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Shoulder Injury?


Introduction

Shoulder injuries are a common injury in the orthopedic field. They contribute to the ongoing number of orthopedic surgeries each year, which has been projected to grow. Rotator cuff dysfunctions, glenohumeral disorders, acromioclavicular joint disease, and pain that is referred from the neck are some of the most common causes of pain. Several studies look at acupuncture for pain management and the healing of specific shoulder injuries. Acupuncture along with several modalities may assist in the healing and management of shoulder pain.

Current Research

Orthopedic injuries are on the rise, and that coincides with the rate of surgeries and chronic pain. In orthopedic surgery alone, there were 5.3 million surgeries in 2010. That number was estimated to grow to 6.6 million in 2020 (Dyrda, 2011). With surgeries come many risks. With orthopedic surgery so prevalent, orthopedic surgeons are the third-highest prescribers of opioids in the United States (Morris & Mir, 2015). With the current opioid epidemic, it would be advantageous to seek alternative ways to prevent surgeries and alternative treatments to help with recovery after surgery. Shoulder pain and injuries are prevalent in the orthopedic field. Self-reported prevalence of shoulder pain is assessed to be between 16% and 26%; it is the third most regular cause of musculoskeletal consultation in primary care, and approximately 1% of adults consult a general practitioner with new shoulder pain annually (Mitchell, Adebajo, Hay, & Carr, 2005). The most frequent shoulder injuries that cause shoulder pain among people are; rotator cuff dysfunctions, glenohumeral disorders, acromioclavicular joint disease, and also pain that is referred from the neck (Mitchell, Adebajo, Hay, & Carr, 2005). Of those conditions, rotator cuff tendinopathy is the most frequent cause of shoulder pain (Mitchell, Adebajo, Hay, & Carr, 2005).


Tendon pain is the most common chronic connective tissue disorder in the sports medicine field (Kastner, 2014). A study showed that electro-stimulation contributes to collagen formation, which is essential for the healing of the tendons. Furthermore, it also reduced the number of adhesions in healed tendon tissue (Kastner, 2014). Regarding the shoulder, a supraspinatus tendon is the most common tear of the rotator cuff muscles. Tendons are slow to repair due to the low supply of blood and oxygen. Acupuncture allows clinicians to needle directly into the supraspinatus tendon, which cannot manually be treated due to the location. Utilizing electroacupuncture directly to the supraspinatus tendon to enhance the tendon's healing is among one of acupuncture's unique healing abilities (Kastner, 2014).


Acupuncture can be an excellent treatment option for patients suffering from shoulder complications. A recent study investigated the efficacy of acupuncture in decreasing the intensity of pain. One group received acupuncture while the other group received sham acupuncture over four weeks. A visual analog scale and UCLA questionnaires were used as outcome measures. The study found that acupuncture was reliable and provided significant results. Acupuncture was determined to be a considerable treatment for impingement syndrome (Garrido, Vas, & Lopez, 2016).


Acupuncture is known to have pain-relieving properties by releasing beta-endorphins and enkephalins. Acute or chronic pain may present with sharp pain, inflammation, swelling, and have an aversion to pressure. Acupuncture affects the local tissue from the moment the needle is inserted to help with healing and pain reduction. The needles trigger one of the body's most potent vasodilators, which can also lead to the release of other neuropeptides. These chemicals have powerful therapeutic effects on local tissues. It was discovered that local neurochemical accumulation consists of prostaglandins, red blood cells, white blood cells, glutamate, Substance P, and serotonin. These chemicals assist with the mitigation of pain, decrease in inflammation, increase in local circulation, help to fight infection, and promote healing of local areas (Corradino, 2017).


Acupuncture, in conjunction with physical therapy for shoulder pain, is a great combination to accentuate the results. A randomized controlled trial on the efficacy of electroacupuncture with physical therapy for frozen shoulder concluded that adding electroacupuncture can result in faster pain relief for patients (Lo, et al., 2020).


Chinese Medical Theory

Pain and obstruction in Traditional Chinese Medicine are known as the stagnation of qi and blood. Once the stagnation is removed, pain should be resolved. In Traditional Chinese Medicine, there are several ways to treat shoulder pain and injuries. One way is the use of acupuncture, more in particular electroacupuncture. There are several protocols that a practitioner may use when treating a shoulder injury. First, a practitioner will do an evaluation. They will ask a series of questions and do several observational exams. Looking at the tongue in Chinese Medicine gives the practitioner an idea of what is going on in the body. The tongue's body will show the flow of blood. Dark purple shows blood stagnation, which, as mentioned earlier, can be associated with pain. A pale tongue may have some blood deficiency, which may also indicate a stagnation of blood. A red tongue shows a lot of heat in the body, which is also known as inflammation. The pulse on both sides of the wrists is also taken; this provides the practitioner with an idea of what is going on in the body. Since in TCM, we do not have MRI or scans to diagnose, we have to use signs the body gives us to identify dysfunction.


Next, the practitioner will use palpation. They will palpate acupuncture points, muscles, and acupuncture channels to see if there is any tension, adhesion, reaction, or abnormal temperature. Different assessments may also be done to assess pain level and muscular dysfunction. EXSTORE Muscle Inhibition Testing is an excellent test when assessing muscle motor inhibition. This was developed by Dr. Anthony Lombardi, a chiropractor and acupuncturist. He has been teaching the EXSTORE system and mentoring doctors all over the world since 2010 (Lombardi, 2013). Dr. Lombardi has spent years researching before creating this system, and he has treated over 82,000 patients, including professional athletes. He created the EXSTORE system to provide a quick and efficient way of assessing patients and to help clinicians achieve outstanding clinical results (Lombardi, 2013). The assessment is made up of two parts, observational and objective. It is essential to observe the patient's range of motion and their gait to get an idea of where the dysfunction is coming from. The objective part consists of body scans. The body scans are divided into the upper and lower body. The scans consist of precise movements performed by the patients against the resistance of the practitioner. The scans are testing for muscle motor inhibition, which is when the nerve that sends the signal to the brain to contract the muscle is not functioning correctly. This can happen from overuse, neurogenic inflammation, or trauma (Lombardi, 2013). If a muscle is not functioning correctly, it can affect the biomechanics of that whole region, and therefore cause pain and weakness. Once the dysfunction is detected, it is imperative to activate that muscle again by using electroacupuncture.


Distal points can be useful for immediate pain relief. A systematic review looked at the effectiveness of pain relief for shoulder adhesive capsulitis by using the acupuncture point Stomach 38 . This point is located on the lateral side of the leg, halfway between the tibiofemoral joint line and the prominence of the lateral malleolus and lateral to the anterior crest of the tibia (Deadman, Al-Khafaji, & Baker, 2016). The study concluded that St38 had achieved statistically significant effects in improving shoulder adhesive capsulitis (Yang, et al., 2018). Another study found that needling contralateral to the affected shoulder was more effective than needling the ipsilateral to for immediate pain relief (Hu, et al., 2019).


Treatment Plan

For shoulder injuries, a patient should seek treatment two times a week for three weeks, then reevaluate to see how they are responding (Reaves & Bong, 2009). Typically, a patient will need six weeks of treatment. Cupping and Gua Sha are exceptional modalities to add to shoulder injury cases. This will help move qi and blood and remove stagnation from the area of injury. They both will also help relax muscles. Gua sha is an excellent tool to use to break up adhesions on the tissue. Infrared heat can be added to support inflammation and circulation of the area.

Alternative Approaches

Other non-invasive options a patient with shoulder pain can take is yoga or physical therapy. Both of these therapies will help with range of motion, stretching, and strengthening. Heat can also be applied to the area to help with the pain and healing. The heat will allow for vasodilation, which, in return, can promote healing. A patient should avoid icing the area because icing will cause vasoconstriction and inhibit healing, a cooling liniment like White Flower may be more appropriate.


Biomedical Considerations

Patients with shoulder injuries will typically be referred to an orthopedic. They will observe the area by using a series of orthopedic testing. The empty can test, and the arch of pain test are used to examine the supraspinatus muscle and tendon (Reaves & Bong, 2009). Next, X-Rays and MRI are ordered to see if there are any structural issues. A surgeon may recommend physical therapy or surgery, depending on the grade of the tear. For pain management, they recommend anti-inflammatory medication. Frozen shoulder usually is assessed by looking at the patient's external rotation (Reaves & Bong, 2009). Physical therapy and anti-inflammatory medications are habitually prescribed in cases of frozen shoulder. Pain from injury of the acromial-clavicular joint may also need an X-ray and MRI. Physical therapy, ultrasound, shoulder sling, and strengthening are all recommended therapies for these disorders. Cortisone injections are also a biomedical treatment that an orthopedic doctor may use to treat shoulder injuries.


Community Resources

Community doctors are where a patient with a shoulder injury should consider. Starting with your primary care doctor is an excellent resource because they will refer you to an appropriate doctor for an assessment. Several internet resources allow for easy access that can help guide a patient into making the next steps. Local yoga studios or online classes can be beneficial for those suffering from shoulder pain.


Prognosis

When it comes to injury of the rotator cuff, the patient needs to seek medical care quickly because that can help with their prognosis. The reason for that is that if a patient has a partial thickness tear, there is a potential for it to become a full-thickness tear, which then may require surgery. Tendons have three phases of healing; the first phase is immediately after the injury and can last up to 24 hours. The second phase is seen as the repair phase, which may last up to six weeks, and the final stage is the remodeling phase, which can last up to twelve weeks (Kastner, 2014). Early detection of a tear will allow the patient to take precautions to further damage and avoid surgery. If a patient does require surgery, they still have a long recovery road after. Typically a patient will be prescribed opioids and physical therapy after the surgery. If a patient incorporates acupuncture when they are injured, it may help them avoid shoulder surgery, or if a patient does have shoulder surgery, acupuncture can help with the recovery.


Key Learning

Orthopedic surgery and procedures can be invasive and require a long recovery road for patients. Shoulder injuries are prevalent in orthopedics because of their unique structure. The most frequent shoulder injuries that cause shoulder pain among people are; rotator cuff dysfunctions, glenohumeral disorders, acromioclavicular joint disease, and also pain that is referred from the neck. Acupuncture combined with other traditional Chinese medical modalities can help manage pain, treat the injury, and assist in recovery. There is not a ton of options that patients are referred to, typically a patient will do physical therapy, and if that does not work, they get surgery or cortisone injection. With surgery comes so many risks. Tendons are slow to heal and are involved in a number of shoulder injuries; if caught early, acupuncture could help prevent surgery. Many surgeons are looking for a way to help their patients with pain without prescribing opioids.

Written by:

Dr. Melissa Levy, DACM, AP

References

Corradino, M. D. (2017). Neuropuncture: a clinical handbook of neuroscience acupuncture. London: Singing Dragon.

Deadman, P., Al-Khafaji, M., & Baker, K. (2016). A manual of acupuncture. East Sussex, England: Journal of Chinese Medicine Publications.

Dyrda, L. (2011, May 26). Number of Orthopedic Surgeries to Reach 6.6M by 2020. Retrieved from https://www.beckersasc.com/orthopedic-spine-driven-ascs/number-of-orthopedic-surgeries-to-reach-66m-by-2020.html

Garrido, J. C. R., Vas, J., & Lopez, D. R. (2016). Acupuncture treatment of shoulder impingement syndrome: A randomized controlled trial. Complementary Therapies in Medicine, 25, 92–97. doi: 10.1016/j.ctim.2016.01.003

Hu, S., Zhang, S., Shi, G., Wang, Z., Wang, T., Yan, C., … Liu, C. (2019). Immediate analgesia effect of contralateral needling at Tiaokou (ST38) in patients with chronic shoulder pain: A randomized controlled exploratory trial. Journal of Traditional Chinese Medical Sciences, 6(1), 95–100. doi: 10.1016/j.jtcms.2019.01.007

Kastner, M. (2014). The Treatment of Tendon Pain with Traditional Chinese Medicine. Journal of Chinese Medicine, 106(October), 5–9.

Lombardi, D. A. J. (2013). Exstore Assessment & Treatment System (2nd ed.). AJL Publishing.

Lo, M.-Y., Wu, C.-H., Luh, J.-J., Wang, T.-G., Fu, L.-C., Lin, J.-G., & Lai, J.-S. (2020). The effect of electroacupuncture merged with rehabilitation for frozen shoulder syndrome: A single-blind randomized sham-acupuncture controlled study. Journal of the Formosan Medical Association, 119(1), 81–88. doi: 10.1016/j.jfma.2019.03.012

Mitchell, C., Adebajo, A., Hay, E., & Carr, A. (2005). Shoulder pain: diagnosis and management in primary care. Bmj, 331(7525), 1124–1128. doi: 10.1136/bmj.331.7525.1124

Morris, B. J., & Mir, H. R. (2015). The Opioid Epidemic. Journal of the American Academy of Orthopaedic Surgeons, 23(5), 267–271. doi: 10.5435/jaaos-d-14-00163

Reaves, W., & Bong, C. (2009). The acupuncture handbook of sports injuries & pain: a four step approach to treatment. Boulder, CO: Hidden Needle Press.

Schneider, C. (2011). Traumeel – an emerging option to nonsteroidal anti-inflammatory drugs in the management of acute musculoskeletal injuries. International Journal of General Medicine, 225. doi: 10.2147/ijgm.s16709

Yang, C., Lv, T., Yu, T., Wong, S., Lu, M., & Li, Y. (2018). Acupuncture at Tiaokou (ST38) for Shoulder Adhesive Capsulitis: What Strengths Does It Have? A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Evidence-Based Complementary and Alternative Medicine, 2018, 1–11. doi: 10.1155/2018/4197659

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