Osteopathy and Early Shoulder Management | Slings

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Shoulder problems are a significant part of the workload of a osteopath and an orthopaedic surgeon, with various injuries and conditions affecting this joint. The shoulder has the greatest range of motion of any body joint and this requirement leads to risks of injury and the development of pathologies. As the shoulder is a very unstable joint it is vulnerable to dislocation in falls or vigorous activities at the end of its range. Its structure and the repetitive movements we perform predispose the shoulder to cuff tears and its function as an emergency support when we fall makes fractures a common occurrence.

Osteopaths pay close attention to the shoulder as there are many different operations, fractures and degenerative conditions which can affect this area and have an important role in the management of shoulder conditions after elective surgery or trauma, ensuring adherence to the surgical and rehabilitation protocols. On initially seeing the patient a useful strategy is to quickly go over the presenting problem from the beginning as this can indicate errors or misunderstandings which can then be corrected. Osteopaths should also give the patients an opening so that they can feel they have told their story.

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.

When fitting the Seton sling the elbow should fit right back into the gutter with the sleeve folded back slightly if necessary to allow the hand to be clear of the sling. There may be a small Velcro strap to place across the upper forearm to keep the gutter closed but this should not be tight or it can cut in to the tissues, especially if there is a lot of thick swelling such as after humeral fracture. The long strap is then taken from the elbow side of the sling over the opposite shoulder and down to the wrist. Tightening this up is where it gets trickier.

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.

To get the sling right needs two people, the patient and a helper. The helper lifts the elbow of the affected arm in the sling while the patient tries to let the shoulder relax. Then the helper gets hold of the part of the strap along the back and pulls it up towards the shoulder, holding it there. The helper lets go of the elbow and adjusts the strap whilst still holding the back part of the strap under tension with the other hand. Having completed this manoeuvre the elbow should now feel heavy and supported in the sling and the patient feel it is quite comfortable.

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.