During our earliest years, we learn to identify 'the shoulder'. We touch the tips of both shoulders while singing the popular nursery rhyme: Head and shoulders Knees and Toes.
This simplistic shoulder identification changes as we mature, and learn through life experience, that our shoulders cannot always be defined by this singular point of contact.
The exact definition of the word ‘shoulder’ can be ambiguous because, from a non-anatomical perspective, the borders that encompass the human shoulder region are vague and poorly defined.
We sometimes have difficulty finding the words to define this part of the body, but we are unanimous in our belief that the shoulders play an essential role in everyday life.
The word ‘shoulder’ is ubiquitous. It is used as a noun, a verb, and an adjective. Figures of speech, or idioms, using the word ‘shoulder’ or ‘shoulders’, are frequently used in our everyday language.
‘Shoulder”, when used as a noun, can represent the human variety, but it also describes a similar region on many animals. Parts of inanimate objects are identified as the ‘shoulder’ because of their unique shape or position. The shoulder of a road or the shoulder of a key cut for example.
We ‘shoulder’ a heavy load and determine that our hair is ‘shoulder length’.
Why has the word ‘shoulder’ permeated so much of our everyday language?
I think that we can agree that the human shoulder is an important part of our anatomy, but the word ‘shoulder’ represents something more vital.
Our shoulders represent our physical strength, but they also embody our emotional stability, integrity, and ability to defend and protect. While many familiar idioms have become cliched over time, their sentiment is irrefutable…
‘Carrying the weight of the world on your shoulders’, ‘putting your shoulder to the wheel’, working or marching ‘shoulder to shoulder’, standing on the ‘shoulders of giants’,
'a shoulder to cry on' and ‘an angel at your shoulder’ are familiar expressions that we use because they trigger memories and emotions. Who hasn’t felt the weight of the world on their shoulders at some point?
Sunshine on my shoulders makes me happy
Most readers, born before the end of the last millennium, are already humming this familiar tune.
Shoulders are also effective in portraying non-verbal messages. In fact, according to Vanessa Van Edwards (Article Here), “The shoulders are the busiest body part we have. Reading a person’s mind is knowing how a person positions their shoulders.”
Both negative and positive emotion is easily recognized when we see a quick shoulder shrug, shoulders back and up, hunched shoulders or a hand on the opposite shoulder.
I think that we can all agree that humans value their shoulders and what they represent, but can we agree on which part or parts of the human body can be included, or not included when defining the shoulder?
A survey of seven dictionary sources providing the noun/human description for the word ‘shoulder’ is shown below:
The part of your body where your arm is connected
Between your neck and the tops of your arms
The laterally projecting part of the human body formed of the bones and joints with their covering tissue by which the arm is connected with the trunk the two shoulders and the upper part of the back —usually used in plural
The top part of a person’s back (shoulders). One of the two parts of the body at each side of the neck that join the arms to the rest of the body (shoulder).
The part of each side of the body in humans, at the top of the trunk, extending from each side of the base of the neck to the region where the arm articulates with the trunk. Usually shoulders. these two parts together with the part of the back joining them
One of the two parts of your body between your neck and the top of your arms
Either of the two parts of the body between the top of each arm and the neck
So…which definition is the right one? Is the shoulder where the arm connects to the body or is the shoulder also part of the body? Is the “back” part of the shoulder, or is it just the part between the base of the neck and the top of your arms?
If you are feeling pain in your upper arm, would you report that as shoulder pain? How about pain between your shoulder blades or pain that is in the front of your upper chest…is this shoulder pain?
Often, pain that comes from structures in and around the shoulder will be felt in a wider area. If a patient perceives that the ‘shoulder’ is a localized area where the arm attaches to the body, pain from a wider area may not be noticed or mentioned during a medical visit.
Pope et al. examined this issue in their 1997 paper, Prevalence of shoulder pain in the community: the influence of case definition, where they looked at estimates of how often shoulder pain was reported when different approaches were used to define ‘the shoulder’. A random selection of men and women, aged between 18 and 75 years were provided with four definitions of shoulder pain. The first definition was based on a direct question. The second and third were based on drawings, where respondents were told to shade in areas where they experienced pain.
From Pope et al. 1997- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1752371/pdf/v056p00308.pdf
The fourth definition was based on a direct question asking about symptoms in a pre-shaded area including the upper trunk and neck.
A total of 51% of the respondents reported pain according to at least one of these definitions.
The lowest prevalence was observed when respondents were asked directly whether they had experienced symptoms in their shoulder (first definition). As one might expect, the number of positive responses increased as the defined anatomical area increased in size.
Pope et al. determined that part of the increased ability to detect shoulder problems (increased sensitivity) may be related to symptoms that originated in the shoulder, but the most likely cause of symptoms in the adjacent areas was due to problems unrelated to the shoulder.
In other words, a broader definition will likely lead to less accuracy in identifying a problem with the shoulder (lower specificity). Based on their findings, Pope et al. concluded that either definition one or definition two would be a reasonable tool for epidemiological study.
Can definition one or definition two provide a ‘gold standard’ for describing or identifying shoulder pain?
No. Definition one and definition two do not encourage or allow responses where pain is felt outside of a specific area. While pain, identified in regions shown for definitions three and four, is less likely to be related to a specific shoulder diagnosis, it might be related to a specific shoulder diagnosis. The difficulty with this kind of shoulder pain is that it often indicates a complex condition, and complex shoulder pain is much more difficult to sort out.
Most English-speaking adults have learned that the word ‘shoulder’ represents something more substantial than the singular point where the arm appears to join the body.
When the word ‘shoulder’ is used among medical professionals, do they appreciate and evaluate a ‘broad’ shoulder definition, or do they limit their investigation to a defined or localized region?
The answer to this question is not a simple one. Medical professionals rely on scientific data that is constantly being updated. They can and do provide a 'black and white' definition for' shoulder', but if you dig deeper into the research, you will discover many layers of grey.
Watch for Blog #2 where we explore how medical professionals define the shoulder.