In politics and many religions or denominations people seek to paint the world in black and

white. Life is simpler when there is a right or wrong, discrete, understandable solution to the
problems that life deals us. Many people expect that should be the case with their medical
problems as well. For those with shoulder problems, this article will be a disappointment.
When a lay person thinks about the shoulder their most common thought is about the ball and
socket joint known as the glenohumeral joint which is more of a ball that rolls and glides on a
small saucer, continuously being re centered and kept in place by the muscles of the rotator cuff.
This joint is unique in that it is not supposed to be stabilized by ligaments. The ligaments of the
joint capsule only come into play if the muscles are failing or if trauma is unanticipated and the
muscles are not able to react in time. The capsule must be loose in order to allow the range of
motion the shoulder displays.
Kapanji, the author of the most commonly cited books on biomechanics of the joints, recognizes
the shoulder girdle complex as including the glenohumeral joint, the A-C/acromioclavicular
joint, the sterno-costo-clavicular joint all of which are true anatomic joints as well as the
subdeltoid joint and the scapulothoracic joint which are classified as physiological joints. True
joints have joint capsules attaching bone to bone and the joints typically have fluid in them. The
physiological joints are surfaces that interface and glide past one another but are not necessarily
made of bone and ligaments. The sub deltoid joint is a space under the deltoid muscle that is
enhanced when the deltoid muscle contracts and space is created to allow for movement of the
supraspinatus tendon. If the space is not created, pinching and irritation takes place in
association with movement. The scapulothoracic joint is the interface of the chest with the
shoulder blade. The shoulder blade starts moving by the time the arm reaches 60 degrees out to
the side.
An osteopath complicates the picture even further. The profession recognizes that in order for
the scapula to be able to glide normally over the rib cage all of the ribs under the shoulder blade
need to be functioning properly. There are 6 ribs under the shoulder blade and each of them
attaches to the sternal cartilage and then to the sternum , adding two additional types of joints to
the calculation and most ribs attach to two vertebrae via two different types of joints. Some
would argue that the joints between the upper 6 thoracic vertebrae need to be working properly
for the ribs to work properly. By the time things are all said and done, there are 39 joint
articulations making up each shoulder girdle complex.
Adding further to the misery of those seeking a black and white answer are the facts that
mechanical dysfunctions of the cervical spine can impact the nervous supply to the shoulder and
arm and via an impact on the sympathetic nervous system can impact the blood supply to the
arm. There are embryologic relationships between the muscles that make up the arm and organs,
especially the liver and the lungs. Health or mechanical problems with those organs may also
need to be addressed during treatment.
An osteopathic approach to shoulder pain respects these complexities and often times must start
by re-establishing a healthy foundation starting with the ribs and vertebrae before ever beginning
to work with the shoulder joints or soft tissues. Not helping the patients body establish a
healthy foundation for the shoulder often leads to partial improvement and recurrence of pain in
a repetitive cycle.
Exercise alone may, on occasion, restore mobility and painless function of a shoulder and it is
certainly necessary to optimize health and function. When portions of the shoulder girdle
complex are mechanically not functioning or when there are soft tissue restrictions impacting
blood flow or neurological input or output exercise may aggravate pain, whereas osteopathic
evaluation and treatment may relieve impediments to recovery and function.




Kapandji, A.I. Physiology of the Joints. Vol. 1, The Upper Limb, 6
th
Ed. 2007 pp 22, 23, 41.