The shoulder is the most mobile joint in the body and so shoulder pain and injuries are common. The surrounding shoulder muscles, such as the rotator cuff muscles, are vital in providing dynamic stability, particularly in weak or unstable shoulders. In many cases, shoulder pain is associated with muscles that are weak or that are not working in a coordinated and controlled manner.

A thorough physiotherapy assessment of a painful or stiff shoulder includes examination of the shoulder joint itself, the neck and surrounding soft tissues, which can refer pain to the shoulder. This allows a comprehensive treatment plan to be developed, for both short and long-term improvements in pain and/or stiffness. Research shows that managing shoulder injuries conservatively with physiotherapy is very successful.

Common shoulder conditions include:

Bursitis

Shoulder bursitis is a condition involving inflammation or irritation of the bursa in the subacromial space. This can occur as a result of repetitive activities, poor shoulder positioning or traumatic events, such as a fall onto the shoulder causing injury to the bursa and pain in the shoulder or upper arm area. Typically, pain will be associated with movements involving reaching forwards or sideways, such as putting a jacket on, washing hair, reaching to high cupboards or lifting weight.

Physiotherapy is important to assist in correct diagnosis as well as identification of additional factors contributing to the problem. Treatment may involve exercises to strengthen postural and rotator cuff muscles, shoulder mobilisation and stretching.

Impingement

Shoulder impingement, or subacromial impingement, refers to the biomechanical pinching of soft tissue within the shoulder joint. This may include pinching of the subacromial bursa and/or the rotator cuff tendons. Rather than being a diagnosis itself, impingement is a symptom that occurs secondarily to another injury of the shoulder, such as bursitis or a rotator cuff tendinopathy or tear.

Physiotherapy is important in order to help recovery by assisting in identifying the physical and biomechanical factors that may contribute to shoulder impingement.

Rotator Cuff Tears or Tendinopathy

The rotator cuff is the group of shoulder muscles that help support and provide mobility to the shoulder joint. The rotator cuff muscles include the supraspinatus, infraspinatus, teres minor and subscapularis. These muscles all work together to keep the humerus centred in the shoulder joint as the arm moves in different directions.

Rotator cuff tendinopathy describes an acute or chronic condition involving painful irritation of a rotator cuff tendon, whereas a rotator cuff tear refers to a partial or complete tear of the muscle or tendon. Both conditions can result in pain associated with moving the arm or sleeping on the affected side and difficulty lifting or carrying heavy items.

Treatment may involve a period of rest from aggravating activities then gradual loading and strengthening of the affected rotator cuff and surrounding postural muscles.

Acromioclavicular (AC) Joint Injury

The acromioclavicular (AC) joint is located at the point of the shoulder where the end of the collar bone meets the acromion (part of the shoulder blade). This joint helps create a strut where forces from the arm can be transferred to the rest of the trunk through the collar bone. The AC joint also allows for overhead movement of the arm as the collar bone rotates.

The AC joint is typically injured by a fall onto the point of the shoulder (for example in a rugby tackle, or upon landing after flying over the handlebars of a push bike). Some of the strong ligaments surrounding the AC joint can tear causing pain and instability. The shoulder can feel like it is dragging and heavy and sometimes a gap will be apparent.

Treatment may initially involve stabilisation with tape, a sling, or even surgery, followed by graduated exercises to regain normal range of motion and control as the joint recovers.

Labral Injuries

The socket of the shoulder joint is very shallow. The labrum is a rim of cartilage that helps deepen the socket, making it more stable. The labrum is also the attachment site of some tendons and ligaments and despite being a sturdy structure, it can be injured. Common modes of injury include mishaps during throwing, suddenly catching at a heavy load and shoulder dislocation. SLAP lesions (Superior Labrum Anterior to Posterior) are the most common, and involve the labrum peeling off the socket near the insertion of the biceps tendon. Another type of labral injury is a Bankart lesion, which can happen during a shoulder dislocation.

Instability, Subluxation or Dislocation

The shoulder joint is often described as similar to a golf ball (the humerus) resting on the golf tee (the glenoid). The difference between the small surface area of the glenoid and the large area of the head of the humerus allows for the full range of shoulder movements. Shoulder stability is achieved from the cohesive working of the rotator cuff muscles, ligaments and the labrum. Shoulder instability is the result of a defect with one (or more) of these structures.

A subluxation is the name given to an injury, usually traumatic, where the humerus comes partially out of the socket before relocating back into normal position on its own. A dislocation means that the humerus comes out of the socket and stays out. Dislocations usually require a hospital visit to relocate the bones to the normal position and to xray to determine if any damage was done. Physiotherapy can be a helpful part of recovery as soft tissues can be overstretched, muscles weakened and range of motion restricted. Physiotherapists are trained to rehabilitate all of these conditions.

Hypomobility, or Frozen Shoulder

Hypomobility can mean something different to frozen shoulder. Hypomobility means restricted range of shoulder motion. This often presents as stiffness and restriction of one or more movements, such as reaching over head or to the side. This can occur after a period of disuse or immobilisation, such as following a fracture or surgery. Physiotherapy is helpful in reducing stiffness, improving movement and strengthening associated muscles.

In comparison, frozen shoulder, or adhesive capsulitis, is a clinical condition involving pain and a gradual loss of range of motion. This is due to a thickening of the shoulder joint capsule itself without a known cause. Frozen shoulder tends to follow a predictable course of three stages as follows:

1. “Freezing” stage: Pain can be significant and movement of the shoulder joint is gradually reduced
2. “Frozen” stage: Pain gradually improves, however movement is still reduced
3. “Thawing” stage: Movement gradually returns to the shoulder joint

As the shoulder thaws, exercise is also very helpful in restoring normal function.

Physiotherapy can be helpful in correctly identifying this condition and providing education on the current stage and expected outcomes.

Fractures

A fracture to the shoulder may involve the humerus, collarbone or even shoulder blade. Generally fractures are the result of a traumatic incident (stress fractures in the shoulder are very rare). Once the bone is healed it can be difficult to regain full and normal movement of the shoulder as well as regain normal arm strength. Physiotherapy can be helpful in regaining normal shoulder range of motion with manual therapy, stretches and range of motion exercises. Physiotherapy can also assist in regaining strength throughout the shoulder and arm to stabilise the joint and prevent future injuries.

The neck, or cervical spine, is the most mobile segment of the spine and is stabilised by many layers of surrounding soft tissue. Neck pain and stiffness can develop gradually over time, particularly in people who spend prolonged periods of time in a fixed posture. Neck conditions can also develop acutely, for example following a bad night’s sleep or a rear-end car accident.

In many cases, the pain and stiffness being experienced is often associated with significant tension throughout the muscles of the neck, shoulder and thoracic spine. With appropriate massage, manual therapy and strengthening exercises, many neck conditions can recover quickly.

See below for common neck conditions.

Posture-related Pain or Tension

Poor posture can have a significant influence on strength, pain, mobility and function throughout the body. Due to their close proximity to the neck, the position of the shoulders and thoracic spine often contribute to neck pain and stiffness.

For example, people who tend to slouch will often demonstrate increased curvature of the thoracic spine and shoulders that are rolled forward. This position places more load on the structures surrounding the neck and may cause them to become painful. Poor posture can also lead to weakness and deactivation of particular muscles, increasing the likelihood of developing neck pain.

Posture-related neck pain is common in occupations requiring prolonged periods of sitting or standing. Office workers are often prone to developing neck pain and stiffness, especially when they have a poor workstation setup. Postural abnormalities associated with sports and hobbies can also lead to neck pain and stiffness.

Posture-related neck pain can be prevented and treated effectively with physiotherapy. While treatment may vary between patients, it often involves a combination of manual therapy, massage, strengthening exercises and posture correction.

Acute Wry Neck

Acute wry neck involves a sudden onset of sharp neck pain and stiffness, typically following a sudden, quick movement or after sleeping in an abnormal position. Often, patients will have pre-existing abnormal postures or muscle deconditioning prior to the onset of pain. Acute wry neck can affect joints and discs in the cervical spine and may result in a protective tension response in surrounding soft tissues, further exacerbating pain.

Treatment of acute wry neck often involves the use of heat, passive mobilisation of the cervical spine, gentle range of motion exercises, release of surrounding soft tissues and strengthening exercises for muscles that support the neck. Education about the importance of movement in treating acute wry neck is also essential to successful and timely recovery.

Whiplash

A whiplash injury occurs after a sudden acceleration-deceleration incident, such as a rear-end collision or a tackle in football. A whiplash injury can affect multiple structures in the cervical spine, including muscles, ligaments, joints and neural tissue. Common symptoms of whiplash include neck pain, headaches and neck stiffness. In more severe cases, neurological symptoms or a cervical spine fracture may be present.

Early treatment of a whiplash injury is very important for recovery and should include education about the condition and gentle neck movements within a comfortable range. Following this, treatment should include a combination of specific exercises, manual therapy and ongoing education.

Cervical Radiculopathy

Cervical radiculopathy, more commonly known as a pinched nerve, arises as a result of compression on a nerve root in the neck. This compression can be caused by osteophytes, disc changes, spondylosis or inflammation of a nearby structure. Symptoms may include pain, pins and needles, numbness or sensation changes in the shoulder and arm.

Initial treatment may include use of heat, traction, neural tissue mobilisation and passive mobilisation of the cervical spine. Following the acute phase, treatment is aimed at preventing recurrences and may include posture correction and muscle strengthening.

Cervicogenic Headaches

Cervicogenic headaches, or cervical headaches, are caused by tension or abnormalities in the structures of the neck. These structures can include joints, muscles, fascia and neural structures. Symptoms of a cervicogenic headache can also be influenced by posture, poor upper body biomechanics and emotional stress.

Typically, cervicogenic headaches are described as a dull ache on one side of the head, however they can also be bilateral. Physiotherapy treatment for cervicogenic headaches varies between patients, but may involve soft tissue therapy, passive mobilisation of the cervical spine, correction of any postural or biomechanical abnormalities and strengthening of the deep neck muscles.

Jaw Pain – Temporomandibular Joint (TMJ)

Jaw pain is often caused by abnormal temporomandibular joint (TMJ) alignment. The TMJ can be located by placing your second and third fingertips just in front of the lower end of your earlobes, then opening and closing your mouth. Signs of TMJ dysfunction include locking, grating, clicking, or pain and stiffness with opening and closing the mouth.

The TMJ can often develop faulty movement patterns, particularly after events such as prolonged dental appointments, sitting or standing with poor head posture or eating a large, hard apple. Dysfunction of the TMJ can also be a source of headaches.

Some physiotherapists are trained to assess and treat TMJ function. This generally involves internal mouth mobilisation (a gloved hand technique) to reduce stiffness, massage and exercises to address the specific direction of tightness or weakness. Treatment can also involve advice regarding posture to improve the position and function of the TMJ.

At Hawker Place Physiotherapy and Pilates, we offer a range of treatment techniques, including specialised exercise programs, massage and manual therapy, dry needling and mechanical traction, as well as clinical pilates. We also believe in the importance of educating patients about their condition, our treatments, self-management strategies and the management of more complex conditions, such as chronic pain.

Exercise Programs

Exercise forms an integral part of most rehabilitation programs. Exercise helps to increase energy and range of motion, build muscular strength, increase flexibility and improve cardiovascular health. Strengthening and stretching are often core components of exercise programs designed to reduce pain and rehabilitate injuries.

Strengthening

Muscle strengthening is essential for decreasing pain, improving function, increasing stabilisation around joints and preventing injury. For many conditions a structured program of progressive strengthening exercises has been found to be more beneficial than medication or surgical intervention. For example, the 2018 guidelines published by the Royal Australian College of General Practitioners recommends land-based strengthening exercises as the best form of treatment for hip and knee osteoarthritis.

Strengthening exercises should be undertaken following a thorough physiotherapy assessment and should be continuously monitored and progressed throughout the rehabilitation of injuries.

Stretching

Stretching aims to increase the flexibility of muscles and improve joint range of motion (ROM) by elongating muscles and associated soft tissues, such as connective tissue and scar tissue. Stretching is often indicated following periods of inactivity or rest, or in the presence of excessive muscular tightness. Rehabilitation programs for many injuries often include stretching as it can also promote healing and prevent future injury.

Massage & Manual Therapy

Soft tissue massage and manual therapy aim to improve circulation, decrease tension, increase joint range of motion, decrease stiffness and relieve pain.

Massage

Massage therapy can be an important adjunct to exercise-based physiotherapy treatments. Conditions that may benefit from massage therapy include postural tension and headaches, neck and back pain and general muscle tension following sporting injuries. Massage therapy includes several different techniques, which are applied based on individual patient needs. Some of these techniques include:

• Trigger point massage: Also known as ischaemic pressure, involves sustained holds over trigger points, which often present as tight, painful knots in muscles
• Myofascial release: A form of soft tissue manipulative therapy that stretches the thick fibrous bands of tissue beneath the skin to remove tightness and reduce tension
• Effleurage: Long, gliding strokes in the direction of the lymph nodes, which can improve circulation and promote relaxation

Manual Therapy

Manual therapy includes techniques such as mobilisation and manipulation, designed to improve joint range of motion and decrease stiffness. Manual therapy can be particularly useful following periods of immobilisation, such as prolonged use of a sling following shoulder surgery, or immobilisation in a cast following a fracture.

Although soft tissue massage and manual therapy can provide short-term relief, they are most effective when combined with an individualised and structured exercise program. In many cases, massage and manual therapy should not be used as stand-alone treatments if long-term improvements are desired.

Dry Needling

Dry needling is a physical modality that aims to relieve trigger points in tight muscle tissue. Not be confused with the Eastern practice of acupuncture, dry needling is a technique that can be implemented by physiotherapists with specific training.

Dry needling can be categorised into superficial and deep dry needling. As the name implies, superficial dry needling does not reach the myofascial trigger points and is painless. Deep dry needling however, elicits a twitch response by releasing myofascial trigger points. In some cases, this can provide immediate pain relief. However it is also possible for deep dry needling to elicit the full pattern of referred pain, before providing relief.

While dry needling can provide temporary relief of pain and muscle tension, it is important to still determine the source of pain with a thorough physiotherapy assessment.

Mechanical Traction

Traction is a treatment technique most often used in the presence of low back or neck pain. It involves drawing adjacent vertebrae apart to increase intervertebral space and relieve pain and associated symptoms. Traction can be applied manually with a therapist’s hands, or mechanically via a machine.

Research shows there is limited evidence that mechanical traction is an effective treatment for low back or neck pain. However, some patients find it provides significant relief and enhances their other physiotherapy treatments.

At Hawker Place Physiotherapy and Pilates, we take the time to complete a comprehensive assessment and work with patients to develop realistic and relevant treatment goals. Based on these assessments, we provide treatments individualised to each patient and their injury or condition.

Musculoskeletal Screening

Musculoskeletal screening involves an in-depth analysis of movement patterns, strengths and weaknesses, flexibility and other biomechanical factors. The assessment is specific to individual needs, sports or hobbies.

A comprehensive musculoskeletal assessment can significantly reduce the likelihood of injury, particularly when combined with an individualised exercise program based on identified imbalances.

This assessment is useful for people who are:

• Commencing a new exercise regime or sport and may be concerned about their risk of injury
• Entering pre-season for their sport, especially if they have not been as active during the off-season
• Wanting to identify any remaining deficits following an injury

Ultrasound

The function of ultrasound varies according to the frequency of the sound waves. At Hawker Place Physiotherapy and Pilates we use diagnostic ultrasound (also known as real-time ultrasound) to observe, assess function, and rehabilitate certain muscle groups.

The use of real-time ultrasound can assist:

• Retraining the deep core stability muscles such as the transverse abdominis and pelvic floor muscles
• Assessment of bladder function in men and women with various bladder conditions
• Rehabilitation of pelvic floor muscles in males pre- or post-prostatectomy surgery
• Retraining the abdominal muscles and pelvic floor muscles in women with pelvic floor issues or during the postnatal period
• Assessment of the correct activation of particular muscle groups, such as gluteal muscles

At a higher frequency, ultrasound can also be used to stimulate cellular activity and promote healing, as well as relax very tight and tender muscles.