Shoulder

Type I and II AC injuries, where the ligament tears are incomplete and the joint is still intact, are treated conservatively. There is a lot of debate on the best way to treat type III injuries. In these injuries, AC and CC ligaments as well as the joint capsule are ruptured, elevating the clavicle. The damage to the AC joint may injure the cartilage within the joint and can later cause arthritis of the joint.

The mechanism of injury to the AC joint can be either direct or indirect. Direct impact can be caused by collision or a fall onto the shoulder with the arm next to the body (ie, in an adducted position). Indirect injuries are less common, but can occur after a fall onto an outstretched arm. In most indirect injuries, the AC ligament is more commonly affected than the CC ligaments. AC joint injuries—the type III injuries—are often seen after falling off or colliding with bicycles, in contact sports and in car accidents.

AC joint injuries are diagnosed based on your medical history as well as by a physical examination. Your physiotherapist looks for a ‘step’ deformity of the joint, any swelling or bruising, and feels for any tenderness over the AC joint and outer edge of the collarbone. Range of motion of the shoulder will be limited because of pain. To test for an AC joint injury, your physiotherapist will lift your arm up to 90^o and take it passively across your chest with the elbow flexed (cross arm adduction). If the AC joint is injured, this test will cause pain. You may also be sent for an X-ray to see how severe the injury is.

Curiously, Stage I AC sprains are more painful in the short term than the more serious Stage III. This is because the total tearing of the ligaments (Stage III) removes all loading from them, whereas the partially torn ligaments of a Stage I injury are stressed by any movement of the shoulder blade (and arm).

In the early stage after injury, your physiotherapist can tape your AC joint and/or apply a sling so your forearm is supported. You will need to use a sling for 3–4 weeks, particularly if your arm is hanging for long periods of time, but this will depend on your symptoms. If your pain has significantly decreased and your function has improved, you may only need a sling for a week, particularly if you have a type I AC joint sprain.

You will need to support your arm while you are sleeping and, to begin with, you may prefer to sleep propped up in a recliner chair. You may find initially that ice is helpful in decreasing the swelling and bruising.

One to two weeks after the injury, your physiotherapist may suggest you do gentle swinging exercises for your shoulder below 90^o (pendular exercises), as well as gentle scapular setting exercises. After 4–6 weeks, your physiotherapist may gently mobilise your shoulder joint (glenohumeral joint) and collarbone (distal clavicle) to prevent excessive scarring and improve joint mobility.

Once full range is achieved within a pain-free state, you will be given progressive resistive exercises (isometrics, isokinetic exercises and sport/activity-specific exercises). Initially the exercises will be closed chain exercises, meaning that your hand remains in contact with a stationary surface, before progressing to open chain exercises where the hand is free in space. You will find that the closed chain exercises are easy to begin with, as they unload the weight of your arm, which means you can do more exercise without provoking pain.

Physiotherapy is effective for managing type I and type II AC joint injuries, according to two 2014 scientific reviews. It is also effective for managing type III injuries, with studies showing that the rehabilitation time is shorter and just as effective as surgery, although the cosmetic outcome is worse. Surgery for AC dislocation can reduce the deformity, but this treatment has more complications and could in fact compromise the function of the shoulder. More severe grades of AC dislocation (types IV-VI) are treated more effectively with surgery.

With an AC joint injury you must rest until the structures are healed. You won’t be able to drive your car and you must avoid activities where you are lifting your arm across your body or lifting your arm past 90^o. You can do exercises to strengthen your legs and your core, but only if you don’t stress your shoulder. This means sit-ups should be avoided. To maintain your fitness, you can ride a stationary exercise bike.

Activity can be limited for more than six months, particularly with type III injuries. Although AC joint injuries treated without surgery do heal, it is important to note that there is the potential for residual pain, inflammation and possible long-term degenerative changes. Some individuals still feel AC joint symptoms up to 10 years after their injury.

First phase—pain phase
The pain is unbearable and there seems to be no position where your arm feels comfortable. Sleeping is particularly difficult at this time, because of the severe pain.

Second phase—stiffening phase
The covering around the shoulder joint (known as the capsule) is becoming stuck to the bone, so you struggle to move your shoulder partly due to pain but partly due to it ‘freezing’ into place.

Third phase—frozen phase
The capsule is completely stuck to the bone so the shoulder can’t move, not because of pain but because of stiffness.

Final phase—thawing phase
The capsule is loosening, allowing the shoulder to move.

Frozen shoulder can occur after a shoulder or arm injury, particularly if the arm has been immobilised in a sling. It can also occur after shoulder surgery, open-heart surgery, or breast cancer treatment (either after the surgery or with radiotherapy treatment). But sometimes there is no obvious cause for the frozen shoulder.

Frozen shoulder is more common in the non-dominant arm of women of menopausal age. It is also more common if you have diabetes, have had a stroke or have Parkinson’s disease. There seems to be a genetic tendency for frozen shoulder and it has also been linked to a family history of a condition called Dupuytren’s contracture, where the tendons of the ring finger and little finger shorten so the fingers can’t straighten.

The first signs of frozen shoulder vary between women and men—a woman may have difficulty doing up her bra, or a man may have trouble getting his wallet out of the back pocket of his pants. Your shoulder may also be painful when you reach to put on a seat belt or to take the ticket from the machine in the car park.

A quick test that your physiotherapist will do is to ask you to tuck your elbows into your side with your forearms bent to 90^o, and then ask you to take your forearms out from your side. That movement will be restricted on the painful side.

In the initial stages where you can’t move your shoulder due to pain, if anyone massages, mobilises or dry needles your shoulder your symptoms will increase because the lining of the joint is highly reactive. At this stage, you need:

• advice about how to support your arm for sleeping
• strategies to minimise your driving as this will make your symptoms worse
• forearm support on your office chair to decrease the gravitational loading of your arm.

You may find heat, cold or acupuncture is helpful in decreasing your pain. It is a case of trial and error, as everyone is different. Low-level laser can be effective for pain relief in this initial stage. Taping to support the shoulder can be helpful in minimising the shoulder pain and helping you to sleep. At this stage, loosening the mid-section of your back between the shoulder blades (provided you don’t experience any increase in pain) can promote better activity of the shoulder blade muscles, which may improve the position of the shoulder and help your shoulder pain.

Your physiotherapist may give you gentle exercises such as lightly swinging the arm while resting the other arm on a table or crawling your fingers as high as you can up the wall. However, all of these activities must be in the pain-free range and not provoke your pain. Sometimes your physiotherapist may give you a home pulley device where you can slowly work on your own range.

In the stiffness and thawing phases you may find that mobilisation, massage, trigger point therapy and dry needling by your physiotherapist are helpful in improving the mobility of your shoulder. Any treatment you’re given should not increase your symptoms, so it’s important to let your physiotherapist know if you experience pain. You may be given a home program of exercises to improve the way your rotator cuff and shoulder blades stabilise, as well as some stretching exercises.

No treatment, surgical or otherwise, has been shown to be effective for frozen shoulder. Although individual trials have suggested that certain treatments can be helpful, these are not considered to be of a high enough quality to be useful. Other trials have shown treatments to make a difference initially, but in the long-term there was no difference.

There is evidence that although the condition resolves itself, many people don’t have full restoration of their range of movement without some form of intervention, whether it is individualised physiotherapy or a class-based program. Once the thawing stage is evident, physiotherapy can be a great strategy to regain as much movement as possible and to retrain muscles that have been under-used for many months. This will help you to achieve a healthy, strong and useful shoulder (and arm), while being careful not to overload this area.

The best thing to do at home is to make sure your arm is supported with a pillow when you are sleeping because if you don’t get sleep, life becomes difficult. You should try to minimise driving because this will make your symptoms worse. You can try pendular exercises (swinging your arm back and forth while resting the other arm on a table). ‘Crawling’ your hand up the wall with your fingers is helpful in the shower as the warm water may decrease muscle spasm and you can measure your progress using the tiles. Maintaining strength in your shoulder and upper body with exercises that are pain-free may help to improve the outcome of your injury and your ability to use your shoulder.

Frozen shoulder is one of the most painful musculoskeletal conditions, with the pain stage lasting anywhere from 3–6 months. At this point you need to do anything you can to minimise your symptoms, which may mean even taking a few weeks off work if your pain is continually being aggravated by your work.

The stiffness phase is not very painful but it can be frustrating because the arm simply cannot move, which restricts your daily activities. At this time you can try doing some gentle stretches to improve your range of movement. It can take 2–3 years before your arm feels normal again.

Rotator cuff tears are the most common cause of shoulder pain. Tears can be acute (sudden onset) or chronic (long-term fraying). The outcome of your injury can be influenced by the size and location of the tear.

The supraspinatus is the most frequently torn tendon. Partial tears here of just one tendon respond well to physiotherapy. When the tear involves a second or third tendon in the rotator cuff, the effect on the shoulder dynamics, pain and recovery are much worse. In these cases, surgery may be required followed by extensive physiotherapy rehabilitation to regain strength, movement and confidence.

Acute tears involve an injury or trauma, usually in people who have had no shoulder pain before (for example, a fall on the arm while skiing). Chronic rotator cuff tears occur gradually and are common as people age. This is because the tendons, which attach the muscles to the upper arm bone, degenerate and fray. Up to 40 per cent of people over 65 will have degenerative tears of their rotator cuff and most do not have pain. Instead, they will notice their arm is weaker with overhead activities.

Younger individuals participating in repetitive overhead activities for their job or sport (such as carpenters, painters, swimmers or throwers) are also more at risk of injuring their rotator cuff. A family history of rotator cuff tears, as well as poor blood supply (which is affected by smoking) can predispose you to a rotator cuff tear.

If you have torn your rotator cuff acutely, you will experience intense pain in the shoulder and upper arm. You may have difficulty lifting your arm or you may have a painful arc of pain between 60 and 120^o when you lift your arm out by your side. Chronic tears don’t have that intense pain. However, in both acute and chronic tears, there is a deep, dull ache in the shoulder and you may have difficulty sleeping, particularly if you are lying on that shoulder or on your back. Your arm will feel weak and you’ll have pain reaching for your seat belt or trying to brush your hair.

To confirm whether you have torn your rotator cuff, your physiotherapist will ask you to lift your arm away from your body slightly and turn your hand down, as though you are emptying a can. Your physiotherapist will then push against your arm to see if it is weak and painful.

Your physiotherapist or doctor may send you for an ultrasound scan, which will confirm the diagnosis and determine the size of your tear.

Pain and loss of function after a rotator cuff tear are not related to how long you have symptoms or the size of the tear. The main factors that will affect your recovery are related to your shoulder blade muscles, how these work and how strong they are. This means physiotherapy and sticking to the exercise program your physiotherapist gives you will be most effective in relieving some of your symptoms.

Initially, you may not be able to perform any exercises even if your arm is supported because the pain is too severe. To combat this, your physiotherapist may tape your shoulder to decrease the pain and support the torn tendons. Some of the larger muscles around your shoulder may be working too much to protect your injured shoulder. Your physiotherapist may use dry needling or trigger point therapy into these muscles to help decrease the over-activity.

Your physiotherapist will prescribe exercises and stretches that can be done easily at home and that do not provoke symptoms. The focus will be on the shoulder blade muscles, as 21^st century lifestyles (driving a car, computer-based work, etc) mean that these muscles become lengthened and do not work optimally. An easy strategy to overcome this is to elevate your breast-bone (sternum) before you lift your arm. Your physiotherapist may try to loosen your upper and middle spine (thoracic spine) because if your thoracic spine is looser, your shoulder blade muscles will be easier to activate.

As part of your home exercise program, you may be given a light elasticised band or tubing to gently pull out away from your body, particularly with the elbows tucked into the side and the forearms moving out to the side. There are many other exercises that can be given to improve your shoulder’s function, but the main thing is that you need to do the exercises regularly, particularly in the acute phase.

Physiotherapy is very effective in decreasing symptoms of rotator cuff tears. In fact, the outcomes of surgery for rotator cuff tears are no different to the outcomes of physiotherapy. If a patient does not choose to have surgery in the first 12 weeks of physiotherapy, they are unlikely to require surgery.

Taping has been found to be effective in improving range of motion and muscle strength. Strengthening of the shoulder blade muscles has also been effective. If patients stick with their exercise program and believe physiotherapy will be helpful, they are more like to have a successful outcome with physiotherapy.

You can improve your posture by elevating your breast-bone (sternum), which will help to activate your shoulder blade muscles and gradually strengthen them. You can also strengthen these by doing the exercise with elasticised tubing where you tuck your elbows into your side and pull your forearms out from your body. To begin with, you need to improve the range (ie, how far you can pull your forearms out), rather than working on the strength, because you want to make sure you stay in your pain-free range. This is not a question of ‘no pain, no gain’.

Initially, you need to minimise your usual activities around the house such as sweeping, putting the clothes on the line or making the bed, as these activities will be painful and may delay healing. Remember that you can use your other arm to help lift the sore arm up, which will keep the range of movement in your shoulder and minimise the risk of the torn rotator cuff becoming a frozen shoulder.

During the first six weeks you will have difficulty sleeping, brushing or touching your hair and putting your seat belt on, as you will have a great deal of pain. In the following six weeks you will see some improvement, but you will still have problems with many activities. Generally speaking, you will be able to return to most activities after six months, but in some cases this may be up to 12 months.

Physiotherapists have many skills that can help with your rehabilitation. 95 per cent of shoulder dislocations are anterior, where the humeral head moves in front of the body. Anterior dislocations usually occur in younger individuals. Posterior dislocations, where the head of the humerus is displaced backwards, are much less common but as a consequence can often go undiagnosed initially.

As many as 90 per cent of athletes aged under 40 will repeatedly dislocate their shoulder. This is because of the position of the shoulder (abducted and externally rotated) during overhead activities such as swimming and throwing. Sometimes the axillary nerve may be damaged during the dislocation, which can cause temporary weakness to the deltoid muscle making it difficult to lift the arm.

Anterior shoulder dislocations are often caused by a direct blow to the shoulder or by a fall on an outstretched hand.

Some people have very loose joints and are very mobile so can easily put their palms to the floor and place their thumbs back onto their wrist. These individuals often have recurrent dislocations and subluxations (partial dislocations) of their shoulders in what’s called a ‘postero-inferior direction’. This condition is referred to as multidirectional instability (MDI).

You can also see downward (inferior) subluxation of the shoulder in people who have had a stroke, because the muscles around the shoulder are weakened. The shoulder muscles cannot stop the downward pull of gravity, so the humeral head gradually falls down out of the socket. Shoulder subluxation can be a great source of pain for a stroke patient.

You will have acute, searing pain radiating down your arm and you will be unable to move your arm from its current position. Your shoulder will look out of position and someone examining you will not be able to feel the bone at the back of your shoulder. Your arm may feel numb, indicating nerve damage. You will need an X-ray to determine the position of your humeral head relative to the socket and to determine if there is also a fracture. A first-time shoulder dislocation will often need to be treated in the emergency department of the hospital.

Initially an acute shoulder dislocation needs to be relocated and then immobilised for 3–6 weeks to allow the soft tissues to repair. The shoulder can be immobilised in a sling, but the best method is to use tape so the soft tissues are shortened. Exercises that involve isometric (without joint movement) muscle contractions of the shoulder blade muscles (scapular muscles) can be started at this point.

Once your shoulder is pain-free more functional training can be started with your rotator cuff muscles. 

Deltoid strengthening is also a focus of physiotherapy, particularly if you injured your axillary nerve. Your physiotherapist must ensure you have good control of your core and legs so you are not putting extra pressure on your shoulder. You will need to build up the endurance, as well as the strength of your shoulder muscles.

You will be given exercises to improve the ‘proprioception’ of your joint, because your injury means the subtle adjustments your shoulder automatically makes in response to different loads will no longer occur as normal and will have to be retrained.

Unfortunately, re-dislocation is extremely common in young, athletic individuals. This is due to incomplete or prolonged healing of the ligaments that keep the humeral head in place.

This means physiotherapy alone may not be effective in stabilising the joint. If you work hard at your physiotherapy rehabilitation program following a dislocation, you will give yourself the best chance of regaining strength and muscle control, perhaps to the point where you can avoid surgery. If surgery is required later your efforts are not wasted, because you will go into the operation with a fitter shoulder that has a better chance of recovery.

If you have had more than one dislocation you may need stabilisation surgery, after which you will need to follow an intensive post-operative physiotherapy program to achieve the best results.

With an acute dislocation you must rest until the structures are healed. You won’t be able to drive your car and you must avoid activities where your arm is out from your side and your shoulder is externally rotated (hand back behind elbow), for example putting on your seat belt or doing your hair.

Once your shoulder is pain-free with all movements, you can do exercises at home to strengthen your rotator cuff muscles. Place your arm out to the side just out from your body to begin with (you don’t want to reinjure yourself), and let your forearm go gently back past the elbow (comfortable external rotation), while you maintain a lift of your sternum. You will then gently bring your forearm slightly forward so the hand is just in front of the elbow (small amount of internal rotation), using a light resistance band. The band can be used for resistance to control concentric (shortening) and eccentric (lengthening) exercises of your rotator cuff.

You can also do exercises to strengthen your legs and your core, provided you don’t stress your shoulder. This means sit-ups should be avoided.

A dislocated shoulder takes up to three months to feel more secure, but if you want to return to sport it will be 6–12 months before you will be able to participate safely in your chosen sport. Your return to sport must be guided by achieving rehabilitation milestones, how confident you feel using your shoulder and a performance test before a full return to training.

Running should be avoided for at least six weeks, as the action of the arms will delay healing and increase pain. One option for maintaining your fitness is to ride an exercise bike.

Shoulder impingement syndrome can come about for many different reasons.

One reason is when the space between the arch of the shoulder blade (acromion) and the shoulder bone (humerus) becomes narrower than it already is. This narrowing can result in irritation and damage to the cuff tendons, resulting in a painful response.

Narrowing of the space can be caused by changes in the bony structures, such as spurs from the AC (acromioclavicular) joint, or soft tissue changes, such as thickening of the subacromial bursa, or loss of muscle function of the rotator cuff or shoulder blade (scapular) muscles.

Poor posture: A habitual round-shouldered or slumped posture can result in poor functioning of the shoulder blade muscles, which may predispose you to impingement.

Change of activity: If you suddenly increase the amount of overhead activities you’re performing, this may predispose you to an impingement problem.

If you have shoulder impingement it will be painful to lift your arm, especially out to the side. The pain will be worse between 60^o and 120^o.

The pain of impingement syndrome can be worse at night, especially if you lie on your affected shoulder and therefore you might have difficulty sleeping. If you have injured your shoulder, the pain is acute and comes on quickly. If there was no injury, pain can come on gradually with repeated or sustained hand over head activities. You may also hear or feel a popping or grinding sensation when you move your shoulder. However, these feelings alone may not be a problem.

Your physiotherapist will perform a few tests to confirm the diagnosis. One is the ‘empty can test’, where you lift your arms out from your side, placing your arms out straight with thumbs facing the floor, and your physiotherapist applies resistance. If this test is painful, it indicates your supraspinatus is inflamed.

Another test, the Hawkins and Kennedy test, involves your physiotherapist applying a gentle passive movement downward to your forearm while your upper arm is supported out in front. If this causes pain then your physiotherapist will suspect that your bursa is inflamed.

It’s important to remember that no single test can give all of the answers. Your body’s response to a variety of clinical tests will assist your physiotherapist to provide the best treatment for you.

Pain management

Initially the goal of physiotherapy treatment is to reduce pain and inflammation, as well as to prevent further impingement and tissue damage. Your physiotherapist will most likely recommend modifying some of your activities, resting and icing the shoulder. To help with the pain, your physiotherapist may perform some massage to your muscles or mobilisation of your joints, to loosen your shoulder, neck or thoracic spine (the part of your spine that is between the shoulder blades).

In this acute phase, you may find ice or heat helpful. There is no evidence that either is superior to the other in the treatment of impingement syndrome, so personal preference will determine the effectiveness. Your physiotherapist may use low-level laser to reduce your pain and inflammation around the tendon

Changing posture or position

Often taping is useful to change your shoulder posture, allowing more space for the inflamed tendon and/or bursa. Your physiotherapist will give you simple strategies to change your posture so that your shoulder does not hurt so much. This will allow your shoulder blade (scapular) muscles to work better and improve the inflammation. Some strategies might be thinking about lifting your breast bone (sternum) up or imagining you are doing up a zipper from your belly button to the bottom of your ribs.

Strengthening

A complete rehabilitation program for the shoulder always includes some strengthening exercises. Your physiotherapist will give you an elasticised band for you to strengthen your shoulder blade and rotator cuff muscles. As your symptoms improve, your physiotherapist will progress the range of these exercises (how far you can move) and start adding resistance with different coloured bands, making the exercises more functional. All the exercises should be pain-free. Report to your physiotherapist if things don’t feel right.

If you play a sport involving overhead activities (such as tennis or volleyball), your physiotherapist may start you doing some strengthening for your gluteal (buttock) muscles as the stronger they are, the less force you need to generate from your shoulder muscles.

Your physiotherapist may use biofeedback (a machine that measures muscle activity) so you have more information about how your muscles are working and to help you increase the activity, particularly in your scapular muscles.

If you participate regularly in overhead athletic activities, your physiotherapist may video you throwing to analyse your technique, help minimise the potential impingement problem and hopefully improve your performance.

Physiotherapy has been shown to be effective for shoulder impingement syndrome. A 2014 study found that one year after a shoulder impingement injury, the patients who received physiotherapy had fewer episodes of shoulder impingement syndrome, requiring fewer visits to their GPs (37 per cent vs. 60 per cent) than the patients who had received initial corticosteroid injections. The patients who received injections often required additional injections as their impingement symptoms recurred.

In terms of specific treatments physiotherapists use, manual therapy is effective for relieving pain in shoulder impingement, but there is little evidence that electrotherapy, except for low-level laser, is effective in managing the condition. Doing exercises at home, with regular physiotherapist consultations, according to a program of progressive shoulder strengthening and stretching is effective in sustaining the improvements in the condition.

At home, you can make sure you sit and stand with a better posture. When standing, you can adopt a modified ballet third position making sure some part of your legs touch each other. This will stop you standing in a slumped position. Some people feel better with their shoulders held broad. Others find that if they lift their breast bone (sternum) up whenever they are lifting anything, their pain is improved.

A good range of motion exercise is placing your hands on your hips, then straight out in front, then placing your hands behind your head, taking your elbows back then straightening out your arms to the side and slowly lowering your arms down. Do this twice, two times a day. If straightening your arms out to the side is painful, don’t push your elbows back as far, as this exercise should be pain-free. Sometimes you are not aware that the muscles around your shoulder blades are working too much, so you can practise shrugging your shoulders up towards your ears with a breath in, then slowly letting the muscles go downwards with a breath out. This will decrease some of the tension around the neck and shoulders.

Overall the best home fix is an exercise program prescribed by your physiotherapist based on your individual condition and capacity.

Shoulder impingement is due to inflammation of the tendon or the bursa, so you need to make sure you are not continually inflaming these structures.

If you keep a better posture and avoid using your arms repetitively above your chest, the shoulder impingement will settle relatively quickly (6–12 weeks).

If you are participating in overhead sporting activities it will take longer to settle, as often your technique may have to be corrected to make sure you are not continually re-inflaming the structures.