Could Your Liver Be Contributing to Your Shoulder Pain? The role of the hepatosomatic reflex and how manual medicine can help

by Dr. Robin Sharma and Dr. Vikas Sharma Manual Medicine Practitioner and Visiting Master at AyurMa

Have you been dealing with right shoulder pain that won't go away?

Chronic right shoulder pain often resists standard treatments like physical therapy, injections, or rotator cuff exercises. When localized shoulder treatments fail, the true culprit may lie within the abdomen.

In manual medicine - including osteopathy, chiropractic, and visceral manipulation - we often investigate the liver as a hidden cause of right shoulder pain. Within this field of knowledge, the organ and its enveloping fascia are well-recognized sources of referred right shoulder pain. Let’s look at the reasons why:

1.    The Anatomical Blueprint: Visceral Fascia and Membranes

The liver is the body’s largest internal organ, situated directly beneath the right dome of the diaphragm. It does not float freely; it is anchored firmly to the abdominal wall and diaphragm by a complex network of connective tissue or fascia, known as ligaments.

The fascia surrounding the liver is continuous with the fascia of the diaphragm, meaning that every time you breathe in, your diaphragm moves down and your liver has to slide down with it. If fascia becomes stiff or distorted, your liver loses its ability to slide smoothly. Any loss of elasticity or distortion in the fascial network can significantly disrupt normal body mechanics.

2.    The Neurological Link: The Phrenic Nerve Highway

The primary mechanism behind liver-induced shoulder pain is a neurological phenomenon called referred pain, driven by the phrenic nerve. The causal chain is illustrated below:

Liver Fascial Distortion / Inflammation

                  │

                  ▼

Irritation of Diaphragmatic Pleura

                  │

                  ▼

Phrenic Nerve Afferent Signals (C3-C5)

                  │

                  ▼

Spinal Cord Segment C3-C5 Misinterpretation

                  │

                  ▼

     Referred Pain to Right Shoulder

So what causes liver fascial stiffness and distortion?

Several factors can alter the health and mobility of the hepatic fascia. These include:

·         Visceral Inflammation: Fatty liver disease (NAFLD), chronic alcohol consumption, or low-grade systemic inflammation can cause the liver to swell, putting mechanical tension on its fascial capsule.

·         Surgical Scar Tissue: Past abdominal surgeries (such as gallbladder removal, appendix surgery or laparoscopies) can create fascial adhesions that bind the liver to surrounding tissues.

·         Postural Compensation: Chronic slouching compresses the right side of the abdomen, causing shortening of hepatic ligaments and restricting diaphragmatic excursion.

Manual Medicine Assessment

In manual medicine, practitioners do not view the shoulder in isolation. When evaluating right shoulder pain, a manual medicine practitioner will assess the mobility of the liver and diaphragm using precise palpatory techniques (examining the body using hands and fingers). These can include:

·         The Inhibition/Exclusion Test

The patient performs a shoulder movement that triggers the pain. The practitioner then manually lifts and supports the liver to take tension off the fascia and repeats the shoulder movement. If the shoulder pain decreases or range of motion increases, the liver fascia is confirmed as the primary driver.

·         Global Listening

The osteopath stands behind the standing patient, placing a hand lightly on the head to feel for an antalgic, fascial pull. Tight liver fascia typically pulls the patient's posture into slight flexion and right lateral bending.

·         Mobility Assessment

The practitioner tests how the liver moves in response to diaphragmatic breathing and manual manipulation.

·         Motility Assessment

The practitioner rests a hand over the liver to feel its intrinsic, subtle rhythmic cycle (motility), checking the quality, amplitude, and freedom of its expid (moving toward the midline) and impid (moving away) phases.

Manual Medicine Management

If the liver is identified as contributing to the shoulder pain, manual medicine can help resolve the issue. Management techniques used include:

·         Visceral Diaphragmatic Manipulation

The practitioner uses gentle, targeted manual forces to relieve restrictions in the diaphragm and its fascial connections to internal organs like liver, stomach and lungs. This in turn encourages the liver to glide freely against the diaphragm and immediately unloads the mechanical tension on the diaphragm.

·         Restoring Three-Dimensional Mobility

Gentle, targeted pressure—such as a "liver lift" or diaphragm doming—is applied by a skilled practitioner to stretch and break up restrictions in the connective tissue. This allows the liver to glide freely against the diaphragm during breathing, reducing referred pain.

·         Autonomic Balancing

Easing fascial tension reduces chronic nociceptive (pain) signalling to the spinal cord. This calms the nervous system and breaks the feedback loop maintaining the shoulder pain.

·         Cervical Spine Integration

Because of the C3-C5 connection to the phrenic nerve, treating the upper-to-mid cervical spine is often paired with visceral techniques to fully resolve the neural facilitation.

Addressing the fascial distortions of the liver allows manual medicine practitioners to treat the root cause of referred right shoulder pain, restoring pain-free mobility.

Simple Home Stretches

If you suspect your right shoulder pain might be linked to your liver, these simple movements and stretches can help. With a focus on restoring three-dimensional mobility, they help to elongate the hepatic ligaments and release tension in the right diaphragm.

 1. The Right Lateral Fascial Stretch

●      Stand up and raise your right arm straight up towards the ceiling

●      Slowly lean your upper body to the left

●      Take 5 deep, slow breaths into your right side, feeling your lower ribs expand

●      Repeat 3 times

 2. Manual Diaphragmatic Release

●     Sit comfortably and slump forward slightly to relax your stomach muscles

●     Place your fingertips gently right under the edge of your right rib cage

●     Breathe out completely. As you empty your air, gently press your fingers up a little bit under the rib bone

●     Take a slow breath in. You will feel your liver push down against your fingers

●     Move your fingers an inch to the right and repeat

●     Do this gently for 2 minutes

 3. The Rib Cage Opener

●     Get on your hands and knees on the floor

●     Place your right hand behind your head

●     Inhale and twist your right elbow up toward the ceiling, opening up your chest

●     Exhale and lower your elbow back down

●     Repeat 10 times to get the tissues sliding smoothly