Understanding Shoulder Pain
The shoulder joint allows for a considerable amount of movement, leading it to being vulnerable to injury and shoulder pain. Injury results in pain and restriction with overhead movement, reaching behind the back and lifting objects, and occurs mostly commonly through sport and exercise, however some pathologies are of an insidious onset. The location of shoulder pain varies depending on the injury, with anterior, lateral and posterior pain common and often pain down the arm depending on the irritability of the condition.
The most prevalent shoulder pathologies include;
- Sub-acromial Impingement
- Adhesive capsulitis or frozen shoulder
- Rotator cuff tears
- Glenohumeral joint dislocation
Sub-acromial impingement is the most common diagnosis of shoulder pain. It presents with a gradual onset, with pain location varying from the anterior and lateral aspect of the shoulder and muscle tightness posteriorly. Patients will note that there has been a change of activity, work or exercise in the lead up to pain presenting.
Impingement results in compression of the bursa and supraspinatus tendon within the sub-acromial space. When reaching overhead or behind the back, this space is compressed, resulting in pain, with more irritated presentations causing more severe pain. Other activities which will compress this space include lying on the shoulder and adopting a poor posture when sitting at the work desk. If this is left unaddressed, pain will persist and be harder to manage.
The common finding in assessment of sub-acromial impingement is the presence of muscle imbalance around the shoulder. Muscles which act to stabilize and move the scapula become inhibited and weak, resulting in overload of the rotator cuff, causing pain and tightness along with aberrant movements of the joint. Physiotherapy treatment first aims to target pain relief through treatments such as soft tissue massage, clinical dry needling, taping techniques and joint mobilisations. These passive treatments are important for first line treatment, however active management through exercise prescription is the most integral part of the rehabilitation as it addresses the muscle imbalance present around the shoulder. Your physiotherapist will prescribe exercises based on which muscles are weak and progress them as required, with the aim to improve muscle control and strength, along with improving postural awareness.
Adhesive Capsulits (Frozen shoulder) is a condition which mostly presents in those who are aged between 40 and 60 years old. Pain presents as a diffuse ache around the shoulder and upper arm, with most cases having no known incident. It has three phases;
- Painful stage – Where range of movement is painful and progressively reduces
- Adhesive/frozen stage – Stiffness is the main concern, with a large limitation of movement, however decreased pain
- Thawing stage – Movement gradually returns to the shoulder
Duration of adhesive capsulitis will vary, with cases lasting between 6 and 18 months, and although it causes severe disability, a full recovery occurs with time. Physiotherapy treatment can help in the management of this condition with pain relief in the first two stages, and speeding up the recovery of movement in the third stage. Corticosteriod injections are also of use to help with managing pain in the first stage, and may make daily tasks more comfortable. Hydrodilitation injections are new, however can help with improving movement as they help to stretch out the tight joint capsule.
Rotator cuff tears present with a specific mechanism of injury such as lifting an object, a rapid twist of the shoulder or landing onto the arm from a height. There will be an immediate onset of pain and restricted mobility along with a lack of strength. The application of the RICER principle (Rest, ice, compress, elevate, refer) is the correct first line management to decrease swelling and inflammation, followed by a visit to the physiotherapist for management.
Management is similar to impingement, with initial passive therapies used to remedy pain. As the pain eases, physiotherapy aims to strengthen the rotator cuff and scapular stabiliser muscles to restore full function and prevent injury in the future. If left untreated, a rotator cuff tear can progress to impingement, which will take longer to recover.
With more severe tears, surgery may be required. High grade tears will present with a very forceful injury (commonly falling from a height onto the arm) and will produce greater restriction of movement and muscle weakness. Smaller tears will see improvement over one week of rest, whereas a larger tear will not. Having your shoulder assessed by a physiotherapist can help determine the extent of injury.
Glenohumeral joint dislocations result from impact injuries during sport. Sports which use the upper limb such as football, rugby and basketball can result in a dislocation to the shoulder. This commonly occurs when external pressure is placed onto the shoulder when the arm is overhead or out to the side, although there are other mechanisms for injury too. A dislocated shoulder should only be relocated by a medical professional so as to avoid any damage to other structures around the shoulder; therefore, dislocations should be managed by placing the upper limb into a sling and being sent to hospital. Following relocation, the arm should remain in the sling to allow the injured ligaments to rest and to help with pain relief. The duration of this may vary depending on what was recommended by the individual who relocated the shoulder.
Rehabilitation for a dislocation consists of minimal passive treatment, and is largely exercise based. Muscles surrounding the shoulder are required to be strengthened to provide greater support and stability to the joint and to prevent future injuries. Exercises are progressed into overhead and unstable positions to retrain muscles and develop strength in these areas which are most vulnerable to injury.
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