Shoulder pain and injury
The shoulder is one of the most common areas where people end up with problems, – irrespective of age or activity level.
The main reason for this is the huge amount of mobility available in this joint (think about how much freedom of movement you have in your shoulder compared to your hip or thumb!) – as a result it requires a lot of dynamic stability provided by the muscles and tendons – but if your muscles are uncoordinated or don’t have appropriate strength you will be predisposed to injury and will no doubt at some point suffer from shoulder pain.
Often specific treatment and exercises are required. In 20 years of clinical practice my experience has taught me that most people fail their shoulder rehabilitation as a result of poor exercise prescription (or the patient not doing the exercises!)
Normally, managing your shoulder injury with physiotherapy is successful and you should usually try conservative therapy (i.e. non-operative/non-surgical approach) before seeking a specialist opinion. If our physiotherapists feel you need a specialist review we will of course refer you on.
Acromio-clavicular joint sprain
A common site of injury in sports people who fall onto the point of the shoulder. Commonly seen in mountain bikers at this clinic.
The acromio-clavicular joint is between your collar bone and the front part of your shoulder blade at the front of your shoulder.
There are various degrees of injury from a mild strain to a complete rupture (which is less common). Your physiotherapist will assess thoroughly to ascertain how severe your injury is and manage accordingly using the principles of ligamentous repairing.
Treatment may include:
- Immobilisation in a sling (time depending on injury severity)
- Supportive taping
- Static strengthening exercises
- Range of motion mobilisations and exercises
- Strengthening through range and eccentric training of the scapulo – humeral complex (i.e. the whole upper limb movement dynamics)
- Gradated programme to return to sport / other functional activities
A fracture is a break – common sites where your arm bone (humerus) can break: –
- Neck of humerus (just below the ball that goes into the socket)
- Greater tuberosity – a non displaced break of this area is reasonably common with a fall onto the shoulder – we see it in skiers. It is often not picked up immediately which can lead to a less than optimum recovery.
- Lesser tuberosity
- Humeral head
- Shaft of humerus
Because of the muscle attachments at different sites of the bone it is important to get advice on what you should or should not be doing for your shoulder.
Physiotherapists can refer you to X-ray to get your fracture diagnosed. If you have a fracture you will probably need to be in a sling or collar and cuff (for about 6 weeks).
When you are allowed to start moving your shoulder it is vital to see your physiotherapist to get the optimum recovery – there is a window of time when if you don’t get moving appropriately you will end up with a stiff shoulder.
You also need to keep your elbow and shoulder blade movement free while in the sling. – You physiotherapist can give advice for every part of your rehabilitation.
How to care for your shoulder whilst in a sling: –
- Only remove the sling for exercises or washing – wash your arm with it hanging down like a pendulum
- Sleep in a high sitting position
- Focus on your posture – don’t let your shoulders roll forward and keep your shoulder blades down and back – your physiotherapist can help you with the idea of this position as many people find it hard to know what is best posture
- Maintain range of movement in the elbow, wrist and hand
- Make sure you see a physio who can help you with post-fracture care
- Avoid smoking and alcohol – it will slow down bone healing
- You will not be able to drive
Frozen shoulder or adhesive capsulitis often occurs as a secondary problem after significant trauma (i.e. fracture or surgery) or may occur spontaneously (usually between 40-60 yr olds).
What happens? There are 3 stages:
1. Freezing – Pain in the shoulder with loss of movement as the capsule starts to fibrose following inflammation and shrinks.
2. Frozen – Pain abates and movement is stuck (i.e. No more loss or gains)
3. Thawing – gradual return of movement – weakness due to the lack of use.
True frozen shoulder is different from other pathologies (such as rotator cuff injuries) which also result in a painful shoulder with limited motion – there is a distinctive pattern (which your physiotherapist can assess) in true frozen shoulder.
A good diagnosis (as always) is the key to getting the best recovery. Remember; frozen shoulder has a completely different regime to rotator cuff injuries or bursitis so an accurate diagnosis is essential.
Rotator cuff related injuries
These are the most common shoulder injuries we see at this clinic. Common in athletes as well as more sedentary people it can be quite a problematic injury if not treated correctly.
If you have a rotator cuff injury it is vital to have appropriate rehabilitation. DON’T JUST TAKE ANTI INFLAMMATORIES these do help but they mask the pain and consequently can prolong symptoms as you are unaware of what activities you should or shouldn’t be doing.
The muscles of the rotator cuff (supraspinatus / infraspinatus / teres minor and subscapularis) are broad flat muscles that primarily keep the head of the humerus (your arm bone) centred in the glenoid cup of the scapula – i.e. they help control the stability of your shoulder joint. Your shoulder joint is very mobile and as a result has little bony stability so these muscles are vital – however they are not designed for heavy work. If you continually overload them by working your arm in a poor position (that round shouldered posture) it is easy to cause micro trauma to these muscles. Also, repetitive work or sudden load (especially in a bad position) can damage the muscles or tendons.
If rehabilitation is not completed or you return to work sport too early, these injuries often reoccur.
- Rotator cuff tears
- Rotator cuff impingement
- Rotator cuff tendonopathies / or tendonitis
Rotator cuff tears
There are two mechanisms of injury:
1) Sudden trauma or overload e.g. lifting your suitcase from the airport carousel
2) Repeated micro trauma – very common – repeated pinching (rotator cuff impingement) will cause swelling and inflammation and as there’s not much space between the cuff and its bony covering. Further impingement and damage to the tendon will occur.
- Pain in the shoulder which may refer further down the arm (not usually past the elbow)
- Difficulty with awkward movements especially above or at shoulder height
- Pain lying on the shoulder
Most rotator cuff injuries respond well to a course of physiotherapy. Large tears may require surgery – your physiotherapist can diagnose and arrange onward specialist review if appropriate.
Rotator cuff impingement
(impact of your acromion bone into your rotator cuff tendons or bursa) should not occur during normal shoulder function. When it does happen the rotator cuff tendon becomes inflamed and swollen, a condition called tendonitis. Likewise if the bursa becomes inflamed, bursitis will develop.
Both of these conditions can occur together.
Postures where there is little clearance between the acromion and cuff:
- Your arm directly overhead
- Your arm working at or near shoulder height
- If you allow your shoulder blade to drop forwards and down (i.e. rounded shoulder posture)
So repeated overhead arm movements such as tennis, golf, swimming, lifting or throwing a ball are likely to predispose towards impingement problems.
- An arc of pain when your arm is at shoulder height and /or when your arm is overhead.
- Pain lying on the shoulder
- Shoulder pain at rest as your condition deteriorates
- Weakness or pain when attempting to reach of lift
- Pain when putting your hand behind your back or head or reaching for the seat belt.
In between the rotator cuff tendons and the bony arch is the sub-acromial bursa (a lubricating sack), which helps to protect the tendons from touching the bone and provides a smooth surface for the tendons to glide over – this can bunch up and get pinched during movements if it is inflamed. The bursa has a lot of innervation so can be extremely painful.
Bursitis commonly occurs with rotator cuff tears or tendonitis.
Prevention and Treatment of Bursitis
Eliminating the causes of primary and secondary impingement is the key to preventing shoulder bursitis and rotator cuff problems. Factors such as posture, muscle length, shoulder stability and rotator cuff strength need to be addressed and can be optimised with specific exercises as prescribed by your physiotherapist.
Rotator cuff tendonitis or tendonopathy
Rotator cuff tendonitis (or Tendinitis) is injury to the tendons of the rotator cuff.
What causes rotator cuff tendonitis?
The shoulder is a complex joint where several bones, muscles, and ligaments connect the upper extremity to the chest.
A bony arch (acromion) covers the top of your rotator cuff tendons, and the subacomial bursa helps to protect these tendons.
Normally, these tendons slide effortlessly within this space. However, in some people this space can become too narrow for normal motion and the tendons and bursa become inflamed. Inflammation leads to thickening of the tendons and bursa, and contributes to the loss of space in this location. Eventually, this space becomes too narrow to comfortably fit the tendons and the bursa, and every time these structures move between the bones they are pinched – this is why the condition is called impingement syndrome.
Physiotherapy management is the best solution for short-term and long-term relief. Treatment is ultimately aimed at preventing a future or larger rotator cuff calcification or tear.
You should have your shoulder accurately assessed and treated by a physiotherapist for appropriate treatment and rehabilitation.
Normal treatment of shoulder problems
All shoulder injuries require thorough rehabilitation and the following components are vital to all injuries. Depending on the stage of your injury (acute or chronic) and the cause, some components may be more important than others. Progression through the components will vary but remember, pushing though too quickly may result in delayed progress or re-injury.
1) Early injury protection: pain relief & anti-inflammatory tips
As with most soft tissue injuries the initial treatment is RICE – Rest, Ice, Compression and Elevation.
Ice is a simple and effective modality to reduce pain and swelling. Apply for 15-20 minutes every 2 to 4 hours initially or when you notice that your injury is warm or hot.
Advice: With active rest from pain-provoking postures and movements i.e. you should stop doing the movement or activity that caused the shoulder pain and avoid doing anything that causes
pain in your shoulder.
You may need to wear a sling or have your shoulder taped to provide pain relief. Pillow support for sleep may be required.
Your doctor may prescribe anti-inflammatory medication. Natural substances such as arnica are also available.
Your physiotherapist will utilise a range of pain relieving techniques including joint mobilisations, massage, acupuncture or dry needling to assist you during this painful phase.
2) Restore full range of motion
If you protect your injury appropriately the injured tissues will heal. Inflamed structures (eg tendonitis, bursitis) will settle when protected from additional damage.
Symptoms may take several weeks to improve. During this time it is important to get advice to return to “as normal use” as quickly as possible to prevent a recurrence.
It is important to lengthen and orientate your healing scar tissue joint with mobilisations, massage, shoulder muscle stretches, and light active-assisted and active exercises.
You may also have developed short or long-term protective tightness of your joint capsule (usually posterior) and some compensatory muscles. These structures need to be stretched to allow normal movement.
You should be able to move your shoulder through a full range of motion. In the early stage, this may need to be done passively by your physiotherapist or using equipment. As you improve you will be able to do this yourself.
3) Restore scapular control
Your shoulder blade (scapula) is the base on which all of your shoulder and arm movements take place.
Poor shoulder blade control (scapulo-humeral rhythm) is a major cause of rotator cuff impingement. Any deficiencies should be an important component of your rehabilitation. It is vital for pain-free powerful shoulder function.
Scapular stabilisation exercises are a key ingredient for successful rehabilitation.
Your physiotherapist will prescribe appropriate exercises for your shoulder blade. It is vital that you do these exercises.
4) Restore rotator cuff strength
This should not be attempted too early in your treatment programme as if a structure is injured primary healing needs to take place before loading with anti-gravity and resistance exercises.
These exercises need to be progressed in both load and position for specific rotator cuff tendons which are injured and whether or not there is a secondary condition such as bursitis.
Your physiotherapist will prescribe the most appropriate programme for you.
5) Restore normal neck and thoracic function
Your neck and upper back (thoracic spine) are very important in the rehabilitation of shoulder pain and injury.
Neck or spine dysfunction can not only refer pain directly to your shoulder, but it can effect a nerve’s electrical energy supplying your muscles causing weakness and altered movement patterns.
Painful spinal structures from poor posture or injury cannot provide your shoulder or shoulder blade muscles with a solid pain-free base from which to act. Reduced thoracic spine movement will also result in a decrease of functional arm mobility.
In most cases, especially chronic shoulders (i.e. if you’ve had the problem more than a couple of months), some treatment will be directed at your neck or upper back to ease your pain, improve your shoulder movement and stop pain or injury returning.
6) Restore high speed, power, proprioception & agility
In order to prevent a recurrence as you return to sport, your physiotherapist will guide you with exercises to address these important components of rehabilitation to both prevent a recurrence and improve your sporting performance.
Depending on what your sport or lifestyle entails, a speed, agility, proprioception and power program will be customized to prepare you for light sport-specific training.
There is no specific time frame for when to progress from each stage to the next. Your injury rehabilitation status will be determined by many factors during your physiotherapist’s clinical assessment.
It is also important to note that each progression must be carefully monitored as attempting to progress too soon to the next level can lead to re-injury and frustration.
For more specific advice about your bursitis injury, please contact your Central City physiotherapist.