Physiotherapy for Shoulder Pain

Frozen Shoulder

What is Frozen Shoulder?

Frozen shoulder is a painful condition that can come out of nowhere. The shoulder joint starts out very painful and begins to stiffen leaving you with reduced range of motion. It is characterized by inflammation inside the shoulder joint. It is not an injury exactly. It is best understood as a condition or disease process that happens to affect your shoulder. People with diabetes or thyroid dysfunction tend to be at a higher risk of developing frozen shoulder, but perfectly healthy people can get it too. Unfortunately, having a frozen shoulder in one arm also seems to increase the chance you will eventually develop it in the other arm, but it does not seem to re-occur in the same shoulder more than once. It can take up to three years before frozen shoulders completely resolve and some people are left with stiffness and pain permanently. However, with a good treatment plan you can ensure you get your shoulder function back.

How Do I Know If I Have Frozen Shoulder?

If your shoulder pain seemed to come out of nowhere, and was very painful at the beginning, followed by increasing stiffness, there is a good chance you are dealing with frozen shoulder. People who have frozen shoulder find it very difficult to raise their arm above their head, and tend to shrug rather than properly raise their arm (Image 1).

They also tend to lose the ability to externally rotate their shoulder (Image 2).

The diagnosis is made by an experienced clinician with a simple physical examination.

How Do I Fix My Frozen Shoulder?

Frozen shoulder is a disease process that takes some time to resolve. But there are a number of things that you can do to help ensure you get your shoulder back to normal as quickly as possible.

• Talk to your doctor about the possibility of a cortisone injection or anti-inflammatory medication.
• A daily exercise routine to maintain and restore your shoulder range of motion is important.
• Regular hands on manual therapy treatment to restore tissue mobility.
• Avoid “pushing through the pain” this will just create more inflammation and slow your progress.

Tendonitis

What is Shoulder Tendonitis?

Tendonitis is inflammation and breakdown of a tendon. In the shoulder the most common tendons that are affected are the long head of bicep tendon and the rotator cuff tendons. Tendonitis occurs from overuse. Simply put, when our activities create more tension or stress than a tendon can manage, and we don’t allow it to fully recover between stressful events, it becomes inflamed and begins to break down. In some cases the tendon will break down with little or no inflammation. In that case we refer to it as tendinosis rather than using the suffix :”itis” as it refers specifically to inflammation.

In some cases people can develop Calcific Tendonitis of the shoulder. This means that the body deposits calcium into the tendon that can be seen on x-ray. It tends to be more painful and can create more mechanical damage to the tendon as the calcium deposit takes up space in the shoulder.

How Do I Know If I Have Shoulder Tendonitis or Tendinosis?

People with shoulder tendonitis experience the following symptoms;

• Pain with certain movements that involve stressing the tendon.
• Tenderness over the tendon itself.
• Have a recent history of repetitive shoulder movements or overhead work.
• Except in extreme cases people usually have normal range of motion (albeit a bit painful).

Tendonitis and tendinosis is most often diagnosed with a simple physical exam. If calcific tendonitis is suspected an x-ray or ultrasound image can confirm.

How Do I Fix My Shoulder Tendonitis or Tendinosis?

If the tendon is acutely inflamed, it must be allowed to rest and recover. This will mean eliminating activities that are making the situation worse. Often it requires a break from performing overhead work, or a reprieve from the gym. If the inflammation is under control, treatment should be focused on loading the tendon appropriately with exercises and providing adequate time for it to recover from the stress. This will stimulate your body to strengthen the tendon and prepare it for the stresses of your daily life. Your physiotherapist will determine what your tendon is able to withstand and will design a program that will stress the tendon appropriately and allow for the right amount of recovery time. Lastly, an experienced physiotherapist will look at the rest of your shoulder and spine to see if there are any problems that have contributed to your tendon breaking down. For example a winging shoulder blade can cause your tendons to become overloaded with relatively minor lifts. If you follow through on your physiotherapy program your tendonitis will resolve nicely.

Shoulder Impingement

What is Shoulder Impingement

Shoulder impingement refers to an abnormal contact of the upper arm bone (Humerus) with the cup of the shoulder (Glenoid) when raising the arm. The collision of these two surfaces can damage sensitive structures that lie between the two bones including the rotator cuff tendon, the shoulder bursa and the biceps tendon. If impingement is allowed to continue it can develop into shoulder bursitis, or a degenerative rotator cuff tear.

How do I know if I Have Shoulder Impingement?

People who are experiencing shoulder impingement commonly report the following symptoms;

• Pain when elevating the arm that is located right where the arm meets the thorax and sometimes travels down the upper arm a few inches. This pain typically will not disappear if you continue to elevate the arm all of the way through the range of motion. Whereas tendonitis (above) may cause pain in the middle of the range of motion that disappears as you continue to elevate. This phenomenon is called a ‘painful arc’.
• Tenderness of the ‘pinched’ structure.
• Clicking or popping when elevating the arm may be present.
• There will not typically be pain at rest.
• A diagnosis can be confirmed with a detailed physiotherapy assessment

How Do I Fix My Shoulder Impingement?

The first step is to determine the cause of the impingement. Common causes include;

• Poor shoulder blade control or movement patterns
• An arthritic acromioclavicular joint.
• A calcium deposit in the rotator cuff tendon
• Poor spinal or shoulder blade mobility

To successfully resolve your shoulder impingement the treatment plan must address the cause. If your shoulder blade wings, you must strengthen the muscles that control it. If you have poor mobility of your spine, that must be improved. If the cause of your impingement is a large abnormality inside the shoulder joint such as a calcium deposit or advanced arthritic changes to the bone, a surgical procedure may be required to remove the offending material. In most cases however, a rehabilitation plan created by a physiotherapist that understands how the components of the shoulder need to work together to produce normal movement will resolve the issue.

Rotator Cuff Tears

What is a Rotator Cuff Tear?

Your rotator cuff is made up of four muscles that attach your shoulder blade to your upper arm. They are responsible for maintaining good alignment of your upper arm bone in the socket of your shoulder. These muscles and their tendons can be torn in two main ways.

Degenerative rotator cuff tears - these may occur slowly as a consequence of untreated shoulder impingement or long standing tendinitis or tendinosis. These can be thought of as ‘wear and tear’.
Traumatic rotator cuff tears - In a traumatic rotator cuff tear the tendon is torn all at once due to a force well beyond the limits that it can withstand. These happen suddenly and it is typically obvious to the individual that they have injured their shoulder. Common ways to tear your rotator cuff include falling on an outstretched arm or lifting a heavy object while holding it away from your body and moving the arms.

How do I Know If I Have a Rotator Cuff Tear?

Degenerative rotator cuff tears are very common. In fact most people have some amount of rotator cuff tearing by the age of 50, and many do not even realize they have them. These injuries only become a problem when the tear gets large enough to impede the function of the shoulder. These types of tears have a similar presentation to tendonitis above, but typically are shown to be weaker when testing the rotator cuff muscles. A rotator cuff tear can be confirmed with an ultrasound image.

Traumatic rotator cuff tears are more obvious. There is usually a period of major weakness and sometimes a total inability to elevate the arm using a normal pattern of movement. If the tear is partial (which most are) you may be able to elevate the arm one way, but struggle to elevate it another way. For instance someone dealing with a supraspinatus tear may be able to elevate their arm in front of them reasonably well, but when asked to elevate the arm at their side they are unable. An experienced orthopaedic physiotherapist can diagnose a rotator cuff tear with a clinical examination. This examination can be supplemented with ultrasound imaging if required.

How Do I Fix My Rotator Cuff Tear?

Most rotator cuff tears (degenerative or traumatic) resolve following a physiotherapy program. The program will focus on restoring mobility and strength to the remaining rotator cuff muscles and normalizing the movement patterns of your shoulder. Approximately 5% of rotator cuff tears respond poorly to rehabilitation. These larger tears can be repaired surgically.

When Shoulder Pain is not from your Shoulder

It is important to note that not all pain you feel in the shoulder is in fact coming from the shoulder. Many patients come into the Physiotherapist for shoulder pain that turns out to be arising from a neck injury. If your shoulder pain is affected by head movements, if it radiates down your arm past your elbow, or if it is accompanied by numbness and tingling, be sure to have a complete assessment by a qualified physiotherapist. There is nothing more frustrating than doing an ineffective rehabilitation program because the diagnosis was wrong in the first place!

The shoulder is a complex joint that is held together mostly by muscle. This leaves it vulnerable to injury. However it also means that we can have a profound effect on the joint with strengthening and stretching exercises. If one of these common shoulder injuries sounds familiar, get in to see your physiotherapist to get the diagnosis confirmed. Once you have your diagnosis, use the information above to ensure your treatment plan is appropriate.