The shoulder is our most mobile joint making it very functional for activities such as overarm throwing in sports, or day to day activities like reaching up to a cupboard or getting dressed. This mobility can however have consequences & may lead to problems with overuse, impingement of soft tissue and/or bony structures, or instability.
The shoulder is made up of 3 bones; the humerus (arm bone),
the clavicle (collar bone) & the scapular (shoulder blade).
A group of muscles surround the shoulder forming the rotator cuff which along with ligaments play an important role in stabilising the shoulder joint. The humerus head (ball) sits against the glenoid; a shallow cup on the scapular. As the surface of the glenoid is small, the labrum (a structure which forms a cup for the humerus head to sit in) helps provide a more stable base.
Bursae are small sacs of fluid that sit within the joint between the tendon and bony structures giving lubrication to the tendons allowing them to glide smoothly when the arm moves.
Shoulder muscles: the rotator cuff is made up of 4 muscles that start from the shoulder blade and merge together around the shoulder joint and insert into the humerus. These rotator cuff muscles are the supraspinatus, infraspinatus, subscapularis and teres minor. When these muscles contract they are responsible for rotating the arm internally (hand behind back), externally (rotating away from the body), and assisting flexion (forward movement) and abduction (sideways movement).
They work with the other main muscles of the shoulder: the biceps, deltoid and pectoralis muscles and the scapular muscles; serratus anterior, rhomboids, trapezius & latissimus dorsi. Some of these muscles are responsible for gross movements and strength, and others work on control and stability throughout the movement, keeping the joint in alignment. This happens alongside the ligaments in place around the joint surface which work to prevent too much movement or dislocation.
As the shoulder is made up of a complex of structures it can be prone to many different problems, as described below:
Common shoulder problems
Rotator cuff Tear:
An injury to the shoulder could mean a strain of the muscles or a tear. A strain or pulled muscle is where the muscle is overstretched and creates pain or stiffness usually to a mild degree. A tear to the muscle is more severe and the tendon attached to the humeral head becomes damaged or ripped. This can be a partial tear where a portion of the muscle tears but not fully, or it can be a complete tear also known as a full thickness tear, where the tendon has separated from the bone. This type of tear is more likely to need surgical repair.
A tear is either the result of an injury/ trauma, or can be degenerative. An injury can have an impact at the time where a single event created pain immediately, sports related or not eg. From sudden overstretching or lifting a heavy object or impact from landing on an outstretched arm. There may also be a delay in the onset of pain, stiffness and restricted movements after the injury, usually when the injury is less severe.
A degenerative tear is when tendon tissue has been frayed or damaged overtime. This deterioration can be the result of the natural ageing process, repetitive movements, or the result of a bony spur on the joint where the tendon is rubbing on the bone; known as shoulder impingement. Usually with a degenerative tear the painful shoulder comes on more slowly and worsens overtime. Commonly an acute injury on a degenerative tear can lead to issues involving more pain and slower recovery.
A term for irritation or inflammation of the tendon tissue. In the shoulder this is commonly the rotator cuff tendons or biceps tendon. The severity can range from mild to severe and the onset is usually gradual with the symptoms worsening overtime. Tendinitis can be the result of multiple activities usually involving repetition such as overarm throwing, reaching, repeated lifting and carrying. In many cases the cause is unknown and the symptoms develop overtime which could be the result of poor posture or even sleeping on the shoulder awkwardly. This can occur in young athletes as well as older people carrying out repeated activity.
an inflamed tendon or bursa (tendinitis or bursitis) may mean thickening or swelling of the soft tissue structures. This then leads to narrowing of the joint space causing the tendon or bursae to be pinched (‘Impinged’) between the bony point of the acromion and humeral head. This irritation of the tissue with this pinching or friction within the joint space leads to a painful shoulder when the arm is moving. Impingement is a symptom of a problem within the shoulder resulting in pain rather than it being a condition itself. Another cause of impingement can be a bony spur where the acromion develops irregular enlarged bony points (spurs) that rub on soft tissue causing fraying, swelling or inflammation. A spur can be the result of trauma, degenerative changes to a joint surface or genetic influence.
a condition known as adhesive capsulitis. This is inflammation of the capsule surrounding the joint (which is the connective tissue) leading to tight bands called adhesions. A frozen shoulder commonly occurs in ages 40-60 year olds and is more frequently seen in women or people with diabetes. It can occur following an injury or trauma, or a period of immobilisation such as being in a sling, or it can happen with no known cause.
Is a disease of the bone involving the cartilage on the joint surfaces wearing down. In the shoulder joint the ball (head of humerus) and/or socket (Glenoid) both covered by cartilage become worn. Another joint within the shoulder complex to develop arthritis is the acromio-clavicular joint (ACJ) where the clavicle and acromion (the top part of the shoulder blade) meet.
Usually arthritis develops gradually, and the wear & tear within a joint happens to different parts at different rates, rather than the whole joint surface. This leaves an irregular surface overtime leading to symptoms of pain, stiffness and loss or movement worsening slowly. This will vary from person to person and will depend on the stress and impact an activity has on the cartilage.
Fracture , dislocation or severe soft tissue injury e.g ligament tears, can be the result of high impact trauma, such as a fall at sped from a bike, other sporting events, or even a trip or fall onto an outstretched arm. The immediate onset of high level pain and the inability to move the arm indicates urgent assistance and assessment is needed. Most likely the person would be seen in A&E and x-rays will be taken as the first investigation.
There are a number of common surgeries seen in the shoulder which include arthroscopy (key-hole surgery) for ligament or tendon repair, removal of bony spurs or loose material, repair to the labrum, and release of adhesive tissue.
More invasive surgery would involve an open procedure (making a larger wound to access the shoulder joint) such as shoulder joint replacement, fixation for a fracture or more complex tendon or ligament repair.
Following surgery the shoulder may have a period of immobilisation depending on the procedure and most procedures require a course of physiotherapy rehabilitation to regain normal movement and strength as per protocol from the surgeon.
Physiotherapy Assessment & Treatment:
With on-going shoulder problems an assessment by a physiotherapist would be beneficial.
At Team Physio the assessment would involve a subjective part taking the history of the problem including finding out about any relevant medical issues, followed by the objective part where they would observe the movements of the shoulder ( as well as the neck and elbow if indicated) carrying out various tests to assess the strength, joint integrity and laxity, and palpate the shoulder to feel the structures that may be involved with the issue. It is therefore necessary to wear appropriate clothing to allow the shoulder to be seen easily, such as a vest top or sports bra for women.
If the physiotherapist requires further investigations to be carried out such as an x-ray, ultrasound scan or MRI scan they can refer appropriately usually via the GP.
Treatment: Physiotherapy treatment will follow the assessment when your physiotherapist has determined the cause of the problem. If further investigations are indicated this will be discussed and implemented. Treatment may involve a variety of methods including exercise therapy for stretching, strengthening and proprioception work, usually a home exercise programme would be set to be carried out independently and progressed as needed, manual therapy which involves mobilisation / manipulation of soft tissue & joints, advice and education for self -management strategies such as cold /heat therapy, posture advice & use of supports/braces, taping, Acupuncture, and shockwave therapy.
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