injury tears the
capsular ligament and stretches the structures in relation. Many times
there is only a =subluxation= in which the head of the humerus is
driven upwards in the fossa, usually from a fall or blow on the point
of the elbow. As a rule, after such an accident, the only thing done
is to rest the joint and apply a liniment and, after a time, begin
the use of the arm. It is, however, painful and to save himself, the
patient each time restricts movement until he reaches a point where he
is unable to dress without assistance. It is then found that normal
motion is reduced fully one-half and even this will be accompanied
by pain on movement and in bed. A radiograph will, usually, show the
condition. Articular crepitus and fibrous adhesions are present while
the adjoining structures have undergone changes so that a reduction is
impossible without certain preparation. Very often a trivial cause will
disable a joint; a sudden movement which finds the muscles about the
shoulder unprepared and the resulting lesion is so slight as to, often,
defy detection. At first there will be swelling and pain but, in time,
it settles down to a limited motion with more or less distress.
=Bursitis.=—This is a condition in which the subdeltoid bursa is
involved or where there have been a number of bursæ formed from
overuse of the joint. One authority reports as many as twenty-five
in a shoulder. There may be, also, tenosynovitis primarily or from
extension. These conditions may not be easily diagnosed at first.
=Brachial neuritis= (chronic) beginning with or without an acute attack
is usually from a cervical lesion involving the brachial plexus but
most frequently it is the 5th and 6th cervicals at the origin of the
circumflex nerve. From this the deltoid is particularly affected and
its contraction leads to pressure on the nerve and subsequent partial
or complete paralysis. Brachial neuritis is found in an increasing
number of osteopathic practicians and is the result of overwork of the
arms and to strain of the upper dorsals and lower cervicals. There are
contractions of structures about the joint constantly limiting motion
and pain when a strain is put on them.
Many methods for the treatment of the conditions described have
been employed, all involving the same principle but none of them
systematized. C. H. Spencer has worked out a technique which, while
originally intended for bursitis, has been found well adapted to all
conditions described. It gives a stretching of all structures and
gradually breaks up adhesions, both in the joint and in the tendon
sheaths, so there is no resulting irritation which could easily result
if suddenly done. His technique is[43]:
“First: The patient on the side, the affected shoulder up; operator
facing the patient, places one hand on the top of the shoulder, does
nothing more than fixing it; with the hand grasping the forearm above
the wrist, push the elbow backward, the arm parallel to and almost in
contact with the body, then pull forward in the same plane. Second:
Elevate the elbow with the hands of the operator in the same position
as before, carry the elbow in as wide a circle as possible. Third:
With the hands still in the same position, extend the forearm with
traction; carry it as high in front of the patient as possible. The
foregoing are designed to relieve the congestion about the shoulder,
bring pressure to bear on the subdeltoid bursa and moderate traction on
the supraspinatus, infraspinatus, subscapularis, teres minor and major,
latissimus dorsi and the tendon of the biceps. These manipulations
will be all that is possible in the more aggravated cases for some
considerable period of time. As the tenderness subsides, the second
group may be cautiously started, the hands in the same position as
above noted, with the arm extended as nearly as possible at right
angles with the body, carry the arm in as wide a circle as the pain
will permit. Again, with the arm flexed at the elbow, one hand of the
operator on the point of the shoulder and the forearm of the patient
across the forearm of the operator, the other hand of the operator
resting on the point of the patient’s elbow, push down toward the
middle line of the body and carry the elbow toward the head. Then flex
the arm and place the back of the hand behind the patient, flexing the
shoulder in front with one hand grasping the point of the elbow and
pull forward. This group of movements accomplishes with greater force
the same ends obtained in the previous, and the first in this group
is the most effective in overcoming swelling of the subdeltoid bursa.
Direct manipulation of the muscle masses and this bursa is desirable
from the first.” It will be noticed in all these movements that the
joint is protected by one hand of the operator while the other is
grasping the arm of the patient. This is desirable as it makes the
technique absolutely safe. An additional treatment will be found very
effective, especially where the deltoid is involved. With the patient
on the well side, facing the operator, locate the quadrilateral space
which is bounded by the subscapularis above, the teres minor below
and the long head of the biceps medially and the surgical neck of the
humerus externally, and the circumflex nerve can be easily palpated
along with the artery. If these structures are stretched and the
deltoid lifted from the shoulder it will be found to free the action of
both nerve and artery, one supplying the joint with nutrition and the
other innervating it.
Certain conditions for which these movements are contraindicated arise
and the following differential points by H. Glasscock are well to
remember[44]: =“Rheumatism=: Fever in the joint, with redness, swelling
and other joints involved. =Tuberculosis=: Daily temperature and other
tubercular foci. =Neuritis=: Pain in the neck and shoulder muscles,
also near insertion of deltoid and in the forearm, particularly
musculo spiral. Pain worse at night. No pain on movement. No swelling.
=Bursitis=: No pain in neck. Pain in anterior and posterior part of
joint and on motion. Pain near insertion of deltoid. Arm held close
to the body, motionless. =Infection=: Chill, limited motion, severe
pain with temperature. =Dislocation=: Deformity with preternatural
mobility. =Dislocation= of =acromio-clavicular= joint: Tenderness over
articulation. Arm cannot be raised beyond right angle with the body,
but elbow may be brought across the chest with external rotation of
arm and raised perpendicular with the body without pain.” The infected
joint should never be manipulated and all conditions showing swelling,
redness and pain on touch should be viewed with suspicion. Remember
that all other conditions will almost invariably have vertebral
lesions, primary or secondary and a permanent result will depend upon
their correction.