Shoulder problems are a significant part of the workload of a osteopath and an orthopaedic surgeon, with various injuries and conditions affecting this joint. The shoulder has the greatest range of motion of any body joint and this requirement leads to risks of injury and the development of pathologies. As the shoulder is a very unstable joint it is vulnerable to dislocation in falls or vigorous activities at the end of its range. Its structure and the repetitive movements we perform predispose the shoulder to cuff tears and its function as an emergency support when we fall makes fractures a common occurrence.
Osteopaths pay close attention to the shoulder as there are many different operations, fractures and degenerative conditions which can affect this area and have an important role in the management of shoulder conditions after elective surgery or trauma, ensuring adherence to the surgical and rehabilitation protocols. On initially seeing the patient a useful strategy is to quickly go over the presenting problem from the beginning as this can indicate errors or misunderstandings which can then be corrected. Osteopaths should also give the patients an opening so that they can feel they have told their story.
After operation or injury the weight of the arm hanging from the shoulder may need to be supported in a sling to reduce pain and allow damaged tissues to rest. The broad arm, triangular bandages are cheap but not comfortable around the neck and difficult to customise to the patients specific needs. Putting some foam round the strap at the neck may help slightly but a better solution is to use a Velcro based sling such as the Seton sling. Seton slings are greatly preferred by patients, are more comfortable and are easier to adjust to the specific requirements of the shoulder condition.
Fitting of the Seton sling is not difficult but needs a few pieces of special attention to get the best out of it for the patients comfort. The arm gutter is the main part of the splint and the forearm should be placed as far back in it as possible with the cuff areas turned back so that the hand is free. The forearm gutter can be closed by the small Velcro strap but this should be done lightly to avoid cutting into the swelling in the arm which can occur with fractured upper humerus. Lastly the tightening up of the main support strap is slightly trickier if good elbow and shoulder support is to be achieved.
The Velcro straps are slightly elastic and also hold against clothing or skin by friction, making them less likely to slide when adjusted. Once the sling has been put on and the strap tightened it is very likely that the elbow is not being supported by the gutter. This can be checked by feeling under the elbow to see if the sling is taking the weight. Further tightening of the strap at the front just results in more tension in the strap and not more support for the elbow and thereby the shoulder.
Two people are needed to adjust the sling in co-operation, a helper and the patient. The patient is asked to relax the arm as much as they can while the helper lifts the weight of the arm at the elbow, holding it there as they pull the strap from its attachment at the back of the gutter up and over the shoulder, then fixing it there with one hand. Continuing to hold onto the strap which has been pulled forwards the helper unstraps the Velcro fastening of the main strap and tightens it up. Checking the support of the elbow now will show it to be much better supported.
Sling management advice is useful for washing and dressing, for which the sling can come off. Putting clothes on should be using the affected arm first and the arm needs to be kept in by the body during the process with no active lifting of the shoulder. For washing if the patient keeps the arm bent by the tummy and bends forward they can get access to wash their armpit easily.
The content of this page is informed by feedback from osteopaths in the Middlesex area and also osteopathic practitioners in Worcester. Further input was received from practices in Sheffield and a practitioner in Fulham. Finally a contribution was made by clinics in Derby.