There are many different types of injury that can occur in and around the shoulder. Shoulder injuries are very common and widely spread across many different sports and training. Over 50% of world-class swimmers suffer from shoulder pain. Our in house Physiotherapist, Paul Harrison, has given us an overview of the most common, signs, symptoms, prevention and treatment of these injuries.
1. Frozen Shoulder or ‘Adhesive Capsulitis’
What is it?
Cause of shoulder pain in people aged between 40 and 60, with women affected more than men, also people with diabetes more susceptible. The cause is largely unknown. The condition is characterized by Adhesions and contractures of the fibrous capsule that surrounds the shoulder joint.
Signs & Symptoms
The non-dominant shoulder appears to be affected more than the dominant shoulder.
Patients with frozen shoulder usually experience 3 distinct phases with differing signs and symptoms.
- The first phase is referred to as the ‘Freezing‘ phase. During this phase pain comes on slowly and leads to a gradual loss in shoulder movement. Some patients may not notice anything until they begin to struggle. Eventually, over the space of a couple of months, the pain becomes so severe that it interferes with sleep because there is an exquisite pain when attempting to lie on the affected shoulder.
- The second phase is referred to as the ‘Frozen‘ phase due to the continued restriction of shoulder movement, which can last for up to a year.
- The final phase is referred to as the ‘Thawing‘ phase. This can take anywhere between 5 months and two years, although some patients can experience a more rapid recovery. During this time there is a gradual increase in shoulder range of motion.
As it is the soft tissues, specifically the capsule, that are affected by frozen shoulder, x-rays are clear.
Ice Therapy or Heat Packs can be effective to help pain relief, depending on personal preference.
The main aim of physiotherapy treatment is to gently stretch the shoulder joint capsule. This is achieved through performing passive mobilisations which are done at various points in the range of shoulder movement. In addition, the patient must keep up a regular active stretching program to gently improve shoulder range of movement. All this stretching should be pain free.
Some evidence suggests that more aggressive shoulder mobilisation in conjunction with local anaesthetic and corticosteroid injections can provide pain relief and restore shoulder range of movement.
If the arm can’t be lifted to the level of the shoulder after three months then manipulation under anaesthetic (MUA) by an orthopaedic consultant may be appropriate. Following the procedure, the affected arm is held ‘abducted’ away from the trunk in order to maintain range of movement. The day after the MUA, the patient must begin a series of active exercises to restore the full range of motion. If these conservative measures fail then surgery may be indicated to release the adhesions and restore range of movement.
It is important to avoid total disuse of the affected arm. This can lead to muscle wasting in the forearm and hand. Grip strength and dexterity should be maintained.
Because the causes of Frozen Shoulder are not fully understood, there is no proven prevention strategy for this condition.
2. Rotator Cuff Injury
A Rotator Cuff injury is a common cause of shoulder pain. Injury to the Rotator Cuff will usually begin as inflammation, often referred to as Rotator Cuff tendonitis. The Rotator Cuff muscles (Subscapularis, Supraspinatus, Infraspinatus and Teres minor) are small muscles situated around the shoulder joint.
People are often told that they have injured one particular Rotator Cuff muscle or tendon, with the most common diagnosis being Supraspinatus tendonitis. However, it is unlikely that the problem is with just one of the muscles in isolation.
Although the Rotator Cuff can be injured by a single traumatic incident, this is not common.
Injury to the Rotator Cuff will usually begin as inflammation (tendonitis) caused by some form of micro trauma (a small but continuous source of irritation). If the cause of the inflammation is not addressed, and continues over a long period of time, partial tears may develop in the cuff that could eventually become complete tears.
There are three main causes of micro trauma to the rotator cuff:
- PrimaryImpingement – Many people will have a naturally small Subacromial space, which is just bad luck, but the space can also be reduced by conditions such as Osteoarthritis. Whatever the cause of this small Subacromial space, repetitive overhead activities (such as throwing a basketball or dusting high shelves) can cause the Rotator Cuff to become continuously squashed against the Coraco-Acromial arch, causing inflammation of the cuff.
- SecondaryImpingement – Many people will have what is called shoulder instability (a lax shoulder joint). This laxity may have been present since birth or may be due to an injury. Often it will have occurred over time due to repetitive overhead activity, poor posture or inactivity. Due to this instability, the Rotator Cuff has to overwork to stabilise the shoulder, causing it to become inflamed. Eventually, the Rotator Cuff will become weak and tired, and will not be able to prevent the humeral head from squashing up against the Coraco-Acromial arch. Because this type of impingement is not due to a small Subacromial space, it is called secondary impingement.
- Overstraining – During forceful throwing actions (e.g. tennis service, pitching and throwing), the Rotator Cuff has to work very hard. With repetitive throwing, the cuff is prone to being overloaded, resulting in inflammation and tissue breakdown.
Signs & Symptoms
- Loss of full movement
- Shoulder pain;
The amount of pain will depend on the extent of the injury. Patients with early-stage inflammation may only have pain with overhead activities, while those with a Rotator Cuff tear may not be able to sleep because of the pain.
Physiotherapists have a number of physical tests designed to diagnose the presence and severity of Rotator Cuff injury. It is also important to look for signs of shoulder instability. X-rays can give clues as to the presence of a rotator cuff injury but an MRI scan is the investigation method of choice to determine whether a tear is present. An ultrasound scan may be just as effective if carried out by an experienced sonographer.
Tears of the Rotator Cuff are best treated by surgical repair.
Physiotherapy is often effective in treating acute (short-term) inflammation and chronic (long-term) degeneration of the cuff where a tear is not present.
The first aim of treatment is to reduce the amount of inflammation using ice therapy and anti-inflammatory medication prescribed by a doctor.
For those who want to continue with sports and work activities a neoprene shoulder support can provide support and reassurance.
A corticosteroid injection (an injection of a naturally occurring substance that can slow down inflammation) that bathes the Rotator Cuff, rather than being injected directly into it, is advocated by some doctors. However, even this may carry a risk of causing further damage and should be used with caution.
Once the inflammation and pain has settled, exercises to regain full movement can begin, followed by a carefully-graded strengthening and stabilising programme. Resistance bands can be very useful for this. Faults in sporting technique that may have caused the problem in the first place must also be rectified.
Operative treatment of chronic inflammation and degeneration of the Rotator Cuff may be necessary if no progress is made with physiotherapy. The use of surgery aims to enlarge the Subacromial space (Subacromial decompression), thus reducing the risk of impingement.
Attention must be paid to flexibility, strength and endurance of the shoulder muscles, ensuring that the muscles of the scapula are not neglected.
Learning the correct technique and choosing proper equipment are also important.
Any increases in the amount of training must be gradual so as not to overload the rotator cuff. Resistance Bands are ideal for shoulder strengthening.
Finally, a proper warm up and cool down may also help to prevent injury.
3. Shoulder Bursitis
Shoulder bursitis is a common cause of shoulder pain that is related to Rotator Cuff Tendonitis.
Specifically, Shoulder Bursitis is inflammation of a structure called the ‘Subacromial bursa’. This condition is sometimes called Shoulder Impingement Syndrome.
Within the shoulder, bones and ligaments form an arch over the top of these rotator cuff muscles. In between the rotator cuff muscles and the arch is the Subacromial space, which is filled by the Subacromial bursa, a sac of fluid that is designed to prevent friction.
Because of its position, the Subacromial bursa can become irritated and inflamed during repeated overhead shoulder movements as a result of being squashed or ‘impinged’ between the muscles and the bone, Sometimes, because the bursa lies so close to the rotator cuff, it can become irritated and inflamed when the rotator cuff is injured.
Shoulder impingement is classified as primary or secondary, depending on the cause:
- PrimaryImpingement – Some people will have a naturally smaller space for the bursa, which is just bad luck, but the space can also be reduced by conditions such as Osteoarthritis. Whatever the cause of this small space, repetitive overhead activities (such as throwing a basketball or dusting high shelves) can cause the rotator cuff to become continuously squashed against the bone, causing inflammation of the cuff.
- SecondaryImpingement – Many people will have what is called shoulder instability (a lax shoulder joint). Often this will have occurred over time due to repetitive overhead activity, poor posture or inactivity. Due to this instability, the rotator cuff has to overwork to stabilise the shoulder, causing it to become inflamed. Eventually, the rotator cuff will become weak and tired, and will not be able to prevent the head of the Humerus from squashing up against the bone of the shoulder blade, thus squashing the bursa. Because this type of impingement is not due to a small Subacromial space for the bursa, it is called secondary impingement.
Shoulder Bursitis usually comes on gradually, although occasionally a fall onto the affected shoulder can start things off. Typically, it is related to overdoing overhead activity that requires the arm to go up and down repeatedly. A weekend of home improvement or repeated sports activities such as tennis or volleyball in people who are not regular players, can be enough to trigger Shoulder Bursitis.
Signs & Symptoms
- Shoulder pain
- Reduced range of movement.
The pain is located over the tip of the shoulder and often it radiates down the arm. Activities such as washing hair and reaching up for the breakfast cereal in a high cupboard become very restricted due to shoulder pain.
There is also shoulder pain at night in people who habitually sleep on the painful shoulder or those who sleep with the painful shoulder above their head.
Although it is possible for a physiotherapist to differentiate Shoulder Bursitis from a Rotator Cuff Injury using manual tests, this may be difficult because the two conditions tend to occur together. An ultrasound or MRI scan should reveal whether the subacromial bursa, rotator cuff, or both structures, are involved.
Shoulder Bursitis that has just started can be improved with physiotherapy treatment, provided it is caught early enough.
Chronic (long-term) Shoulder Bursitis is less likely to clear up with physiotherapy and a corticosteroid injection may be required.
The first priority of physiotherapy treatment is to reduce the pain and inflammation using ice therapy.
Once the shoulder pain and inflammation have resolved, physiotherapy treatment is focused on exercises to restore shoulder range of movement, muscle strength and stability.
Shoulder stability exercises involve very precise re-training of the movements of the shoulder blade. Stability exercises are practiced with minimal resistance at first, but Resistance Bands and Cords are ideal for improving shoulder stability.
These exercises also play a key role in the prevention of shoulder problems.
The key to preventing Shoulder Bursitis and rotator cuff problems is to address the problems of primary and secondary impingement.
Where impingement is occurring, the space for the subacromial bursa is reduced. This space can be optimised by practicing shoulder stability exercises.
These exercises concentrate on controlling the movement of the shoulder blade, by ensuring that muscle contract in the correct sequence during shoulder movements, to ensure that the ball of the upper arm remains stable in the shoulder socket during work, sport and functional activities.
4. Shoulder Separation Injury
A ‘Shoulder Seperation’ is a common shoulder injury in sports that produces immediate shoulder pain.
The term Shoulder Seperation refers to an injury of the ligaments at the Acromioclavicular (AC) Joint.
The joint is kept stable by four ligaments: the Acromioclavicular ligament, the Coracoacromial ligament, the Trapezoid ligament and the Conoid ligament.
The AC joint ligaments are most commonly damaged through a fall onto the tip of the shoulder, although in collision sports this force may come from an opponent.
The impact forces the shoulder blade down and stretches the ligaments away from the collar bone. The Collar bone and Shoulder Blade become separated, hence the term ‘Shoulder Seperation’.
There are 3 basic types of injury:
- If the force is not great, a Type 1 injury will occur, in which there is only a mild sprain of the ligaments.
- With more force, a Type 2 injury occurs. This is a more severe sprain and the AC joint is slightly separated but still intact.
- The most severe injury is the Type 3 injury, in which the ligaments of the AC joint are ruptured and there is a dislocation. In this situation, the collar bone becomes loose and can come to rest in several unorthodox positions.
Most obviously, there is pain and tenderness on the outer part of the collar bone.
This shoulder pain is made worse by shoulder movements.
The injured person will instinctively cradle the affected shoulder and try to keep it still.
If there is a Type 3 injury, the outer part of the collar bone may be sticking upwards and producing a visible lump.
An x-ray should be taken to confirm the diagnosis. This will reveal the degree of separation within the AC joint.
In the acute stage of the injury pain-relieving medication is helpful.
A Physiotherapist can apply a taping technique, which will push the collar bone downwards, and the shoulder should then be placed in a sling and rested. Whilst the shoulder is in a sling it is important to keep the fingers, wrist and elbow mobile by going through their full range of movement.
Strengthening exercises using Resistance Bands can be started so long as there is no pain.
In the case of Type 1 injuries, the symptoms usually subside in 7 to 10 days and the sling should then be discarded.
Gentle pendulum exercises for the shoulder should be initiated and the range of movement in the shoulder should be gradually increased within the limits of pain.
Heavy lifting should be avoided until there is full painless range of movement in the shoulder and the tenderness has subsided.
The treatment for a Type 2 injury is similar, but the sling will have to be worn for about two weeks.
After a week gentle range of movement exercises should be started.
Contact sports and heavy lifting should be avoided for at least 6 weeks. Many people find that a Shoulder Support is useful following a Shoulder Seperation injury.
Because of the traumatic nature of Shoulder Seperation injuries there is not a lot than can be done to prevent them.