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:
- “Freezing” stage: Pain can be significant and movement of the shoulder joint is gradually reduced
- “Frozen” stage: Pain gradually improves, however movement is still reduced
- “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.
