Shoulder pain

The shoulder is a very complex joint so this section will be broken into sub-sections of INSTABILITY, IMPINGEMENT/CUFF TEARS and CAPSULITIS.

The shoulder is held in place partly by a thin membrane called a capsule. This is then supported by strands of tough ligaments that help fix the arm bone (humerus) to the shoulder blade (scapula). Attached to the scapula are the rotator cuff muscles, a group of flat muscles with thin tendoninous insertions onto the humerus. The collar bone (clavicle) fixes to the top of the scapula forming the acromio-clavicular joint which sits over the top of the humerus preventing upward movement.

Possible diagnosis:

• Rotator cuff Tear
• Impingement
• Dislocation/Instability
• Frozen shoulder

Impingement/Cuff tears:

Impingement occurs when a structure, such as a tendon, becomes trapped between the arm bone and shoulder blade. The tendon is squashed and may become tethered resulting in inflammation and therefore pain. A Cuff Tear denotes a lesion affecting the tendons surrounding the shoulder joint. It may be traumatic or occur in association with an impingement.

Causes:

• Poor posture i.e. sitting, computer work, manual occupations
• Trauma to the acromioclaviular joint
• Congenital abnormalities (problems since birth)
• Falling onto an out stretched arm
• Stretching beyond normal ranges

Symptoms:

Symptoms include: Difficulty putting on a coat; tucking in trousers; reaching behind to grasp safety belt; reaching for a cupboard. Pain may be elicited when rolling onto the shoulder at night. The arm may be weak where a tear has occurred and movement will be noticeably obscure.

Treatment:

Treatment is directed at the cause to ensure the causative factors are resolved. Electrotherapeutic modalities like ultrasound can help reduce pain and inflammation around the tendon and help optimize healing where a tear has occurred. The joint often becomes stiff and limits mobility therefore stretching and mobilizing techniques are indicated. Prevention measures and rehabilitation will often include postural exercises, core training, shoulder strengthening and ergonomic intervention (changes to work environment). Surgery is indicated where conservative methods have failed.

Frozen shoulder (Idiopathic Adhesive capsulitis):

Frozen shoulder is characterized by severe pain and a gradual loss of movement. Generally speaking it refers to a sticky joint where adhesions from inside the capsule and cause a restriction of movement.

Causes:

• Sometimes Unknown
• More Prevalent in Type II Diabetes
• Posture
• Trauma (may result in capsulitis)
• After a Broken arm (may result in capsulitis)
• Post dislocation in the older patient (typically 40 and above)

Symptoms:

• Initially Severe Pain
• Gradual loss of movement
• Increasing pain with movement
• Difficulty sleeping at night

Treatment:

Stretching, mobilisation, electrotherapy, acupuncture and manipulative therapy to the spine have been shown to provide benefit, relief and in some cases complete resolution. A cortisone injection is often helpful, particularly in the early stages and your GP should be consulted on this. The condition can resolve after 3 months with appropriate treatment. Untreated there have been reports of it lasting for up to 5 years. Surgery is sometimes indicated if all conservative methods have failed, however only after trying non-surgical treatment for at least 4 months.

Instability:

This is where the joint capsule and ligaments becomes loose and the muscles surrounding the joint become weak, this may predispose the joint to dislocation. It is sub categorized in to traumatic and a-traumatic.

Symptoms:

• Traumatic - where the joint comes out of place, this looks visually out of position and is often very painful.
• A-traumatic - the feeling of impending dislocation, intermittent and non-specific pains which may be multi-directional.

Causes:

• Traumatic - Violent blow, arm stretched beyond physiological ranges.
• A-traumatic - Posture, upper thoracic stiffness, congenital (since birth)

Treatment:

If the instability occurs via a traumatic episode a period of rest will be indicated and the patient will be asked to abstain from their chosen activity or occupation if manual for a few weeks. In the older patient, usually above 40 years (average), mobilization is encouraged early on to avoid stiffness developing. In the younger athlete the joint is already lax and therefore will need a period where the joint can stiffen up. In both traumatic and A-traumatic cases strengthening, core and postural work is essential. Local work to the shoulder can also be indicated if there are areas of soft tissue damage or there is a pre-existing spinal stiffness. Where conservative methods have failed or significant shoulder damage has been identified, surgery may be indicated.