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Ask an expert - muscles and bones- shoulder

15 questions

Q: I've wrenched a muscle in the top of my right arm pushing something? I get pain when I lift my arm shoulder height.  I have no pain below or above, just at shoulder height?

A: As you may be well aware, the shoulder can be affected in some very specific ways from injury which restrict movement in one direction only while leaving everything else unaffected. The glenoid cavity in which the head of the humerus sits is a very 'open' socket, and its stability comes from several groups of muscles whose tendons insert in and around the joint. The main issue for you is whether there has been a tendon strain or actual tendon damage.

 You do not mention whether you have seen your GP, but we would advise that it is probably a good idea to follow this route anyway in order to line up a consultant if need be. Our experience has been that if there are tears in the tendons these do not always heal spontaneously, mainly because it is very difficult to immobilise the joint. If there is a need for microsurgery, then you would be well advised to find out sooner rather than later.

 If it is a tendon or muscle strain, it would not take the practitioner very long to determine which groups of muscles and tendons are involved. Although we are committed to treating the individual, not simply the problem with which they attend, some problems are what they are. There may be a background against which one could anticipate that tendon tears were more likely (some people have their muscles at straining point for much of the time) but in the average case attending to the problem directly can be a viable option. This will very often involved needles where the problem is located and along the channels with which these areas connect.

 We tend to take the view that it may be necessary to supplement acupuncture treatment with exercises, and a considerable number of our members are trained in treating sports injuries. We don't keep separate listings of these, but it is usually fairly easy to track down a BAcC member who is suitably trained.

 The best option, and one which we invariably recommend, is to contact a BAcC member local to you and seek an informal face to face assessment. Most members are happy to give up a little time without charge to prospective patients to determine whether acupuncture is the best option. It might also be in your case a way of locating someone known to the local network as a 'go to'person for musculo-skeletal problems. It also has the advantage that you can meet the practitioner and see where they work before committing to treatment.


Q:  Can acupuncture be used with someone who has muscular dystrophy, not to help with the condition, but with a pinched muscle in the shoulder. 

A:  There is no reason of which we are aware that someone with muscular dystrophy should not have acupuncture treatment.

 We are always extremely careful as a professional body to set down clear guidelines to our members about when it would be unwise or even contra-indicated to use acupuncture. We do this both from a western medical perspective and also from a Chinese medicine perspective (there are, for example, good reasons to avoid some points in pregnancy, and other points which can cause a rapid drop in blood pressure which might affect some patients). We have never come across anything which suggested that acupuncture treatment would be a problem for someone with muscular dystrophy.

 As an aside we did come across this article, of which you may already be aware, which suggests that acupuncture may be a useful adjunct in treatment packages to help with the common symptoms of DMD.

 http://musculardystrophynews.com/2015/08/10/traditional-chinese-medicine-used-help-dmd-patients-study/

The Chinese undertake hundreds of thousands of trials every year on almost every health problem you can imagine, and as interesting results emerge the studies then tend to be translated and circulated more widely. 

 Even where the treatment is used for a specific purpose, like a pinched muscle, proper traditional acupuncture treats the person, not simply the condition, and we have sometimes found that with chronic degenerative problems the rate of deterioration appears to slow down. This is impossible to verify experimentally because conditions like this are so variable anyway, but we have seen several patients whose problems seem to plateau for longer when they are having regular treatment. However, we would never encourage people to have treatment on this basis, and in this case we would suspect that treatment for a pinched nerve may well be beneficial in itself, however the rest of the system reacts.

 

Q:  I have been diagnosed with a rotator cuff tear. Whilst I wait for a operation I am thinking about trying some acupuncture for the pain and deferred  pain after my recent cortisone injection. I have had 2 injections and they have helped with my shoulder pain but not stopped the deferred  pain.

A:  There are two questions here: is acupuncture any good for deferred pain in rotator cuff injuries and can it be done alongside cortisone injections.

As far as the deferred pain is concerned, a great deal depends on what is causing it. In answering a question on rotator cuff injuries a while ago we said:

There are a number of trials which have shown encouraging results, two of which can be found at

http://www.ncbi.nlm.nih.gov/pubmed/10534595
and
http://www.ncbi.nlm.nih.gov/pubmed/19489707

but a review of all the trials was less than conclusive

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0013397/

Acupuncture has been used as a form of pain relief in both eastern and western/medical traditions for many decades, and there is no doubt that there is sufficient evidence to demonstrate efficacy in relieving pain. The question, however, is whether that relief is sustainable and for how long, and whether it promotes eventual healing or simply operates as a non-pharmaceutical alternative for pain relief. If it is the latter then it may be a prohibitively expensive option unless someone cannot use conventional pain-killing medication.

Having said that, the theory of Chinese medicine treatment is based on the premise that pain arises from malfunction or blockage, and pain is treated not so much as a thing itself but as a symptom of a failure of function or flow in the system. By restoring flow or balance the practitioner would hope both to encourage healing and reduce pain.

There are a number of strategies involving both local needling and systemic treatment, depending on the nature of the pain and the injuries or strains which people have experienced. There is no real alternative, though, than to seek face to face advice from a BAcC member who can give you an accurate assessment based on the specific presentation you have.  
 

From a Chinese medicine perspective we would normally be classifying deferred pain in terms of blockages or disruptions in the flow of energy to the area where the pain occurs. This may have been caused by the injury or may in some cases result from the cortisone injections themselves. It would be extremely important to have sight of the areas of pain to make sense of them, and be able to offer a more definitive view. If it is a case of blockage or change in the flow, then there is a good chance that treatment may have an impact. However, if this is really a case of referred pain in the conventional sense it means that the pain trigger still exists elsewhere, and until that is resolved the pain may continue.

As far as cortisone injections are concerned, there is no definitive answer from the research literature or from conventional medicine about the use of acupuncture after a cortisone treatment. There is nothing which indicates that it should not be done, but you will probably find that most practitioners will not needle in the area directly around the injection site until a week or more after an injection. This is mainly for energetic reasons, with most practitioners taking the view that until the area has stabilised again it is better to wait and see what effect the injection has both on the primary condition and on the tissue in the area itself. Once everything has settled down, there is no reason not to have acupuncture treatment.

We strongly recommend having a face to face chat with a BAcC member before committing to treatment. In our experience rotator cuff injuries can present unique challenges, not least in that it is a very difficult joint to immobilise and lead an ordinary life, so continued aggravations of the initial injury are quite common. Most BAcC members are happy to give up a little time without charge to assess a problem and give a more balanced view than we can offer at a distance.

 

Q:  I have a frozen shoulder (and have had it now for 6 months with no sign of recovery). Can acupuncture help and how much does each session cost? On average, how may sessions are needed to treat a frozen shoulder ( know that's like asking 'How long is a piece of string?, but there must be some guideline.

A: 

You will not be surprised to hear that we are often asked this question, and we tend to repeat an answer we gave some time ago.
 

Can accupuncture help a frozen shoulder?

 

Frozen shoulder can be a difficult condition to treat. Our fact sheet on the website 
 
http://www.acupuncture.org.uk/a-to-z-of-conditions/a-to-z-of-conditions/frozen-shoulder.html
 
is not overly encouraging, but the main point to note here is that there haven't been a great many studies. What counts as 'frozen shoulder' can vary considerably and creating a number of groups with identical problems for trial purposes is not that straightforward.

One major problem with the shoulder joint is that it's mobility means a dependence on groups of muscles and a relatively open socket into which the head of the humerus fits. It is very easy for there to be a minor displacement or small dislocation of the joint, and equally easy for a problem with one set of muscles to cause a ripple effect throughout all of the groups holding the shoulder joint stable. There are often secondary problems which may need to be addressed.

Chinese medicine has obviously been used to treat problems like this for thousands of years, and as well as treating locally to where the problem is on the body there are a number of functional treatments which are aimed at affecting all muscles and a couple of 'empirical points', points which have been used for centuries to help with all shoulder problems. There are also points which can be used to help reduce some of the pain and inflammation which results from the muscle and tendon strains.

However, there is no doubt that it really pays to have treatment with someone who fully understands the dynamics of the joint in great detail and can make an informed and careful assessment of the precise problem. There are a considerable number of BAcC members who are also trained in osteopathy and physiotherapy, and equally a number of osteopaths and physios who use acupuncture on a regular basis, and the combination of manipulation, movement and acupuncture may be the optimum package.

It may be helpful to seek the advice of a BAcC member local to you. Most know of colleagues within their area who specialise in this kind of condition, and many also work very closely with local osteopaths and physiotherapists, and maybe able to put together a co-ordinated package of treatment to get you back to good health and mobility. 

 
This remains an accurate summary of our views. Since publishing this, this particular expert has had a couple of good outcomes treating the problem, but the fact that it came as a surprise that it worked so well probably tells you what you need to know about how unpredictable the outcome of treatment can be.
 
The average cost per session depends largely on where you are. For the first session, in London you might be paying £50-£75, for each follow up session (which can last between half an hour and an hour) you might be paying £40-£50. In the provinces this cna be a little lower, £40 - £60, and £30 - £45, but again, it depends on the kinds of premises which you visit. Like any business, the more salubrious the surroundings, the greater the cost and the more likelihood that this will get charged on to the patient.
 
The first session costs more because it is generally longer and is a full diagnostic session. As the great Canadian physician William Osler once remarked, 'tell me about the patient who has the disease, not about the disease the patient has', and this is fundamental to Chinese medicine. The body has a fantastic ability to recover, and looking at the whole picture enables the practitioner to see what is preventing recovery, whether something is simply stuck where the problem is or whether the 'stuckness' is happening because of weaknesses elsewhere.
 
Most practitioners will set a defined number of sessions when taking on a problem like yours and do a thorough review to see if any progress has been made. This is usually four or five sessions. It is very helpful to have some objective markers for checking whether anything has changed, and the degrees of abduction, extension and flexion are usually a reliable indicator of whether joint is is improving or not.
 
We like to avoid situations where treatment just carries on and on after some hold grail of change long after it has become clear that acupuncture treatment is not working. Herein lie complaints!   
 

A:  As you can imagine we have been asked about frozen shoulders before and one of our earlier answers, to which we have added supplementary comment, was:

Can acupuncture help a frozen shoulder?

Frozen shoulder can be a difficult condition to treat. Our fact sheet on the website

http://www.acupuncture.org.uk/a-to-z-of-conditions/a-to-z-of-conditions/frozen-shoulder.html

is not overly encouraging, but the main point to note here is that there haven't been a great many studies. What counts as 'frozen shoulder' can vary considerably and creating a number of groups with identical problems for trial purposes is not that straightforward. There was very positive article in the national press a couple of years ago

http://www.dailymail.co.uk/home/you/article-2082722/Health-Take-pain-frozen-shoulder.html

which is useful because it describes a number of conventional treatments which are also used for treating the condition. If you have not been offered any of these options, or not had the full range of investigations, we strongly advise you to make sure that your GP known how much pain you are in and gets the joint scanned to see if there is something which is seriously out of place. It is possible, for example, to tear one of the tendons near the joint which will cause almost unceasing pain, and although acupuncture treatment may help to ease the pain temporarily, the problem may require minor surgery to be fully resolved.

One major problem with the shoulder joint is that it's mobility means a dependence on groups of muscles and a relatively open socket into which the head of the humerus fits. It is very easy for there to be a minor displacement or small dislocation of the joint, and equally easy for a problem with one set of muscles to cause a ripple effect throughout all of the groups holding the shoulder joint stable. There are often secondary problems which may need to be addressed.

Chinese medicine has obviously been used to treat problems like this for thousands of years, and as well as treating locally to where the problem is on the body there are a number of functional treatments which are aimed at affecting all muscles and a couple of 'empirical points', points which have been used for centuries to help with all shoulder problems. There are also points which can be used to help reduce some of the pain and inflammation which results from the muscle and tendon strains.

However, there is no doubt that it really pays to have treatment with someone who fully understands the dynamics of the joint in great detail and can make an informed and careful assessment of the precise problem. There are a considerable number of BAcC members who are also trained in osteopathy and physiotherapy, and equally a number of osteopaths and physios who use acupuncture on a regular basis, and the combination of manipulation, movement and acupuncture may be the optimum package.

It may be helpful to seek the advice of a BAcC member local to you. Most know of colleagues within their area who specialise in this kind of condition, and many also work very closely with local osteopaths and physiotherapists, and maybe able to put together a co-ordinated package of treatment to get you back to good health and mobility.

There isn't a great deal more we can add. Acupuncture has a long history of being used for pain relief, and the question which a practitioner needs to resolve for themselves when treating someone for chronic pain is whether the amount of relief they can help the person to achieve is sustainable enough to warrant the continuing expense. In most cases, however, they will make this a consideration secondary to seeing what can be done to fix the problem itself.

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