The management of shoulder injuries and pathologies is a big part of the caseload of orthopaedic surgeons and musculoskeletal osteopaths. The shoulder has a long list of injuries, conditions and operations associated with it. As a significantly unstable joint with the most joint mobility of any bodily joint, it is at risk in many cases to repetitive stresses and injuries. Due to its instability it is more likely to dislocate in a fall or if overstressed at the end of its range. In repeated overhead or heavy work rotator cuff tears can develop and if the arm is used to protect the body in a fall fractures of the upper humerus can occur.
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.
To get the best fitting and most comfortable fit for the sling the osteopath needs to take a few actions for success. The gutter for the arm should have the elbow placed back as far as it will go and the hand can be kept out of the sling by folding back the cuff part. The small Velcro strap to close the forearm gutter should not be tightly fixed as it may cut in to the upper arm, particularly if there is a lot of oedema as swelling can occur after fractures of the upper arm. Tightening up the main strap which runs across the back and upwards over the shoulder is a little more difficult to achieve a good result.
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.
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.
The osteopath will give general advice to the patient about managing in the sling and how to do day to day activities. The sling should only be taken off for washing and dressing initially. If the clothes are put on normally the affected arm must be put in first without lifting or rotating it significantly. Washing under the arm can be achieved by holding the arm in the position it usually is in the sling and bending forward, allowing access to the armpit without lifting the arm up actively.
The content of this page is informed by feedback from clinics in Essex and also osteopaths in the Birmingham area. Further input was received from a practitioner in Luton and osteopathic practitioners in Glasgow. Finally a contribution was made by practices in Nottingham.