Very Early Rehabilitation Of The Shoulder

Osteopaths and orthopaedic surgeons spend significant amounts of time and effort treating shoulder injuries and conditions, of which there are many. The shoulder, an unstable joint with a very large range of movement, the greatest in the body, is vulnerable in many situations to injury or mechanical stresses. Its instability means it can be relatively easily dislocated in a fall or activity at end range. We use the arm to save ourselves if we fall, making fractures common and heavy or overhead work over time leads to rotator cuff tears.

Due to the very large number of potential injuries, fractures and operations which can affect the shoulder it is very important to know the exact diagnosis and plan of treatment. Osteopaths specialise in managing post-operative and post-trauma shoulder problems, following the surgical and trauma protocols agreed with the shoulder surgeons. On meeting the patient initially a good strategy is to review the progress of their case so far, as this can occasionally throw up unexpected anomalies which need exploring. The patient should have a short time to tell their story or they may not feel they have been heard.

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 patient’s 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.

The Velcro straps are slightly elastic and also hold against clothing or skin by friction, making them less likely to slide when adjusted. Once the sling has been put on and the strap tightened it is very likely that the elbow is not being supported by the gutter. This can be checked by feeling under the elbow to see if the sling is taking the weight. Further tightening of the strap at the front just results in more tension in the strap and not more support for the elbow and thereby the shoulder.

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.