Using a Massage Gun for better sleep with frozen shoulder

Massage can be done by self through massage guns or a lacrosse ball. Massaging the small muscles of the shoulder like the pectorals, deltoid, and trapezius, with a massage ball can be painful in the inflammatory phase of the frozen shoulder. In this case, a low-intensity massage with a flat device head can help to soothe the muscles, improve flexibility for a short time and flush out the inflammatory metabolites. 

Best sleeping position for the frozen shoulder:

Sleeping on the other side of the affected shoulder with a pillow under the armpit of the affected one. This is the easiest solution, but if you are turning frequently in sleep, the painful side gets compressed intermittently and that again disturbs the sleep.This can be managed by sleeping on a recliner or using the support of pillows on the affected side.

Using pillows and cushions to improve your sleep:

Sleeping in supine or on the straight back position: 

This position can also be supported well with the pillows under the arm.

Sleeping in a quarter-turn reclined/side-lying position by keeping the pillows under the affected side:

This position elevates the affected side up and even if you tend to turn sides, the pillows would be there to block it.

Modified Foetal Position

Most of us tend to sleep in this easy-to-go position. Sleeping on the non-affected side in this position can be well supported with the pillows between the knees, under the head, and one supporting the arms.

In case of acute pain and swelling, biofreeze spray can be the preferred modality. But for any muscle spasm and fascial tightness issue, moist heat or a heating pad before you sleep generally works the best

Sleeping Positions to avoid:

• Sleeping side lying on the aching shoulder gives the utmost pain. 
• Also sleeping on the stomach frequently puts the shoulder in an elevated position which further strains the upper trapezius and increases the shoulder pain. 

Using a TENS Machine for better sleep

TENS machine helps in numbing down the pain by blocking the thinner pain carrying neural fibres. It is not a treatment modality but definitely can help to tone down the pain just before one sleeps. 

Read more about TENS machines for frozen shoulder

Magnesium Oil:

Magnesium has been used to relieve muscle cramps and facilitate recovery of the overworked muscles.Transdermal application of magnesium oil, helps in rapid absorption and  avoids any gastrointestinal distress symptoms which come with oral ingestion.  A warm water ipsum salt bath combines the dual benefits of magnesium and heat therapy and gives full body relaxation. Magnesium supplementation can also help in easing pain, but it should be taken according to the recommended dietary allowance along with a physician consultation.

THC/Cannabis Edibles:

Depending on where you live and applicable laws, THC, the active ingredient in cannabis, can help with sleep and pain management. 

THC edibles are not approved by FDA and frequently the composition of the compounds are not stringently regulated by the sellers.THC a derivative of Cannabis is the main psychoactive substance responsible for sense of giving a high. Used as a potent sedative and pain reliever in neuropathic pain and intractable cancer, it may have a longer sleep inducing effect.It has potential side effects of varying intensities on those who consume it. The research on use of THC edibles, specific to shoulder pain is lacking and may have some benefit in chronic cases not responding to other modalities of treatment. It is very important with regards to safety  to take any psychoactive substance with a prior consultation with a doctor in accordance with the legal laws of the country.

CBD (Cannabidiol):

Cannabidiol (CBD), also a derivative of cannabis, does not contain any psychoactive substance giving a high. CBD oil, through its anti-inflammatory effects, can be used as an adjunct to improve sleep and reduce pain. Though high-level evidence lacks for the use of CBD, specific to the frozen shoulder, it can be used with precaution and as an adjunct  when available as a well-regulated product.

Melatonin:

Melatonin is a sleep inducing hormone naturally produced by the body through the pineal gland in the night when the darkness sets in. Melatonin is available as a supplement and not controlled as drug by FDA and also as a drug Ramelteon, which is basically a melatonin receptor agonist.  Both of them influence the melatonin action and help in sleeping.Melatonin has a fewer side effects like drowsiness, headaches and dizziness and are seen when it is overdosed. It can be a good supplement for short term use for sleep induction.

Medications:

Anti-inflammatory/OTC Drugs:

Naproxen and acetaminophen, the OTC drug helps in controlling inflammation and blocking the pain and also have some effect on relaxing the muscles.

Muscle relaxants:

Muscle relaxants are generally not sold over the counter and when prescribed by the physician can surely help.

Timing the medications:

These medications especially in the inflammatory phase should be taken an hour before the sleep. Medications taken too early can lose their effect in the middle of the night due to their short half-life and bring back the pain. Hence the medications need to be timed well with the sleep schedule, following with the dosage and physician’s advice.

Cortisone:

A steroid shot coupled with physiotherapy has been shown to reduce the inflammation and pain with a long term effect. It is important to avoid repetitive steroid shots in shoulder as it affects the tendon health in long term, hence the use of exercise is important to sustain the effects of the steroid and maintain the pain free range of motion. Getting a cortisone shot isn’t a decision you make before going to bed tonight, but getting a shot can help you reduce pain and inflammation for several weeks, helping you get some sleep. 

You can find out more about Cortisone Injections and Frozen Shoulder here. 

Hydrodilatation:

Hydrodilatation is the infusion of combination of saline, steroid and local anaesthetic in the shoulder joint capsule to distend it and cause micro-ruptures. It can help in giving good short term results and improving function, but long term evidence for its use is inconclusive and deficient.

Sleep Hygiene:

Good sleep hygiene which incorporates environmental and behavioral modifications helping to facilitate a deeper sleep. Like:

1. Following regular sleep timings which affect your circadian rhythms
2. Reducing the use of bright lights and screen time
3. Abstaining from caffeine use near sleep time 
4. Avoiding alcohol use to facilitate sleep as it slows down the healing
5. Managing stress well and not ruminating at night by following relaxation techniques, mindfulness, and breathwork techniques like box breathing before you sleep.
6. Avoiding noise and making use of soothing music or the podcast  of choice to fall asleep.

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What is a massage gun and what are its benefits? 

A massage gun is a handheld device that uses percussive, vibration therapy, or both to provide the effects of a myofascial release. 

1. Massage guns are a great way to relieve muscle pain and stiffness, by  improving the blood circulation to the tired and taut muscles.
2. The increased blood supply facilitates the removal of waste products and other metabolites like lactate thereby improving the recovery of the muscles.
3. They are also used to relieve the Delayed onset of Muscle Soreness(DOMS),  and as a pre-workout therapy to increase muscle performance.

Massage guns are relatively new devices, but they have quickly become a popular choice for people looking for a quick and easy way to give themselves a massage, decrease pain and facilitate their recovery.

How to use a massage gun on your shoulder

To use a massage gun on your shoulder, start by finding a comfortable position. You can sit or stand, but you must be able to keep the gun steady and perpendicular to the part you are trying to massage while you’re using it. Next, place the massager head against your skin and turn on the device. Start with a low setting and gradually increase the intensity as needed.

The shoulder region has many small and large muscles which get painful at specific points. Also, many sensitive tissue areas are present which might get sore quickly with a high-pressure massage compared to the lower body. For example, it is difficult to use a massage gun on a pectoral, axilla, or around the adjoining neck region, especially with a pointed head.

Small and sensitive muscular structures: Upper trapezius, Pectorals, and Subscapularis

 It is better to massage gently with lower amplitude and frequency in these areas with a flatter head, especially if you are trying out for the first time. A better option can be using a vibrating massage ball for self-myofascial release compared to pointed percussive guns in these areas.

Large muscles with relatively less sensitivity:

On a  large surface area, a vibration gun can be therapeutic on the bigger muscles of the shoulder like the latissimus dorsi and upper trapezius. 

You need to manoeuvre the device in different parts, hence a good ergonomic  handle is a must. Try to take the massager overhead and try to massage your upper trapezius, ideally it should not strain your shoulder much.

For large muscles, a vibratory foam roller can also serve well,  as you can lie down sideways and actively release your tight latissimus dorsi.

Posterior Shoulder muscles:

The smaller posterior deep muscles like the rhomboids, middle trapezius, teres major, and minor are difficult to reach by oneself and can be better massaged with help from an assistant or a friend. A prone position gives better access to these muscles as these muscles are covered by the larger muscles latissimus dorsi and trapezius.

The superficially placed deltoids:

The deltoids can be easily massaged by you by a massage ball, but the posterior deltoid might become difficult to massage by self and might require some assistance.

The subscapularis, the most common muscle to get tight quickly and limit the external rotation, is also difficult to massage by oneself with a gun. An overhead position of the hand and just massaging the outer aspect of the armpit,  at the outer border of the scapula can help to a certain extent. But in this case, a therapist-guided vibration therapy or a self-myofascial release with a ball can help better.

Does a massage gun help with shoulder recovery?

If you have a shoulder injury, recovery is measured by range of motion and pain. Full recovery means you can move your shoulder through its full range of motion without pain. Measure your shoulder recovery with Reflex: Shoulder Mobility App.

What to look for when buying a massage gun

When choosing a massage gun, it’s important to consider the following factors:

Whether it is a percussive or a vibration-based massager device: 

This can be understood concerning the treatment head shape. A vibration device head is generally flat, while that of a percussive device is pointed or rounded to drive it further in.

Whether it’s for a self-use or professional use:

A personal use too can be very simple and easy to carry, keeping in mind the specific muscles of the shoulder which are tight.

For professional use, chiropractors, physios, and athletic trainers, a set of tools can help in customising the experience of their clients for the specific muscles.

Intensity: 

Massage guns come with different amplitudes and frequency levels, so be sure to choose one that’s appropriate for your needs. If you’re new to using massage guns, it’s a good idea to start with a lower setting and work your way up.

A good massage device has a frequency setting of 10 to 60 Hz with 2 to 6 mm of amplitude penetration.

The build and the body of the device: 

A metallic body and a sturdy head help deliver the pressure at a suitable frequency. Some massage guns have heads fully made of plastic which can give away with an added pressure. 

The foam rollers and massage balls with vibratory function can be used for specific muscles without much use of hands, and are easy to carry.

Massage Head: 

The flat metallic head with a bigger contact surface area is helpful for the larger muscles of the body. The flat head goes well in delivering the vibrations at a higher frequency than the percussive device, but a percussive device has the benefit of deeper mechanical stimulation. The use of massage oils and inflammatory creams is easier with flat heads compared to rounded and pointed ones.

The percussive devices come with a variety of heads, which can be used on different body parts, depending upon the girth of the muscles. The pointed heads can be used on the deeper muscles like pyriformis, upper trapezius, and underlying layers of latissimus dorsi. The split-pointed head can be used for erector spinae muscles alongside your spine.

You need to adjust the intensity and the treatment head according to the pain or soreness you are feeling around the shoulder joint.

Battery life: 

Massage guns can be plugged into the plug socket or have batteries installed that are rechargeable. High end massage guns tend to have longer battery life, whereas low price options will need to be charged more frequently. For home use, most massage guns can provide sufficient battery charge to treat yourself, even the low end models. 

Weight and Ergonomic design: 

Massage guns can vary significantly in terms of weight, so be sure to choose one that’s comfortable for you to hold.

Noise level: 

Some massage guns are louder than others. If this is an issue, you may find it’s worth spending a little extra for quiet or ultra quiet models. 

Heat/Cold temperature option: 

Some massagers have the control to adjust the temperature of the moving head. It is an add-on, but not an essential one if on a tight budget.

Price: 

Massage guns can range in price from around $50 to $500, so be sure to choose one that’s within your budget.

What are the types of self-massage devices available in the market?

There are two types of massage devices available in the market.

The vibration therapy and percussive therapy-based massagers.

Some messages have both, percussive and vibratory controls in a single device.

These massagers come in different shapes, sizes, and added functions of temperature modulation.

Heating pads or sleeves are also designed to give vibration therapy, which can be worn as a wrap around the joint and extremities. 

Vibrating foam rollers are available, which can be rolled along the body parts and kept statically at points of tissue restrictions, to deliver vibrations at those points.

What is the difference between Vibration therapy and Percussive therapy massage?

Vibration therapy is based on delivering waves of oscillation that travel inside the body, among the different tissues, and bring about changes in blood circulation. The heads of the devices are generally flat and metallic, and generally deliver higher frequency waves than a percussive device.

Percussive therapy also uses vibrations, but the heads of the devices are designed in more of a rounded and pointed way to penetrate deep into the tissue in form of a piston movement. Percussive therapy can be thought of as combining the parts of conventional massage and vibration therapy.

Vibration therapy has been extensively studied and a vast literature exists to prove its efficacy, while the percussive therapy devices have been recently innovated and research is still an ongoing process.

What is the difference between the Amplitude and Frequency of the massage gun?

Frequency and Amplitude are both the variables of a massage device that determine the intensity of the massage.

Frequency is the rate of repetition of cycles of oscillations delivered to the body per minute. It is measured in Hertz (Hz). Low-frequency guns have frequencies from 15 to 50 Hz, while high-frequency guns have a frequency from 100 to 170 Hz.

Amplitude is the extent to which oscillatory movement happens in terms of displacement away and towards the body. It is measured in millimetres(mm).

Before buying a gun do get a trial of different frequencies and amplitudes to understand what suits you the best.

Best Massage Guns

Vibration Therapy Massage Guns

MedMassager Chiropractic Body Massager

Hyperice Hypersphere Mini – Vibrating Massage Ball for Muscle Recovery, Myofascial Release and Soreness Relief

Theragun | Wave Roller | Vibrating Foam Roller for Full-Body | Bluetooth Enabled

Brookstone Max Hot & Cold Vibration Massager

Percussive Therapy Massage Guns

Hypervolt Bluetooth, Featuring Quiet Glide Technology – Handheld Percussion Massage Gun

LifePro Sonic Pro Percussion Massage Gun Deep Tissue Percussive Back Massager Device for Pain Relief

LAIRLUX All-New Massage Gun|Percussion Massage Gun Deep Tissue|Muscle Massage Gun for Athletes|with Rotating Arm

Theragun Elite – Handheld Electric Massage Gun – Bluetooth Enabled Percussion Therapy Device for Athletes – Powerful Deep Tissue Muscle Massager with QuietForce Technology – 4th Generation

Alternative Devices for Shoulders 

Hyperice Shoulder Cold Therapy – Left

Lifepro Sonic LX Quiet Pro Percussion Massage Gun, and Waver Vibration Plate Exercise Machine Bundle

HoMedics Thera-P Hot & Cold Handled Variable Speed Massager with 8 Custom Attachment for Sore or Overworked Muscles

Heated Shoulder Brace Wrap,Portable Electric Wireless 3 Heating Setting Infrared Pad Strap with Hot Cold Therapy for Rotator Cuff, Frozen Shoulder

FAQs about massage guns

Q: Can massage guns be used on all parts of the body?

A: Yes,  one can use massage guns on any part of the body that is experiencing pain or inflammation. The intensity and treatment head of the massage gun should be adjusted Depending upon the part of the body, span, and girth of the muscle. 

Q: How often should I use a massage gun?

A: There is no one-size-fits-all answer to this question, as it will depend on your individual needs. If you’re using a massage gun to relieve pain or stiffness, as a recovery drill you may want to use it several times per day. If you’re using it for general relaxation, once or twice per week may be sufficient. 

Q: How long should I use a massage gun on each area of my body?

A: Again, there is no one-size-fits-all answer to this question. However, a general rule of thumb is to massage each area moving for 2 to 10 seconds for 3 to 5 minutes in case of a pre-workout activation. In case of very tight muscles, 10 to 30 minutes with the use of oils and creams can help in recovering faster.

Q: Are there any side effects associated with using a massage gun?

A: Some people may experience minor bruising or redness after using a massage gun, but this is typically temporary and will resolve on its own. If you have any concerns, be sure to speak with your doctor before using a massage gun.

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What is the AC Joint?

The Acromion-Clavicular Joint (AC Joint) is the joint between the bony tip of the shoulder (acromion) and the collar bone (clavicle). The Acromion-clavicular joint is one of the synovial articulations of the shoulder complex which connects the axial to the appendicular skeleton.

The synovial joint is formed between the convex lateral clavicular and medial concave acromial ends.

A fibrocartilaginous disc similar to the knee’s meniscus sits between the articulating surfaces. Degeneration of this disc occurs with increasing age and activity and is thought to contribute to pain and disability in the elderly and overhead athletes.

The AC joint has four planes of movement: anterior-posterior and superior-inferior.

The capsule surrounding the joint,  the condensed acromioclavicular ligaments, and the coracoclavicular ligament complex is the restraint that keeps the joint in position and protects it from its dislocation.

AC joint injuries account for 9 to 12% of all shoulder injuries, both traumatic and degenerative injuries. 

Traumatic AC injuries are mostly seen in people aged in the twenties whereas Degenerative AC Injuries are more prevalent in people in their fifties. The AC joint sprains which can be due to direct or indirect force are high in collision and combat sports like hockey, American football, rugby, and karate.

How to find the AC Joint?

The joint can be found by running your fingers along the clavicle, also known as the collar bone, towards the shoulder. At the point where the clavicle ends, depression can be sensed between the clavicle and an overriding acromion. This joint space is the AC joint space. 

Can AC joint injury cause neck pain?

Yes, AC joint injuries can cause neck pain. The stability of the AC joint is provided by trapezius and deltoid muscles dynamically. They help in maintaining the joint position during movements of the arm. Hence any injury to the joint can cause a protective spasm in the upper trapezius and muscles surrounding the joint to guard the joint against further injury. Even some of the experimental pain studies have reproduced pain in the trapezius – supraspinatus, anterolateral neck region, and deltoid region by injecting saline in the AC joint. 

AC joint can cause referred pain in the neck region, for which the joint needs to be tested clinical-radiologically, with good attention given to the mechanism of injury.

How do you treat an injured AC joint?

An injured AC joint is treated according to the mechanism of injury. A degenerative or a micro traumatic AC joint is de-loaded by activity modification or restriction, icing, and taping. The scapular muscles are strengthened statically and dynamically and flexibility is restored to normal length.

An acutely sprained AC joint is generally treated with rest and immobilisation in a sling. Mobility, motor control, and strength are built gradually as the pain settles down and movement becomes easier.

How long does the AC joint take to heal?

The healing of the AC joint depends upon the number of structures injured, the mechanism of injury, the intensity of the traumatic force, the age of the patient, and his/her occupational demands. 

A degenerative joint disorder generally requires three to seven days of sling immobilisation with anti-inflammatories, physical therapy focuses on scapular control and flexibility, followed by activity modifications and strengthening. In some cases, intra-articular injections are also helpful in controlling inflammation. 

Acute AC joint sprains are classified according to Rockwood classification, depending upon the ligaments and trapezius – deltoid fascia involved. Type 1 and 2 injuries are mild sprains without any separation of the joint surfaces. These injuries are treated non-operatively with rest, immobilisation in a sling a gradual physiotherapy program focussing on building strength and scapular kinematics. Depending upon the extent of the injury and other comorbidities it might take 3 to 12 weeks of rehabilitation to heal an AC joint injury.

With respect to athletic injuries, especially in collision sports the player position, injury time compared to the athletic season, and throwing demands are taken into consideration to make treatment decisions. Athletes predisposed to further AC joint injuries are predominantly treated conservatively. Type 3 injuries can be treated both operatively and non-operatively depending upon the case and the structures involved.

Does AC joint separation need surgery?

Most AC joint separations are Types I- III and do not require surgery. Type IV – VI AC joint separations require surgery and can occur in high-impact traumas such as car crashes. These injuries have a high risk of instability of the shoulder joint and are treated surgically with one of  4 types of procedures as follows:

1. Primary repair of AC joint with pins, needles, or rods
2. Distal clavicle resection and reconstruction of soft tissues(Weaver Dunn Procedure).
3. Anatomic coracoclavicular reconstruction
4. Arthroscopic fixation with sutures

 The post-operative rehabilitation is gradual and might take 6 to 12 months for a full recovery and return to sport depending upon the structures involved and the surgical procedures used, with arthroscopic procedures requiring less time compared to the open ones.

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What is a Dislocation?

Dislocation is defined as the complete separation of the two articulating surfaces of a joint. 

What is a Posterior Dislocation of the Shoulder?

Posterior dislocation is defined when the head of the humerus is separated from the glenoid and pushed posteriorly. One of the most missed or the late diagnosed dislocation of the shoulder is the posterior one(1).

This is because the shoulder complex is guarded posteriorly by the scapula and a thick musculature covering it. This makes the posterior dislocation less frequent with about 2 -5% of the occurrence, compared to the anterior one.

About 60 – 79% of the posterior dislocations are missed during the initial examination, hence it warrants a keen examination for a good prognosis(1,2)

Aa per the basic classification, posterior dislocations can be classified as Traumatic and Atraumatic, of which the traumatic being more common.

Posterior dislocations are classified more precisely according to the etiopathogenesis and presentation as- 

1. Acute dislocation
2. Chronic (Fixed/ Locked) dislocation
3. Recurrent Posterior subluxation (more common)

Mechanism of Injury

Trauma

Trauma is the most common mechanism of posterior dislocation. 67% of all posterior dislocations occur with a high energy force directed axially to the shoulder, with the upper extremity in an internally rotated and adducted position(3).

This may be observed in the case of grabbing a dashboard during a motor vehicle collision or falling on the hand(2).

A sudden force while guarding against an opponent in combat or high-intensity sports.

Seizures

Seizures can cause posterior shoulder dislocations. In fact, 31% of the dislocations reported were being accountable due to the seizures of all the posterior dislocations(3).

A seizure is characterised by a sudden onset of high-intensity muscle contraction.

This can cause the larger muscle mass of internal rotators, consisting of the subscapularis, latissimus dorsi, and pectorals to overpower the external rotators mainly consisting of the rotator cuff muscles to posteriorly dislocate the shoulder.

Electrocution

A sudden passage of electric current has an incidence of 2% of total posterior dislocations (3).

Posterior Instability / Microtrauma

The posterior structures of the shoulder are under tension due to repeated episodes of loading. This can be seen in line backs in American Football, goalkeepers,  weightlifters, and overhead athletes who repeatedly are subjected to posteriorly directed force (3,5). A recent study on shoulder instability in the NFL has shown a greater incidence of posterior instability in quarterbacks and linebackers compared to other instabilities(8).  The mechanism of this can be explained as the structures getting stretched. This is seen as a continuum in fact a posterior instability gives rise to frank dislocation during the season, and hence preseason screening – prevention strategies can help in managing the injuries better. 

Anterior vs Posterior Shoulder Dislocation:

The differences between anterior and posterior shoulder dislocations are shown in this table:

Shoulder Dislocation X-Ray

The images below show X-Rays of anterior and posterior shoulder dislocations.

Posterior Shoulder Dislocation MRI

MRI helps in diagnosing the associated soft-tissue injuries like rotator cuff tears , bicep tendon inflammation, extent of reverse hill sach lesion and vascular supply of the humeral head(6,7).

Hence, posterior dislocation of the shoulder, one of the trickiest shoulder instability conditions to diagnose, needs a thorough assessment, a good reason for doubt, and preventive strategies in athletic shoulders, and a series of radiology investigations.

One of the main differentials in the elderly population is frozen shoulder which can give similar signs of restriction in external rotation and abduction. If misdiagnosed as the frozen shoulder the patient loses time and the viable humeral head blood supply(1). Even reduction in more than 3 weeks old chronic cases should be only taken with an in-depth investigation and consultation with a shoulder surgeon.

REFERENCES

1. Perron AD, Jones RL. Posterior shoulder dislocation: avoiding a missed diagnosis. The American journal of emergency medicine. 2000 Mar 1;18(2):189-91.
2. Paul J, Buchmann S, Beitzel K, Solovyova O, Imhoff AB. Posterior shoulder dislocation: systematic review and treatment algorithm. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2011 Nov 1;27(11):1562-72.
3. Robinson CM, Seah M, Akhtar MA. The epidemiology, risk of recurrence, and functional outcome after an acute traumatic posterior dislocation of the shoulder. JBJS. 2011 Sep 7;93(17):1605-13.
4. Rouleau DM, Hebert-Davies J. Incidence of associated injury in posterior shoulder dislocation: systematic review of the literature. Journal of orthopaedic trauma. 2012 Apr 1;26(4):246-51.
5. Tannenbaum E, Sekiya JK. Evaluation and management of posterior shoulder instability. Sports health. 2011 May;3(3):253-63.
6. Basal O, Dincer R, Turk B. Locked posterior dislocation of the shoulder: A systematic review. EFORT Open Reviews. 2018 Jan 15;3(1):15
7. Paparoidamis G, Iliopoulos E, Narvani AA, Levy O, Tsiridis E, Polyzois I. Posterior shoulder fracture-dislocation: A systematic review of the literature and current aspects of management. Chinese Journal of Traumatology. 2021 Jan 1;24(01):18-24.
8. Anderson MJ, Mack CD, Herzog MM, Levine WN. Epidemiology of shoulder instability in the national football league. Orthopaedic Journal of Sports Medicine. 2021 Apr 27;9(5):23259671211007743.
9. Chan O, editor. ABC of emergency radiology. John Wiley & Sons; 2012 Dec 12.
10. https://www.ortho-teaching.feinberg.northwestern.edu/XRreading/shoulder/yview.html
11. Abrams R, Akbarnia H. Shoulder dislocations overview. InStatPearls [Internet] 2021 Aug 13. StatPearls Publishing.
12. https://radiopaedia.org/articles/posterior-shoulder-dislocation

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The Shoulder Complex made simple – from Anatomy to Function

By Manasi Satalkar, Musculoskeletal Physiotherapist

 

 

If you ask me one important joint which can help you to pull through the mountains, deep waters, and beat it out of those gangsters, it would surely be the shoulder.

But what makes this joint so special?

To tell you the truth, no other joint in the human body is as versatile with the dual functions of mobility and stability. With each activity you do, whether it’s punching, pulling, or throwing, the shoulder automates a sweet spot between the stability and mobility to complete each task with precision[1,2].

So, what do you imagine if I ask you:

 

“what do you think the shoulder joint is made of?”

But as you imagined it is not only the ball and socket structure, rather it’s a whole complex made up of other joints such as-

 1. The acromioclavicular joint, joining the scapula at the acromion to the clavicle. Also known as the AC joint

2. The sternoclavicular joint, which joins the other end of the clavicle to the sternum at the centre of the body

 3. The scapulothoracic – where scapula moves on the thorax

4. The thoracic spine – the 12 vertebrae that runs from the base of the neck T1 down to the abdomen T12, and is the only part of the spine that anchors the ribcage

And of course :

5. The ball and socket – glenohumeral joint (from Greek glene, eyeball, + -oid, ‘form of’, + Latin humerus, shoulder) 

 

 

 

Humans as species have evolved where all these joints orchestrate together to make the movement flow into visual music which you see and get enamored by it.

Throwing to precision is the skill as Charles Darwin says humans have, due to natural selection.

 

No other animal can throw with velocity and power as humans do which can not only save the thrower’s life but also is a true marker of performance marvel where shoulder plays a major role [3].

Charles Darwin

To achieve this, the shoulder has anatomical benefits whose major function is to funnel down the force from the ground up and control the object’s trajectory.

So, if you ask what anatomical factors make this possible – The bony ratio of the ball that is the humeral head to the socket which is the glenoid is about 4: 1, this is like a golf ball getting ready on a golf tee [3].

 This golf ball as you see is not overtly thrown in any direction thanks to the Passive or Involuntary ligaments and capsular structures surrounding the joint and The scapular – rotator cuff muscles which stabilize it actively during the dynamic movements[4].

The rotator cuff is like the team of quality control officers of the shoulder movement – consisting of the four muscles fondly called as the SITS –

 

1. Supraspinatus
2. Infraspinatus
3. Teres Minor
4. Subscapularis

 This team works together like a stirrup to keep the ball in the socket during all the varied movements it offers which are nothing but the permutation and combinations of following basic movements [6] –

 

Shoulder Movements

 

1. Flexion

Is an upgoing movement from the front side or the sagittal plane facilitated by the pectorals, anterior deltoid, coracobrachialis and weakly by the biceps. A normal mobility of this movement which we generally refer to the range of motion is generally about 180 degrees.

 

 

2. Extension

Is a backward going movement facilitated by the Latissimus dorsi a.k.a the largest back muscle in terms of surface area, posterior deltoid and the teres major. The normal range of motion is about 45 to 60 degrees.

 

3. Abduction

Is a sideways upgoing movement in the frontal plane brought about by the supraspinatus and the mid deltoid. The trapezius and serratus anterior act as a force couple which spin the scapula in an upward facing socket to give shoulder an overhead mobility. Though the range of motion for abduction is 180 degrees, the force couple is responsible for the range above the 90 degrees of elevation

 

 4. Adduction

Is a frontal plane inward or towards the body coming movement brought about by the Latissimus dorsi, Pectorals and the teres major.

 

 5. Medial rotation

Is rotatory movement along a vertical axis which can be defined as a straight line cutting your body into the right and left halves. Medial rotation brings the arm towards the body and is carried out by the subscapularis, latissimus dorsi, pectorals, teres major and the anterior deltoid. A range of motion of 70 to 90 degrees is generally the observed normal range of motion.

 

6. External Rotation-

Is also the rotatory movement along the vertical axis just in opposition to the external rotation which brings the arm away from the body. It is one of the important components of the throwing position, which is a position of combined abduction, external rotation and a slight extension. The range of shoulder external rotation is one of the important metrics in the field of general orthopedic and sports rehab, with varied conditions like frozen shoulder, rotator cuff injury, dislocation and so on. A functional range of motion between 90 to 100 degrees, in comparison with the normal is considered normal.

 

Ligaments of the shoulder

They not only are the packaging structures which get tightened and slack with the movements but also act as a sensor laden thickening of the capsules to inform the brain where the shoulder is positioned.

The major ligaments of shoulder are –

 

1. The coracohumeral ligament
2. The glenohumeral ligaments – which are a composite of three – the superior or the above one, the middle and the inferior glenohumeral ligaments. These attach the glenoid to the humerus and keep the ball intact in the socket.
3. The coracoclavicular ligament- serving as functional link of joining the scapula to the clavicle to help the clavicle in bringing about the extra scapular range of motion[6].

If we see now the shoulder complex with so many attachments seems like an engine which would surely need some lubrication, this is brought about by the “ bursae”, fluid filled bags which helps in keeping the movement frictionless and smooth. The shoulder complex has three important bursae’s namely –

 

1. The Subdeltoid/Subacromial bursa
2. The Supraacromial bursa
3. The Subcoracoid bursa
4. The Subscapular recess – which is not a separate bursa but an extension of the ball and socket joint .
5. The Scapulothoracic bursae – A total number of six bursae are there out of which two are primary and the remaining four are varied and not found in all [3].

The Scapula plays a major role to take the ball and socket in an overhead position, it syncs it’s movement with it to bring in the extra stability and mobility in the overhead position

The scapula can –

1. Rotate Upwards and downwards during the abduction and adduction

2. Protract and retract with flexion and extension

3. Tilt forward and backward with any upgoing and downgoing movements [4]

The Thoracic spine, which is usually in a slightly bent position, extends to facilitate the smooth overhead movement of the scapula and ultimately the whole upper extremity in the air.

So now as we see the shoulder the king of rotatory range of motion does not function in silos but is simplistically designed complex doing teamwork to make your everyday life and performance better[5,6].

Therefore, in case you feel your shoulder is not doing well, do assess each player of the team, check their metrics and try to improve each of them to bring a perceptible difference in the larger picture.

 

References

 

1. Veeger HE, Van Der Helm FC. Shoulder function: the perfect compromise between mobility and stability. Journal of biomechanics. 2007 Jan 1;40(10):2119-29.
2. Patel RM, Gelber JD, Schickendantz MS. The weight-bearing shoulder. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2018 Jan 1;26(1):3-13.
3. Bain GI, Itoi E, Di Giacomo G, Sugaya H, editors. Normal and pathological anatomy of the shoulder. Springer; 2015 May 5.
4. Neumann DA. Kinesiology of the musculoskeletal system-e-book: foundations for rehabilitation. Elsevier Health Sciences; 2016 Nov 3.
5. Kuhn JE. Throwing, the Shoulder, and Human Evolution. American Journal of Orthopedics (Belle Mead, NJ). 2016 Mar 1;45(3):110-4.
6. Chang LR, Anand P, Varacallo M. Anatomy, Shoulder and Upper Limb, Glenohumeral Joint. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537018/

 

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