A comprehensive treatment and prevention program that includes adjustments, structural support, and rehabilitation exercises can help workers minimize their lost-worktime injuries

By incorporating specific rehab recommendations, doctors of chiropractic can successfully treat many of the injuries that occur in today’s workplaces. Work-related injuries are now rarely the serious falls and fractures of yesteryear. Nearly all industries have worked hard to reduce the instances of acute trauma, primarily through changes in workplace rules and procedures.

Cumulative trauma disorders (CTDs), which are usually the result of repetitive motion or overexertion, are now the leading cause of work injuries. According to a recent report from the US Department of Labor, a survey by the Bureau of Labor Statistics found that sprains and strains were the most common diagnoses of lost-worktime injuries. The shoulders are part of the area that was most frequently involved.¹

Rehab exercises for an injured worker must help the patient regain normal stability and easy, natural movement. A major consideration must be the postures and loads to which each worker’s shoulders are exposed.

Shouldering the Workload
The shoulder is made up of several joints that must function together smoothly to provide the extreme mobility that is possible, and is necessary for many activities. The shoulder joint complex includes the sternoclavicular joint, the acromioclavicular joint, the glenohumeral joint, and the scapulothoracic articulation (a pseudojoint). The upper thoracic spine should also be considered a major contributor to shoulder motion, especially during overhead reaching (when reach is extended as the spine tilts away from the shoulder).² The connective and muscular tissues that support and move these joints will need to be assessed, so that support can be provided for the healing of any injured tissues. Eventually, rehabilitation of all injured tissues will be necessary to regain full function.

Many connective tissues in these joints can be injured, resulting in a shoulder sprain. The sternoclavicular joint is the only point at which the shoulder girdle is firmly attached to the axial skeleton. The ligaments involved there are the sternoclavicular and costoclavicular. The acromioclavicular joint is held in place by the coracoclavicular and acromioclavicular ligaments. A thick capsule composed of several ligaments secures the humerus into the labrum of the glenohumeral joint. The scapulothoracic “joint” has muscular connections only; there are no ligamentous attachments.

Any of the numerous muscles and tendons that contribute to the movement and coordinated stability of these joints can become strained in a shoulder injury. The main muscles associated with the shoulder include: the trapezius, latissimus dorsi, pectoralis major, deltoid, rotator cuff (SITS muscles), serratus anterior, and the biceps and triceps. Manual testing can often quickly identify which of these muscles are weakened and painful (strain) upon contraction after an injury.

Rehab of Sprains
Significant damage to one or more of the connective tissues of the shoulder can result in joint instability and chronic dislocations. Treatment of Grade 3 or moderate-to-severe Grade 2 sprains must generally include some external support (sling or taping) and restricted activities. Once the ligaments have undergone sufficient early repair, controlled passive motion can help prevent the formation of adhesions (scarring in areas of movement).

Resistance exercises are introduced to stimulate a stronger repair and to assist in the remodeling process. Isometric is progressed to isotonic forms of resistance, based on the patient’s tolerance for joint motion. For industrial workers, regaining full stability may require advanced forms of exercise in the functional phase of rehabilitation, such as proprioceptive training and plyometrics. These maneuvers help recoordinate the sensory receptors and motor controls at the spinal cord (nonthinking) levels.³

Rehab of Strains
Injured muscles and tendons of the shoulder girdle may need a brief period of support and restricted activity, but controlled restrengthening should be initiated early. Elastic tubing is a safe and effective method of providing progressive resistance exercises.⁴ A very easy and effective program starts with a consistent isotonic exercise routine using surgical tubing equipment to perform internal or external rotation. This is initially performed within a limited, pain-free range of motion, building to full range as pain subsides.

Eventually, additional shoulder exercises—including flexion, extension, abduction, and adduction—should be performed as indicated. This inexpensive rehabilitative program should initially be practiced under supervision to ensure proper performance.

A factor that is too frequently overlooked is the influence of posture on shoulder-girdle function. Reports by Hertling and Kessler⁵ and Hammer⁶ support the need to evaluate the patient for specific postural distortions, such as thoracic kyphosis and cervical anterior translation (causing a “forward head”). An additional complicating postural factor can be the alignment of the scapula on the thoracic cage—when the shoulder is “rolled forward” (protracted). Correction of these chronic alignment faults will significantly reduce the biomechanical stress on muscular support for the shoulder. CP

Kim D. Christensen, DC, DACRB, CCSP, CSCS, directs the Chiropractic Rehab & Wellness program at PeaceHealth Hospital in Longview, Wash. He has participated as team chiropractor for high school and university athletic programs, as a postgraduate faculty member at numerous chiropractic colleges, and as past-president of the ACA Rehab Council. He can be reached via email: kchristensen@peacehealth.org.

References
1. US Department of Labor, Bureau of Labor Statistics. Lost-Worktime Injuries and Illnesses: Characteristics and Resulting Days Away from Work, 2003. Available at: http://www.bls.gov/news.release/pdf/osh2.pdf. Accessed December 5, 2005.
2. Nordin M, Frankel VH. Basic Biomechanics of the Musculoskeletal System. 2nd ed. Philadelphia: Lea & Febiger; 1989: 235.
3. Kibler WB, et al. Functional Rehabilitation of Sports and Musculoskeletal Injuries. Gaithersburg, Md: Aspen Pubs; 1998:157.
4. Roy S, Irvin R. Sports Medicine: Prevention, Evaluation, Management, and Rehabilitation. Englewood Cliffs, NJ: Prentice-Hall; 1983:195.
5. Hertling D, Kessler RM. Management of Common Musculoskeletal Disorders. 2nd ed. Philadelphia: JB Lippincott; 1990:177.
6. Hammer WI. Functional Soft Tissue Examination and Treatment by Manual Methods. Gaithersburg, MD: Aspen Pubs; 1991:31.