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.
The precise diagnosis of the condition and a clear agreed treatment plan are essential in shoulder conditions as there is a very large number of different fractures, operations and injuries to the shoulder complex. Post-trauma and post-operative shoulder conditions are part of the core work of orthopaedic osteopaths and they follow the agreed trauma and elective surgery protocols, referring patients for further treatment once they are discharged. Going over the case quickly from the beginning once we meet the patient is useful as this can throw up errors and missing facts which need addressing. Patients also appreciate an opportunity to tell their story.
The first consideration is supporting the shoulder to give it some rest or to achieve a particular anatomical goal. Broad arm slings are uncomfortable, difficult to fit (for me anyhow) and awkward to adjust to the patients requirements. If one is used it will pull on the neck with the narrow part of the sling and the knot, causing discomfort which can be only partly alleviated by applying some foam padding. A better solution is to use one of the more complex but much more comfortable and adjustable slings such as the Seton sling, a Velcro based sling which patients get on very well with.
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.
Due to the materials from which the slings are made there is a degree both of elasticity and friction against surfaces when they are adjusted. As the sling is adjusted and tightened up the elbow is often not well supported by the sling at all and patients are usually aware that the support is not that good. The osteopath can easily feel that the sling is not giving the correct support and if they just tighten up the strap it solely tightens up at the front but does not improve the support of the arm. This needs another strategy.
To get the sling right needs two people, the patient and a helper. The helper lifts the elbow of the affected arm in the sling while the patient tries to let the shoulder relax. Then the helper gets hold of the part of the strap along the back and pulls it up towards the shoulder, holding it there. The helper lets go of the elbow and adjusts the strap whilst still holding the back part of the strap under tension with the other hand. Having completed this manoeuvre the elbow should now feel heavy and supported in the sling and the patient feel it is quite comfortable.
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 osteopathic practitioners in Hertfordshire and also practices in Manchester. Further input was received from osteopaths in the Sheffield area and a practitioner in Cardiff. Finally a contribution was made by clinics in Derby.