Right shoulder instability

by Arjun
(Birmingham United Kingdom)

Dear Dr B

I would greatly appreciate it if you could help me an longstanding and ongoing issue with my upper back, primarily with my right shoulder blade.

I first injured the upper back around three years ago whilst performing bent over row weighted exercise at the gym. I didn't warm up sufficiently and felt a deep pain in my rhomboid area, or the area between my right shoulder blade and spine.

I rested and it somewhat recovered but ever since my right shoulder has never felt the same nor does it have the same amount of strength as my left shoulder. In particular, when I attempt to lift my right arm overhead I feel great discomfort, not pain, in my right shoulder blade/scapula. It is a feeling of instability and almost as if my shoulder is about to be dislocated.

One exercise at the gym I found has worked to provide temporary relief is something called a scapula raise, which is similar to a scapula push up, but you are hanging off a pull up bar and lift yourself up without bending the arms, it is a subtle movement but seem to help my scapula stay retracted and down for a while.

I am beginning to think my injury is nerve related rather than muscle related due to the length of time I have had the issue and I am now getting spasms of pain in my rhomboid area which also affects my breathing. I have been to a chiropractor who told me that apparently the rib can poke through the back and that prevents the scapula rotating properly on the rib cage, but the manual release therapy did not provide me with any relief. When standing upright my left lat/serratus anterior feels a lot more activated than the right side which feels as though the muscle is somewhat paralysed. I also struggle a lot with simple push ups where my right shoulder blade area feels very unstable during the movement and there is a clear lack of strength compared to what I could do before the injury.

I am not sure if this is related but I also get the occasional tingling/numbness in my fingers, particular my right hand. Also I regularly wake up at night with completely numb hands. Just one final thing which may also be unrelated to the shoulder issue is that I also get some sciatic pain which runs down the back of my left leg and stretching my hamstrings feels very uncomfortable.

Apologies for the long email but it is hard to find a chiropractor who really knows the body through and through and you seem to have a great level of knowledge.

Kindest Regards

Hallo Arjun,
Ben je Nederlands? There can't be too many Arjuns in England!

This is complicated and I really can't give you a simple answer. There isn't one. My feeling is that you are almost certainly correct; this is neurological fundamentally. The tingling and numbness in the hands is a vital factor in the diagnosis of your back pain and shoulder weakness.

Firstly, start to focus on which fingers are involved. This gives important information to your chiropractor.

The rhomboid area is particularly difficult. I'm not sure what a "rib poking through the back" is about, but certainly the costovertebral joints could be part of the problem.

The rhomboids are supplied by nervous innervation from the lower neck via the dorsal scapular nerve. It's a pure C5 nerve; it's not uncommon that a lower neck problem refers to the midback, and to the arm, or both limbs less commonly. However, C5 doesn't go to the hands.

The fact that raising your arm overhead increases your pain may be very significant. Nerve root impingement is relieved by raising your arm. Read more about the Shoulder abduction relief sign. However, a thoracic outlet syndrome is aggravated by raising the arm. The definitive examination is Adson's test. The pulse in your wrist drops dramatically when you turn your head to the right, look up, and take in a deep breath. It's not a simple test to perform, however.

I think the problems in your sciatic nerve are probably unrelated; in rare cases an impingement in the neck can affect the lower limb.

Then there are referrals from the lungs and pancreas for example that typically refer to the midback. There's nothing simple about your problem.

Look at this letter as the beginning of a journey. Start looking for a chiropractor who is known to be thorough, caring, and will take the time to examine you carefully.

You make no mention of xrays. It's time for a cervical and thoracic spine series and a chest xray. Do you have a cervical rib?

Lastly, as you already are doing, start to looking for those movements that provoke and relieve the pain.

Er is helaas niets gewoon of simpel met uw klacht, Arjun.

Let me know how you get on.

Dr B

» Right shoulder instability

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Interesting challenges of the day

1. Mr S is a 76 year old man with neck pain of some 9 months duration. Luckily, most of the discomfort is upper cervical which is only rarely arthritic; his lower cervical spine is a degenerative mess that I've left alone. After seven treatments his pain and stiffness is 50 percent better, and he's happy in the circumstances. He can sleep through the night now and that makes a huge difference.

2. Mr P is 32 year old man with very severe lower back pain radiating to the big toe which is 30 percent numb. He had an episode three weeks ago, took anti inflammatories and was soon better as is typical of the medial disc herniation. But before it healed, after a trivia it came roaring back, much worse. The characteristic crossed sign was evident; sitting in a chair, straightening the right leg provoked severe left back pain and tingling in the leg. He's doing well.

3. Severe lower back pain is scary; just ask Mrs P. Just watching her get out of the car I she was in trouble; she had a slipped disc at L4 making her lean towards the opposite side; luckily she had no pain in the leg. Despite family pressure that this was far too severe for a chiropractor, she persevered. Within five days she was standing upright, and after two weeks almost painfree. 

Despite a hectic job, she wisely took my advice and stayed home for what I call exercising bed rest.

4. Mr S has had lower back, groin and back of thigh and calf pain for fourth months.

He has a pincer deformity in the hip causing the stabs in the groin, and a degenerative facet causing the sciatica. Both are responding well to chiropractic and he's well pleased; sixty five percent better after three treatments.

5. Mr T is a wise man; he's taken a warning TIA seriously and has lost 15 pounds, and has at least as much again to lose. A change to a low starch diet and half hour daily walk has made the difference; but the walking is making his foot and back miserable. The expensive orthotic is hopeless; luckily his hips and back are fine, but he needs a simple heel lift.

6. I too have had serious lower back issues, luckily fixed by my own chiropractor; so I too have to do my exercises, take care when lifting supers full of honey, gardening and using the chainsaw. Regaining the function of your spine is just as important as the pain.

7. My own granddaughter, only 7 is hypermobile giving her pelvic, knee and ankle issues. Xrays show a mildly dysplastic hip. Years ago we would have called it growing pains. She too regularly needs chiropractic care and luckily responds well. Increased range of motion is more difficult than too stiff in my opinion. Our care is for kids too.

8. This 65 year old lady is a serious gardener; every day she is bending, lifting and digging for 2 to 3 hours a day. It regularly catches her in the sacroiliac joint, so she has a treatment once a month that sorts it out. She does her lower back exercises faithfully.

9. This 88 year old lady is an inspiration; every day she is busy in the community. With a nasty scoliosis she manages very well with a chiropractic adjustment every six weeks and exercises faithfully done.  

10. Mr X is a 71 year old retired man who wants to continue with maintenance care every six to eight weeks; he had suffered from two years of lower back pain when he first came a year ago. He has no discomfort now after 8 chiropractic treatments, but is aware that danger lurks.

11. Mrs C has been having severe headaches, and taking a lot of analgesics. It's a non complicated upper cervical facet syndrome, and she's doing well.

12. Mr D is a 38 old year man with chronic shoulder pain after a rotator cuff tear playing cricket. It responded well to treatment, but he knows he must do his exercises every day; for two years he couldn't sleep on that shoulder.

13. Mr D, a 71 year old man, has a severe ache in the shoulder and midback since working above his head. Trapped nerve tests are negative but he has advanced degenerative joints of Luschka; after just two treatments he is 50 percent better. Can we reach 90?

And so the day goes; chiropractors shouldn't be treating the elderly most medical sites state but that's so much bunkum.

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