Shoulder Pain

The rotator cuff is a group of four muscles that originate on the scapula (shoulder blade) and attach onto the humerus (arm bone). They are supraspinatus, infraspinatus, teres minor and subscapularis. The rotator cuff is the dynamic stabiliser of the shoulder joint, and serves to control the position of the head of the humerus (ball) in the glenoid fossa (socket). There are several ways in which the rotator cuff can be injured and/or have its function impaired that may result in shoulder pain and dysfunction.

1. Rotator cuff tendinopathy: The rotator cuff tendons are often subjected to high and/or repetitive loads and compression, and so develop tendinopathy. Tendniopathy is a degenerative condition characterised by disorganisation of the collagen matrix of the tendon that results in a painful and weaker tendon. All tendons are susceptible, but the most common rotator cuff muscle that develops tendinopathy is supraspinatus. Patients present with pain with overhead activity or elevation of the arm, weakness, and a loss of function. There may also be other underlying or co-existing pathology and symptoms such as instability or arthritis. Treatment involves treatment of the tendinopathic tendons via a graduated loading (exercise) program. This should also be supplemented by manual therapy to improve mechanics and reduce pain, and a global exercise regime about the shoulder girdle to address any underlying mechanics that may be contributing to the onset of this condition.

2. Rotator cuff tears: Tears of the rotator cuff usually occur in the tendon rather than the muscle belly. It is possible for acute tears to occur (from a single incident), but more commonly these tears are degenerative and occur and accumulate over time and so are more prevalent with age. Tears are classified as either complete or partial. Patients present similarly to those with tendinopathy, but symptoms are usually more marked and function is more greatly affected. Diagnosis can be confirmed via ultrasound and/or MRI to determine the extent and location of the tear. All but the most severe tears should be managed conservatively. Individuals who strengthen the other rotator cuff muscles and other shoulder muscles often regain full and pain-free function. Surgical repair should only be considered in those who have failed a conservative treatment approach (a combination of exercise and manual therapy), or who have other severe or complicated co-existing pathologies in the shoulder (for example, a displaced labral tear), or for those whose injury is severe enough that it impacts daily function and ability to self-care for an extended period

3. Rotator Cuff Dysfunction: The shoulder is a ball and socket joint that relies heavily on the coordination of the dynamic stabilisers of the joint to achieve optimal mechanics. In the presence of pain or other pathology, the rotator cuff can become pain-inhibited, and fail to adequately control and coordinate shoulder movements. This control and coordination is known as scapulohumeral rhythm). In some instances, scapulohumeral rhythm may be disturbed by tightness or lack of mobility, weakness, or fatigue in the absence of other pathology. In these cases, the onset of pain is usually gradual and mior to start, but can rapidly deteriorate. These patients often don’t have pain at rest, but complain of pain with specific movements. Manual therapy and targeted scapulo-thoracic or scapulo-humeral exercises can address the underlying mechanical abnormalities to assist in restoring normal scapulohumeral rhythm and address symptoms.

The Acromioclavicular (AC) joint is the joint between the clavicle and acromion process of the scapula (shoulder blade) that sits on top of the shoulder, above the ball and socket joint. Injuries to the AC joint are very common in athletes who may fall onto the point of their shoulder, for example athletes in team contact sports. Stability of this joint is provided by the joint capsule, the acromioclavicular (AC) ligaments, the coracoclavicular (CC) ligaments, and the trapezius and deltoids muscles.

AC joint injuries are graded based on their severity and the structures that have been injured. There are 6 grades of AC joint injury:

1. Partial rupture of the AC ligaments, characterized by pain on movement, local tenderness, but no joint deformity.

2. Complete rupture of the AC ligaments and partial rupture of the CC ligament, and a ruptured joint capsule, characterised by pain with movement, local tenderness and a mild step deformity

3. Complete rupture of the AC and CC ligaments and joint capsule, as well as detachment of the deltoid and trapezius muscles, characterised by pain with movement, local tenderness and an obvious step deformity where the clavicle is elevated

4. Similar to a Type 3 injury except the clavicle is displaced backwards into the trapezius muscle

5. Similar to a Type 3 injury except the clavicle is elevated more than twice what is normal, a very obvious step deformity is present

6. Similar to the above injuries except the clavicle displaces downwards, which is rare

Treatment for Type 1-3 AC joint injuries is generally conservative, requiring physiotherapy and exercise-based rehabilitation. Management of Type 3 injuries has been controversial, with most being managed surgically in the past. Current recommendations are that these are managed conservatively, and only failing that, surgery would be advised. Types 4-6 AC joint injuries require surgical stabilisation followed by rigorous physiotherapy to regain strength, mobility and function. Plain film X-rays can assist in diagnosis and differentiation between the types of injury. Following injury, physiotherapy should commence immediately with the goals of:

• Educate you about your injury

• Assist you in acute injury management, and to minimise pain and swelling

• Protect the injured site

• Commence early rehabilitation

• Organise onward referral if needed

• Plan out your return to sport and activity

The labrum is a ring of fibrocartilage that is attached to the rim of the shoulder socket to expand the size and depth of the socket, to improve the stability of the joint. The labrum can vary in size and shape, and is an attachment point for the shoulder capsule, ligaments, and the long head of biceps tendon. Injuries to the labrum are commonly sustained in repetitive overhead throwing, repetitive overhead tasks, regular carrying of heavy objects, sudden catching of heavy objects, or a fall or other traumatic event. Labral injuries are characterised by pain localised to the shoulder joint which is aggravated by overhead activity and reaching behind the back, and may be accompanied by mechanical symptoms such as popping, clicking, locking, or grinding. Labral injuries can be divided into either SLAP lesions (injuries to the top portion of the labrum that involve the area of biceps attachment) or non-SLAP lesions, and can be further classified as stable or unstable. Classification of the type, severity and stability of the tear requires MRI, as plain film X-rays are often unremarkable in these cases. Conservative management is always recommended as the first port of call, with the goal of restoring functional mobility and strength about the shoulder girdle. However, in some cases where the injury is severe, unstable, or has failed conservative management, surgical fixation and debridement is required, and a course of post-operative physiotherapy is then prescribed. Labral injuries are often associated with shoulder instability, which also needs to be addressed at some point in the rehabilitation process, to avoid further and/or recurrent injury.

Shoulder Impingement syndrome is a term used to describe shoulder pain caused by a compression or entrapment of a rotator cuff tendon and subacromial bursa as the arm is elevated. This movement causes a narrowing of the subacromial space where these structures are situated. Impingement can often be associated with bursitis and rotator cuff tendinopathy. However, shoulder impingement and/or bursitis are often secondary to another underlying deficit. There are a large number of different causes for shoulder impingement which vary between individuals. Therefore, the diagnosis of “shoulder impingement” or “bursitis” is often insufficient to result in effective management of the condition. The primary causes must be identified and addressed to achieve a lasting reduction in pain and improvement in function. Cortisone injections are often recommended to address bursitis, however relief from these injections are usually temporary and often insufficient if the underlying causes are not addressed. These injections may be recommended for temporary pain relief to allow the patient to effectively complete their exercise program, and are usually only recommended if a 4-6 week course of physiotherapy is not effective. Most individuals will at some point require an individualised strength and control program to address deficits in motor control and strength around the shoulder to improve function and reduce pain, and reduce the likelihood of recurrence.

The shoulder joint is particularly susceptible to instability injuries due to its anatomy and high level of mobility. It is a ball and socket joint with very low bony congruency and stability, instead relying on the passive (joint capsule and ligaments) and active (muscles) stabilisers of the joint to maintain its position and function. Shoulder dislocations are relatively common and have an extremely high recurrence rate - as high as 80% in teenagers and 90% in people aged over 20 years old. The shoulder may dislocate anteriorly (forwards), posteriorly (backwards) or inferiorly (downwards), but most commonly will dislocate anteriorly with the arm in an elevated position. The joint may partially dislocate (called a subluxation) or completely dislocate - this is when the head of the humerus is completely removed from the socket. In either case, the shoulder may relocate spontaneously, but complete dislocations often require manual reduction. Following this, plain film X-rays are highly recommended to rule out associated bony injuries such as bankart or hills-sachs lesions, which may have implications for your treatment and recovery. In some cases MRI’s may be ordered to further assess soft tissue damage, such as injury to the labrum, cartilage, joint capsule, ligaments and axillary nerve. Initially you may be placed in a sling to let your shoulder settle.

Most shoulder dislocations are treated conservatively with a course of physiotherapy. The goals of treatment are to

• Diagnose and assess your condition

• Educate you about your condition

• Commence treatment specific to you, which will usually involve both manual therapy and exercise prescription

• Planning out your return to activity and sport

In some cases where shoulder dislocation is recurrent and affecting your function and quality of life, or there are associated injuries requiring stabilisation, surgical intervention may be required. This is also then followed by an extensive course of physiotherapy to regain range of motion and strength.

The shoulder is a highly mobile joint and is susceptible to instability. Multidirectional Shoulder Instability is a condition that is characterised by instability of the shoulder in at least 2 directions (out of 3 - anterior, posterior and inferior). It is usually a result of generalised ligamentous laxity or hypermobility and is not the result of injury, but rather is something an individual may be born with or develops over time, and is usually present in both shoulders. Multidirectional instability can also develop following traumatic shoulder dislocation, but in these cases it is only present in the injured shoulder. Symptoms of multidirectional shoulder instability include pain, weakness, complaints of instability, pins and needles and/or numbness in the affected arm, creaking or episodes of clicking and cracking of the joint, and episodes of subluxation or partial dislocation. Imaging is not normally indicated, as plain X-rays often appear normal. Occasionally MRIs may be ordered to assess the joint capsule and evaluate the anatomy of the joint. The vast majority of individuals with multidirectional shoulder instability manage conservatively with physiotherapy to strengthen the muscles of the shoulder girdle to better control the joint. Surgery is only reserved for repeated failure of non-operative management. The goals of physiotherapy are to

• Educate you about your injury

• Assist you in acute injury management

• Commence early rehabilitation

• Improve strength, control and function

• Guide your participation in sport and activity