Many of us at some point have issues with shoulder pain, it limits our work and prevents us from enjoying our hobbies and sports. So what can we do about it? How can physiotherapy help us to get better? What causes the shoulder pain in the first place? The shoulder is a large subject area so this initial shoulder blog aims to give you an insight into shoulder pain, the most common cause of it and how we here Activate Physiotherapy can help you to recover.
The shoulder is a joint complex which is involved in every action completed with our arm and hand, with a huge range of movement and variation in directions able. However, despite the shoulders importance in upper limb tasks and the benefits of its large range of movement, it is regarded as one of the most vulnerable joints in the body in relation to injury. Anatomically we Physiotherapists relate the main shoulder joint (made up of the large upper arm bone and small shoulder blade cup) as being like a football on a golf tee, the very nature making it a vulnerable structure. The shoulder relies heavily on a system of ligaments and muscles to provide its stability.
How common is it?
Shoulder pain is the third most common musculoskeletal complaint registered according to the World Health Organisation and within our lifetime it has been found to affect up to 30% of us. However, in those of us who are physically active or participate in sport numbers can increase to a 66.7% occurrence rate. Further research has recently pointed to the fact 10% of all athletic injuries are related to the shoulder (Luime, JJ. (2004) Scand J Rheumatology; 33(2) 73-81).
What might cause your pain?
- Anterior join line pain – localised and tender, often aching and dull in nature – suggestive of OA and capsulitis (early frozen shoulder)
- Biceps groove pain – localised and tender, worse with lifting and carrying – biceps tendon pain.
- Anterolateral pain – diffuse and radiates down arm – aching, but sharp pain with overhead activities (eg. brushing hair) – rotator cuff pathology (impingement, tendon tear, calcific tendonitis).
- AC Joint pain – very specific and localised – dull ache, but sharp with extreme overhead activities – ACJ Arthritis in the older population or a sprain or osteolysis in younger.
- Pain over trapezius – persistent, dull ache – can radiate down arm and is sometimes unaffected by shoulder movements – Neck or nerve pain from the neck could be the source or if local could be muscular.
- Coracoid pain – rare – localised tenderness over coracoid and sharp pain with shoulder adduction – Various issues could cause pain in this region many of which are named above.
- Sternoclavicular joint pain – localised and tender, increased with overhead and adduction – SCJ arthritis in older, dislocation or a sprain in younger people.
As documented above there are many reasons why your shoulder may hurt with issues arising from traumatic injury, degeneration, muscle imbalance, faulty shoulder blade mechanics and in some extremely rare cases cancer. However, the most common type of shoulder pathology (injury cause) is shoulder impingement which accounts for 65% of all shoulder cases seen by medical practitioners (Horsley, I. 2005.).
Four muscles closely work to raise and lower the arm which are collectively known as the rotator cuff. The rotator cuff works a depressor and centraliser of the humeral head in the shoulder joint. As the arm is raised the rotator cuff works to depress the upper arm bone allowing it to glide easily underneath the acromion (bony protuberance on top of the shoulder). Should an injury or issue occur in the rotator cuff, the depressing and centralising effect would be lost and the upper arm bone would ride upwards closer to the acromion causing reduction of the space below the acromion causing an impingement.
Issues that cause this are those which effect the rotator cuff such as:
- Rotator cuff strain
- Partial or full thickness rotator cuff tear
- Calcific tendonitis
- A tendinopathy due to long term overuse
- Glenohumeral instability
- Labral tears, in particular SLAP tears
- Abnormal muscle patterning leading to shoulder blade maladaptive positioning
What are the symptoms?
The main complaint is one of pain, often felt on the outside of the upper arm which is commonly felt on moving or lifting the arm above 45 degrees or in twisting movements such as putting jackets and coats on. This pain may also be experienced at night when lying on your arm.
A classic presentation is of a painful arc on movement when the arm is lifted out to the side and up to your ear (Figure 4). This corresponds with the narrowing of the sub acromial space as seen in Figure 3.
What are your treatment options?
- Painkillers and anti-inflammatory medications can be used to help manage the discomfort you feel in the initial stages. See your GP or pharmacist in relation to this.
- Physiotherapy – the key part of shoulder pain management – there is a need to work on good posture, shoulder blade position and strengthening of the shoulder / scapula musculature.
- Injections – Not essential!! but can be used in those with high levels of pain to reduce inflammation and slightly lower their pain level allowing the rotator cuff muscles chance to recover and improve with exercise.
- Surgery – Very rarely is surgery required – the goal of any surgery is to reduce the effects of impingement by increasing the size of sub acromial space which allows for easier movement, less pain and reduced inflammation. However current evidence within the scientific literature points to there being minimal difference in the outcomes of rehabilitation and surgery; a comprehensive rehabilitation programme suggested as the best initial course of management.
What are the key factors / treatment options to address?
- Pain management – The first step is to get pain under control doing so through reduction of load in the shoulder, massage and manual therapy. Activities overhead or with increased pulling movements need to be reduced, whilst an improvement of tension in tight musculature and better shoulder capsule mobility using the above methods are key.
As Physiotherapists we rarely get people to avoid activities altogether instead we modify or reduce them to levels the body can manage at that time.
- Strength and control – Starting with basic exercises to reeducate load capacity of the rotator cuff and improve the function, control and strength of the scapula (shoulder blade) influencing muscles is key in the initiation of the recovery process.
- Load management, functional strength and return to activity planning – A progression in the complexity and load of strength work can be made once pain is under more control and load tolerance capabilities have improved across the shoulder complex. An introduction of sport / activity based movements into rehab and whole body training is key to a full recovery.
How can a physio help?
Shoulder Impingements are a complex set of conditions which require management based not on a set of standardised exercises, but an individual tailored management approach. Using a comprehensive approach utilising strength work, manual therapy, massage and soft tissue release physiotherapists are well placed to help in the recovery from this issue.
- Guide you on the most appropriate exercises for your issue and provide other helpful treatments like manual therapy, soft tissue and massage
- Answer questions related to your shoulder pain and explain in greater detail the contents of this blog where necessary.
- Help you understand why you have shoulder pain, what factors have most likely caused your pain and how to modify your activity to improve your pain and recovery.
- The initial stages of rehabilitation / treatment will look at pain reduction and some early strengthening to build a stable foundation and base for the shoulder to move more efficiently. This allows a graded return back into more normal activities. Whilst in clinic we look to provide taping or manual therapy which can be use to improve pain and flexibility.
- The later phases of rehabilitation and treatment will look to include more advanced and comprehensive strengthening, power, and plyometric work; as well as key continuous management of the rotator cuff and shoulder blade stabilizing muscles which form the foundations of shoulder movement.
As with all advice included in the Activate Physiotherapy blog’s this is not meant to replace assessment and treatment from a trained health professional. Getting a professional opinion can help stop things becoming a persistent problem which further impedes your wellbeing. So if in doubt get it checked out!
Thanks for reading
For all your Physiotherapy, Sports Massage, Acupuncture and Dry Needling needs in Newcastle, feel free to give us a call on 0191 6031121 or view other areas of our webpage https://www.activatephysio.co.uk
Our clinics are in easy reach from Newcastle, Tynemouth, Gosforth, Gateshead, Whitley Bay, North Shields, Wallsend, Heaton and Jesmond.