Learn how to cure and relieve your chronic shoulder pain!

By Unpain Clinic on December 9, 2020

If you have had chronic shoulder pain for more than three months, have tried any other form of therapy, and are still in pain, this podcast episode is for you! Shauna Mann and Uran Berisha share their experiences in treating chronic shoulder muscle pain using Shockwave Therapy in as little as three sessions.

URAN: Hi there! This is Uran and Shauna here at Unpain Clinic and today we are talking to you a bit about chronic shoulder pain, our experience in what we have learned treating it with shockwave and how we get some great results, especially in chronic cases. Chronic shoulder cases are pretty much those that have been in pain for a minimum of three months and up. So, Shauna, do you remember any shoulder client that you had that you helped a lot with shockwave?

SHAUNA: Yeah, actually, right now in my current caseload, I think I’ve got about three or four clients who’ve come in specifically for chronic shoulder pain.  They have all gone on to have diagnostic imaging and showed that, in most cases, there was partial thickness tear in some of the rotator cuff structures and then full thickness tear in others.  I believe I have one right now as well with a dislocated bicep tendon at the same time, so, of course, these clients were coming in with chronic shoulder pain that wouldn’t go away and then, of course, having a diagnostic imaging report in hand, they’re just very nervous and apprehensive coming in for treatment because they’re stuck thinking “What if I need surgery? I need surgery” so it can be tough.

So, for my goals with them, it’s okay just to kind of reset that expectation and just do a little bit more education with regards to what rotator cuff pain syndrome is.  I am really liking that the physiotherapy world is changing that messaging to rotator cuff pain syndrome versus rotator cuff tear.  Clients hear they have a tear, they go onto their computers they’re searching going “oh my gosh, I have a full thickness tear, I need surgery.” So it’s just trying to change that mindset around that. So just kind of explaining okay what does a rotator cuff do?  What is its function and what does your report mean?  Just really trying to be more clear to people that somebody with a massive rotator cuff tear could have very minimal symptoms.

Someone with what we would see on diagnostic imaging to not have a large tear or not much else going on in the rotator cuff, but they just have these pain generating sources that are so extreme and additional loss of function. So, it’s trying to let them know that the diagnostic imaging report is not the be all end all but beyond that 5-40% of people walk around with atraumatic rotator cuff tears, and they don’t even know it.

URAN: Yes, yeah.

SHAUNA: So they’ve got a tear inside their shoulder muscle but it’s not affecting them pain-wise, it’s not affecting them function-wise, so we know we can kind of demystify that concept around, “you have a full thickness rotator cuff tear = you need surgery” into “well, we know that a combination of shockwave therapy, manual therapy if needed, and a 12 week exercise program; we know that this has been shown to benefit your shoulder and potentially delay you even needing that surgery. 

URAN: See, what I say to clients a lot actually when they come with an MRI report and they literally have been through everything and they’re still in pain is, “the first thing, if the cause is actually what is showing up as the painful spot and you have been through all those other modalities and therapies and you’re still in the same pain, then the problem is actually not there because, by this time probably something would have helped you to the extent that you would actually notice 30 or 40% improvement, so we have to look elsewhere.” And the other thing that I say is “we cannot treat the X-Ray, we cannot treat the MRI.  What I mean by that is that regardless of whether or not the physical injury is showing up on MRI as a localized tear, I want everybody to remember that the shoulder joint, it’s not just like one muscle. It’s a muscle group. So, if you only have one tear, that doesn’t mean that now the whole shoulder is going to collapse.  What happens is your body has like a backup mechanism that still supports the joint. And in those cases, there’s a combination of multiple compensation factors. 

As humans, we are very strong so we can compensate for one or two things; but once they become multiple issues then we can’t, and then once that pain starts happening, then people go to the doctor and get an MRI, ultrasound or X-Ray and then we find one physical damage and we start blaming it. 

So, an example: if somebody you know had a C-section or appendectomy, their core muscles become dysfunctional.  We know that because scars actually shut down muscle function so the body actually starts compensating – the core muscles start compensating.  Now you probably do office work where you sit all day and you’re using, you know, the right arm, doing the computer work, your core is not supporting you and your shoulder collapses. And you probably had a previous injury from like a sport or something.  See how things build up?  And because you’re doing that repetitive motion your shoulder starts hurting and then they see a little tear and then they start blaming it. 

In our experience, because we deal with cases that didn’t have success with anything else, we cannot probably judge fairly because we only see those cases.   We don’t get to see the ones that improve. And in those challenging cases we learn that there is actually multiple factors contributing to that shoulder problem and for us to help it we have to go and treat that scar and then we go back and check the neck, the nerve root, if it is the nerve actually affecting the muscles or a muscle.  Especially the deltoid muscle – it’s the biggest muscle in the shoulder; it’s the powerhouse. So, if that guy actually goes down, then you’re going to have the small muscles in your rotator cuff that will take over. And that’s how then it starts giving you more symptoms, it pretty much jams the system.  Another thing to consider is like the elbow or the wrist; we have to make sure that everything in that kinetic chain is working.  It’s looking at the body as a whole, as one unit and not just at the symptomatic pain.

SHAUNA: I look for the root cause, which is what you just explained. Is it something that’s actually coming from the neck or is the shoulder pain actually secondary to a wrist injury?

URAN: Yes.

SHAUNA: So, the shoulders have to overcompensate.  It’s you know the importance of doing a really detailed history, especially when it said insidious onset, where they’re like “I don’t know… this just came out of the blue.”  A really good history to narrow down.

URAN: I want to share with you Shauna a personal experience that I had with a client here.  This was a couple years ago when we used to do shockwave workshops.  They were just like an educational workshop for people that had no clue what shockwave is.  Because we have been doing shockwave since 2011 here in Edmonton and when we started it was pretty much like nobody knew about it. And, yeah, today we are understanding more but it’s still just within the word of mouth community for the most part. Anyway, this guy came in and he had literally gone everywhere, and he just saw on Facebook or I don’t remember exactly, that we’re actually going to talk about shockwave, and he heard about it. So, he came to the workshop, couldn’t move his left arm it was literally attached (stuck) to his body.  And he was actually this big guy, a motorcyclist, you know, strong man, honestly.   I finished the whole shoulder presentation, and I said to him “Can I just like look at your shoulder?” and he said “No, no.  I’m afraid for anybody to touch it because they don’t want to even do surgery on me because I have this massive pain but they cannot find anything wrong.  I just have small tears.”  So, even the surgeons were unsure, you know, what to do with him.  Again, I asked him, I said, “Can I just like do like, you know, five to 10 seconds of a little bit of shockwave on your shoulder and let’s just see how it responds because it won’t hurt anything.”  And so, he let me try and I used the focal shockwave a little bit.

And I asked him “any difference? anything?”  It was very minimal to pretty much none. I think he just felt bad to say he didn’t feel anything. But then I asked him “okay, do you have any surgery in your body from the time you were born to today?” and he said “oh yeah, I have had a carpal tunnel surgery.”  And right away I knew “okay, this might be the trigger” because it’s very close to the hand. And the hand, it’s pretty much the sensory input that feeds the nervous system.  Like, imagine whatever you touch, like heat, texture and all that, and it sends that information to the brain.  As a result, the brain activates the big muscles to respond to whatever the hand is feeling. So, it’s all connected.  I knew right away that this could be actually affecting his shoulder muscles. And I said to him “okay, we must treat this scar. You’re not going to feel anything. Let’s see how the body responds.” So, I treated the scar.  Now I expect, with any scar treatment, I expect like a massive response but not to the point that we saw, honestly, because it was a case that he tried everything.  Now, I’m not that, you know, Superman or super therapist giving a miracle but I treated the scar, and instantly his muscles turned on; he was able to have full range of motion full strength, the pain decreased. Everybody was shocked.  I wish we could actually have a picture like recording that last moment. And when he left after the workshop he actually opened the door showing us with the left arm that he even had strength.  So, sometimes it could be as little as those things that could put you in that kind of vicious cycle, and until that cycle is broken up there’s not much of a solution. 

SHAUNA: So you can equate it to almost like Central Nervous System desensitization and breaking that cycle.

URAN: The nervous system likes to learn to function in patterns, and to be more efficient. Like, how many times do you think about how you hold your spoon when you eat?  You only learn, you know, when you were a kid to hold the spoon.  You’d never think about that again.  So, the same thing happens once you actually have an injury and it’s not treated properly, let’s say for the first six weeks – three months. Now, your body’s going to try to fix it; if it cannot fix it, it’s going to start adapting to the change so it actually creates a specific pathway, a way of communication and using the body.  But it’s a dysfunctional way – it’s a dysfunctional pattern. So, most of the time, the best way to explain this is that it is not just a “hardware” problem, it’s not just a tissue problem.  It could also be a “software” problem, a problem with how your nervous system is actually communicating, how it’s using those muscles. So, therefore, you have to look at bodies as one unit from the two different perspectives like software and hardware. When you actually treat both of those at the same time, then you have the result.

SHAUNA: Sharing an example of one of my chronic shoulder pain after dislocation clients: she was treated previously at the clinic here, for what it sounds like was probably a frozen shoulder. She came very, very late stage.  So, she had had 3 shockwave treatments and it worked really well for her.  So, she felt like she was starting to get some symptoms on her right side and she came in immediately.  I guess my spidey senses kind of started going because we know that with frozen shoulder the literature’s very scarce into truly knowing the pathophysiology of the condition.  So, she was a woman, which was one of the comorbidities associated with frozen shoulder. 

As I started taking her case history I asked “are you by chance diabetic?” She said “Yes.”

So I said “okay well, you know, often if it occurs in one side, it will occur in the other.” But again, my brain just kind of kept nagging at me “I want to get to the root cause of this, I want to get to the root cause.”  Like, the why, why are you experiencing this?  

So yeah she said she was diabetic and I asked “Are your blood sugar levels controlled?” and she’s like, “they’re out of control right now.  My doctor’s put me on new medication. I’m not responding very well and they’re out of control.”  So, then I asked “Well, do you have joint pain anywhere else?”  And she’s like “yeah, I have this knee injury that my doctor and my chiro’s trying to tell me I sprained my ACL but I don’t do anything” and I was like “all of this is related to your diabetes not being under control.”

So, we treated her and I did my classic frozen shoulder protocol on her but then also really made sure that we got in and targeted some of the lymph nodes. And from one treatment she was like 100% better and I purely think it was just because of the lymphatic congestion.

URAN: Yes, to get it back and going better.

SHAUNA: Yes, but she also really took it upon herself – like she never she never truly understood the issues, and the science in what her blood sugars being out of control truly meant.  The systemic effect that it had on it.  And so, that was just a really cool case to show from 

  1. the capabilities of the human body and when we have so much inflammation in excess what it can do to us, but then
  2. also just showing like the instant results that she had from that Shockwave therapy from an inflammatory perspective.

URAN: See, I call the lymph system our sewage system. Yeah, or probably a better example to use, it’s the exhaust of the car. It doesn’t matter what kind of car you have, it doesn’t matter what engine and how much horsepower the car has and how new it is, if you clog that exhaust, nothing works. So, even with the lymph, because the lymph it is responsible to transport hormones, but then at the same time to clear the debris and anything that your body is trying to fix, so as soon as you open it up then you’re breaking up that vicious cycle and therefore things clear.  The advantage with the shockwave that I’ve seen, (we do a lymph treatment protocol for the whole body using shockwave), shockwave is a mechanical sound wave. So, it’s a mechanical vibration, and you actually reach about 20 centimeters deep in the body.  So, when that mechanical sound goes through the lymph nodes it’s physically going to shake them up; it’s physically going to create that mechanical pumping. But then it also creates waves in the fluids and in addition it relaxes the fascia, (because sometimes it’s not just the lymph congestion. Sometimes, it’s just the two layers of the fascia actually fused together, that interrupt the proper fluid flow in that area, whether it’s like blood or lymph). So, when you’re doing this shockwave you’re hitting everything at once, and it’s getting the root cause and therefore, boom, you get that result. 

So, how can we explain to somebody that is listening to us for the first time here, and maybe they have had this chronic shoulder pain from side sleeping problem and they have tried everything.  They probably even have, you know, heard of or been thinking of shockwave or that this is the place for them to  explore and see, like, how we could put it together.  What would we say to a person that is listening to us for the first time, and has been dealing with a shoulder problem?

SHAUNA: So, in regards to the therapeutic effects of Shockwave or what specifically do you mean?

URAN: Yes, like, how can we help them with shockwave?

SHAUNA: Absolutely. So, I think the first step, as a physiotherapist is to take a detailed history on the client stemming from potential mechanism of injury to potential aggravating factors, what causes their pain, what decreases their pain, just to rule out any potential red flags that could be something more sinister going on.  Based on that interview you pretty much already have an idea of what you’re dealing with. So, because I think the first thing that’s important for a client with any type of treatment is you have to have buy in from the client. So, they have to also feel like their story is being heard. So, I think that’s one of the most important parts of the treatment protocol is just allowing that client to tell their story and just asking the right questions, so that you can try to get as clear of a picture as possible from the get-go.

Um, and then obviously doing your head to toe assessment, I stress head to toe assessment because we know that our body doesn’t just work in unison, it collaborates with all the other joints, muscles, ligaments and tendons in the body. So, just because somebody comes in for a shoulder injury, you never just treat or assess the shoulder; you need to look at the entire kinetic chain.  So, I might be treating somebody’s peroneal muscle group in their legs and it’s a neck injury. Just because we know the systems all work together and so taking a look at that.

And I think too you develop that trust with clients when they’re like “whoa, I’m coming in for my shoulder, but they’re looking at my entire body and seeing how I function as a unit” and then, of course, it’s explaining to them in the language that they understand so they understand how the human body works.  

So, I feel like when you can get the client to understand that from the get-go and get them to kind of really mentally visualize what’s going on in their body, and what’s going in the head because you had said, you know, it’s not just upgrading hardware, it’s a software thing too and if we don’t have a brain, we don’t have those things. 

It’s like when I prescribe exercises, I really try to explain that there is a science behind why I say two to three times a day; it’s actually retraining the brain because these motor pathways are using the path of least resistance. You don’t even have to think about this. So, the way that you sit every day, the way that you walk, that’s the path of least resistance.  Is that the correct path?  Not necessarily. So we need to work on changing that.

That’s the first part kind of my treatment protocols is a lot a lot of education first off, so that they can understand how their body works in simplistic terms. So then when they can understand how the body works in simplistic terms, then we add in how shockwave therapy can benefit you. So then it’s explaining again in terms that the client can understand what the shockwave is doing at a cellular level that’s going to improve and upgrade their software.

URAN: Yes.

SHAUNA: And so explaining it in those terms again they can just really visualize what’s actually going on with that shockwave, it really allows them to truly understand what is inflammation? Why is inflammation?  Because everybody thinks inflammation is bad. Well, we actually need inflammation in the body to heal. Yes, for some reason, when that inflammation does not progress through the natural cycle, that’s what becomes a problem.  But for them to actually understand that it’s actually what we want is this inflammation. To start with, so getting them to understand how their body heals how their body processes shockwave.  

And then just explaining to them the benefits of it, the potential side effects of it, what they’re going to feel, what it’s actually doing for them.  I find it works really well.

URAN: Yes. Yeah. And especially again for people that have been in pain for, you know, three months and up and have tried everything else, I just wanted to actually add something about inflammation.  Inflammation, when you get injured and when you have an injury, that’s a really good thing. And this is where people confuse the inflammation term, in general. There is bad inflammation, and that bad inflammation is actually more related to food. You know, it’s like you have food, for instance, that your body doesn’t like and you eat that constantly, that becomes a trigger of your inflammation in the gut and then it spreads out. That’s bad inflammation. 

So, even with shockwave we try to reset everything in the healing cycle back to where it starts, you know, with the good inflammation. And that’s why we typically see after the first session for about 72 hours that people get a little bit sore. And then after that, boom, things start clearing up, like right away and that’s the typical good inflammation and then the body starts with angiogenesis which is new blood vessel growth. And then later on it brings the stem cells to actually go and repair whatever is injured.

SHAUNA: So, with inflammation I also, I do discuss that with clients.  Especially for people when they, in the absence of injury, for example, and they report poor energy levels or you notice patches of excema or, you know, you see them in their shorts and their gut looks bloated.  And you might see that in their chest and tummy but their arms and legs are skinny. That always leads me as well to kind of just dig a little bit deeper into, “well, what’s your diet like?” and then “okay, you know, you’re eating high inflammatory foods. I’m not saying that this is the cause, but because you’re having pain in other areas than just the one, there could be a relationship to your systemic inflammation from the foods that you’re eating.”  And I just say like, “you know, try eating these foods which are considered anti-inflammatory foods” and too especially when you get in with the clients, because we see a lot of chronic pain clients, it’s psychologically demanding.

URAN: Yes, yes, yes.

SHAUNA: I think even just by taking the time to listen to clients sometimes, that’s just even what helps them start to get better because their story is actually being heard. You know it’s not them being shuffled around in the medical system and being labeled as A, B or C.  But then when you kind of go outside, I guess when you go that extra mile to kind of find that root cause, to try to actually get to that.  Like, we’re kind of a profession where we technically could drive ourselves out of business because it is our mission to make everybody better and not have them come back.  But when you actually make that effort to take a look at them systemically as a person and try to give them as many tools as we have in our tool belt, that goes a long way as well towards your recovery.

URAN: See Shauna, the thing is, this is interesting hearing this conversation. Yes, you’re a physiotherapist, I have a background in physiotherapy, but you kind of evolve, even as a practitioner, every time when you hit the barrier, you know, a challenge, like what else?  Why is it not working?  And I know that you’re also a health coach. So, I think that’s part of the reason why you’re looking at the body from all the psychological, nutritional and physical component because that’s your experience.  You know, pretty much looking at somebody you know, in 3D.

It’s interesting, personally, I don’t have much knowledge and experience like with what health coaches are, like what does a health coach do? Can you tell me a bit?

SHAUNA: So, health coaches are essentially ministers of habit change. Okay, so it kind of goes down to we upgrade the software. And we follow the vision for the client and we just help them kind of dig down to the root cause when it comes to behaviors around food, their weight, it can be anything.  The five W’s of life, health, money, relationships, career, the connection to that which is greater, how you do one thing, is often how you do something. 

So, in the health coaching role, your typical client would come to you to say, “I want to have more energy”, or “I want to lose weight.” But as you coach them through the 90-day program it’s very rarely that losing weight is actually the issue; because when you start to get into their programming from when they were a child and the beliefs that they have around self-identity, exercise, etc., you actually dig much deeper into that psychological component. 

And so, again, it’s upgrading that software for them to believe something different about themselves and to create that 1% change per day that’s going to allow them to make lasting habit change.  It’s basically, it’s transformation within.  As a health coach, I don’t specifically fix somebody I hold space for them, ask the right questions; the person fixes themselves.

URAN: Yeah, and that’s exactly it even like with everything it’s almost like a, like a personal trainer; you show them that exercise but they have to do it, I guess.  It’s awesome.  It’s interesting again and the reason why I wanted to ask that because I wanted to explain on the other side like related to the shoulder problems.  Like I had a client recently who she went and shopped at the mall you know for a couple hours, and ended up in severe chronic pain in shoulder blade area. And she is a client of mine I’ve treated her in the past. And it was just this thing, just the way how she explained things, I didn’t see any way that she’d actually hurt her shoulder.  I actually knew it related to her gallbladder, right, because it’s sometimes organs can actually refer pain to the shoulder.  So, if there’s actually an acute intense pain in the shoulder like, you know, horrible on the the right side. It’s not necessarily that it’s just a shoulder problem. So, therefore, we have to look at the body and ask those questions as one unit.

SHAUNA: Well yeah, and then another thing is we know that stress, the stress response we know that biologically in the body it manifests as abnormal blood sugars, which manifests as inflammation. And so that’s another key component that I’ll often ask clients like, “what’s your stress on, you know, a scale of 0 to 10?” because again if they continually have this cycle of pain but it’s usually at a certain time of the day, not even related it’s like “well, what’s going on for you at that moment in time? Are you stressed?”

Because we know sympathetic nervous system’s fight or flight responses is elevated.  What does that do? Well, we hunch our shoulders exercises so we can prepare ourselves for fight or flight. And then if that stress, even chronic low-grade stress when somebody doesn’t think on a day to day level that they’re stressed, but even then our body doesn’t know the difference between “a lion’s chasing me” versus “Oh, I don’t like the way that my husband spoke to me over text.”  The body will react the same and it’s going to elicit the same biological effects. So that’s another thing as well that I really like to tap into with my clients.

URAN: Yes, and I always say to people, just because we have put names on body parts, you know, for communication reasons, that doesn’t mean that there’s actually names inside.  Like the body is just gonna like use everything the same way or like how everything is like responsible to function from organs, like, that’s why we have different cells and all that so if you have you know a chronic shoulder pain after a surgery problem. Again, that doesn’t mean that the pain is there, and you might have the problem, or the cause there, it could be just coming from elsewhere and therefore actually at Unpain here, I love that we have you even as a therapist here because we just clicked we shared the same approach looking the body you know as a, as a one unit, and we look at every single person individually if you don’t go based on like okay, I’ve treated you know, 1000s of shoulders condition for now it’s going to be the same decrease no one is the same. So my question is like what would you say one thing to a person that currently is in pain? Like is there a technique or like one tip that would actually help them today to cope with the pain or somebody who is in a shoulder pain.

SHAUNA: One tip or somebody who’s in shoulder pain, to be honest, I think, again, looking at it from a holistic standpoint, my very first recommendation would be to evaluate your stress level. Can it be decreased.

URAN: Yes.

SHAUNA: Yeah. Okay, and then see if when you can do that, does the pain change?

URAN: Yeah, I’d probably go in the same line with you.  Just focus on the breathing even though it’s your shoulder, bring your stress level down, and then just see how the body responds. And I bet everybody will notice some decrease in terms of the pain; but then if there’s any physical restriction they are still going to need that to be treated.  What we recommend to people is always book a free telehealth session directly with a therapist.  We offer that for everybody so just nowadays it’s easy just go on your phone, or like on even on our website like on www.unpainclinic.com .  Connect with a therapist and see if we can actually help you because that’s the best way to start.  Like we don’t want to waste your time and our time, so that way if we can help, yes, we would be happy. And the good thing with with us is when we say to everybody, you know, “we hope we never see you for a problem but anytime if something is needed, we are here.”

Okay Shauna this was a great conversation I think we could have gone another eight hours but if someone is you know driving by and watching those, they, they need to move on with their lives *chuckles* but we just wanted to throw it out there that this is available here.

Anybody that is in need for, not just the shoulder, we treat literally everything from like head-to-toe or anything like musculoskeletal. And then we do it also you know for headaches and like even anti-aging, you know, for the aesthetic component.  And we also we have a therapist who does men’s health for erectile dysfunction, and all that, and soon we are launching also a wound treatment for open wounds. So yeah, stay tuned and probably until next time until we have a great conversation like this again.  Thank you, bye-bye!