Bone & Joint Expert Care
1 What would cause you to suffer shoulder pain?
85% of shoulder pain arise from the shoulder itself with the remainder usually referred from the neck. Around 10% of people have acute shoulder pain at some stage in their lives.
Some common disorders causing shoulder pain include:
Fractures: A break in a bone
Dislocations/subluxations: Complete or partial separation of bones within the joint
Arthritis: A degenerative process causing pain, swelling, stiffness, and disability
Sprains: Stretch/damage to ligaments and connective tissue within the joint
Rotator Cuff Tendonitis: Irritation and swelling of tendons of rotator cuff muscles
Impingement: Compression/abrasion of rotator cuff tendons by bony and ligamentous structures
Rotator Cuff Tears: Partial or full-thickness tears in the tendons connecting the rotator cuff muscles to part of the humeral head (the ball portion of the joint)
Frozen Shoulder: Stiffness & loss of movement; a tight connective joint capsule
Diabetic Complications: Can cause frozen shoulder
Instability of the shoulder : Excessive movement of the shoulder joint
2. How do you diagnose the cause of shoulder pain?
Finding the cause of shoulder pain begins with a detailed history, physical examination and the use of several diagnostic tests. These tests are used to find out the cause of your pain and not to make your pain better. An anesthetic injection into the shoulder is used to determine the source of the pain. X-rays of the shoulder are usually a first step and will help determine if more tests are needed. An ultrasound scan can be used to diagnose tendon tears around the shoulder. The MRI is commonly used to evaluate the shoulder because it can show abnormal areas of the soft tissues. It is done to find out rotator cuff tendon disorders, infection and tumours. Blood tests are done to look for infection or arthritis.
3. When should you seek treatment?
a) Continuous and persistent shoulder pain.
b) Severe intractable or increasing pain.
c) Associated fever and weight loss.
d) Restriction of shoulder range of motion
e) History of fall and injury.
4. What are the treatments for shoulder pain?
Treatment generally involves rest, altering your activities, and physical therapy to help you improve shoulder strength and flexibility. Common sense solutions such as avoiding overexertion or overdoing activities in which you normally do not participate can help to prevent shoulder pain.
Medications can reduce inflammation and pain. Injections into the shoulder joint of numbing medicines or steroids to relieve pain.
Most patients with an acute injury will benefit from 2-3 days in a sling
Prolonged immobilization should be avoided as it can lead to frozen shoulder and contractures.
Shoulder stability and function can be enhanced by practicing good posture, maintaining a balance of flexibility and strength in all shoulder muscles, and selecting appropriate exercises
and performing them correctly.
Range of motion: Pendular and wall climbing exercises as well as physical therapy can be useful in improving shoulder range.
Strength: Strengthening the muscles that support your shoulder will help keep your shoulder joint stable. Keeping these muscles strong can relieve shoulder pain and prevent further injury.
Flexibility: Stretching the muscles that you strengthen is important for restoring range of motion and preventing injury. Gently stretching after strengthening exercises can help reduce muscle soreness and keep your muscles long and flexible.
Target Muscles: The muscle groups targeted in this conditioning program include:
• Deltoids (front, back and over the shoulder)
• Rhomboid muscles (upper back)
• Trapezius muscles (upper back)
• Teres muscles (supporting the shoulder joint)
• Supraspinatus (supporting the shoulder joint)
• Infraspinatus (supporting the shoulder joint)
• Subscapularis (front of shoulder)
• Triceps (back of upper arm)
• Biceps (front of upper arm)
90% of patients with shoulder pain will respond to simple treatment methods such as altering activities, rest, exercise, and medications. Surgery may be needed for recurring dislocations, infection, tumour and some rotator cuff tears.
5. How do you take care of your shoulder?
Your pain may make it difficult for you to carry out your usual activities, and you might want to avoid using your shoulder completely. However, it is important to resume normal activities as soon as possible. Staying active helps to prevent long-term problems.
You may need to use pain-relieving measures to help you return to your usual activity level. If you are working, the plan could include a
programme of selected duties or reduced hours of work.
Avoid excessive unaccustomed activity with the hands above shoulder height e.g. doing tasks like painting the ceiling, hanging curtains and laundry in short periods of time and overhead activities. If you exercise, ensure you balance your training programme to incorporate strength work for all muscle groups. Take breaks from repetitive shoulder movements and heavy lifting.
In order to avoid frozen shoulder correct your posture - if you slouch, your ability to lift your arm above your head reduces by approximately 30% Sitting and standing in a good posture with your shoulders back will help your movement as well as prevent the tendons in your shoulder catching. Bad posture is the main cause of referred pain to your shoulder and often can be managed by merely improving your posture and keeping your neck moving.
Unfortunately osteoarthritis is a problem we will all have to deal with at some point in our lives. But if you keep yourself fit and active, correct your posture and keep your shoulder strong and flexible you can help to alleviate and manage your shoulder symptoms
There are numerous structures and conditions that can cause shoulder pain, but it is helpful to narrow the problem down to one or more of the following categories :
SUB-ACROMIAL IMPINGEMENT SYNDROME
Shoulder impingement occurs when the structures within the sub-acromial space are compressed between the head of the humerus and the coraco-acromial arch. There are a number of soft tissue structures which may be implicated in sub-acromial impingement syndrome. From superficial to deep they are : the sub-acromial bursa, rotator cuff tendons, the long head of biceps. Rotator cuff tendons are impinged as they pass through the sub-acromial space formed between the acromion, coraco-acromial arch and AC joint above and the glenohumeral joint below. The impingement causes mechanical iritation of the rotator cuff tendons and may result in swelling and damage to the tendons.
The clinical features of impingement tend to be pain on most shoulder movements and activities above 90 degrees elevation and in sports people during overhead activities such as throwing or tennis serving.
Treatment is aimed at settling down the symptoms through soft tissue techniques, electrotherapy, taping, exercises and postural education or corticosteroid injection.
ROTATOR CUFF TENDINOPATHY
The patient with rotator cuff tendinopathy complains of pain during overhead activities and possibly weakness on movements such as lifting. Movements such as ‘hand behind the head’ and ‘ hand behind the back’ are commonly reduced and painful. There are numerous tests which the physiotherapist will carry out to ascertain the diagnosis. Should an exact diagnosis be elusive, then referral for an MRI scan and specialist opinion may be required.
Treatment for rotator cuff tendinopathy includes manual therapy techniques, electrotherapy modalities and rehabilitative exercises. A corticosteroid injection into the sub-acromial space may reduce the patient’s symptoms sufficiently to allow commencement of an appropriate rehabilitation programme.
ROTATOR CUFF STRAINS / TEARS
Minor rotator cuff muscle strains occur commonly in patients seen at the clinic. They usually present with sudden onset of pain or a ‘twinge’ felt in the shoulder area. There is also some limitation of movement and function. These minor strains respond quickly to rest from aggravating activity, stretching and soft tissue therapy.
Complete and partial tears of rotator cuff tendons are commonly seen in older patients who present with shoulder pain during activity. Such patients often complain of an inability to sleep on the affected shoulder. The treating physiotherapist will carry out numerous tests to confirm a diagnosis and may refer the patient for an ultrasound or MRI scan. If the tear is small, conservative treatment with the physiotherapist is appropriate. Full thickness rotator cuff tears require surgical repair.
FROZEN SHOULDER (ADHESIVE CAPSULITIS)
The age group in which spontaneous shoulder stiffness occurs tends to be between 40 and 60 years of age. It is more prevalent in women than men at a ratio of 3:1. It is also more common in patients with diabetes and thyroid disorders.
The diagnosis of frozen shoulder, or adhesive capsulitis, is relatively easy to make. Patients typically present with a combination of severely restricted shoulder flexion, external rotation (hand behind head), abduction and internal rotation (hand behind back).
In terms of treatment, one management option is wait for it to resolve on its own with the aid of appropriate stretching exercises. Otherwise, a combination of manual therapy techniques, postural correction advice and rehabilitation exercises are most beneficial. Should the symptoms not resolve, or prove to be severely limiting and painful, then surgical referral would be indicated.