Shoulder injuries

Shoulder Impingement Syndrome
Otherwise known as subacromial bursitis, this is a very common type of shoulder pain, usually felt as a generalised pain on the outside aspect of your shoulder. This is usually aggravated by activities and movements with your arm above your head or away from your body. It is characterised by inflammation in the space between the top of the humerus (arm bone) and the acromion (bone at the tip of the shoulder). Between these bones lies a group of tendons (forming a single combination tendon) known as the rotator cuff, and the bursa that protects them. Impingement syndrome is a collection of symptoms caused by pinching of the rotator cuff and subacromial bursa between the top of the humerus and the acromion. Normally, the rotator cuff slides freely within this space. However, for various reasons this space becomes too narrow for normal motion, and the tendons and bursa become inflamed. Inflammation leads to thickening of the tendons and bursa, and contributes to the loss of space. There are several factors that can contribute to the narrowing of this space, but the end result is the same; pinching of the tendons and bursa. It is important not to simply ignore this pain as if it persists you can develop more chronic problems with your rotator cuff tendons and eventually they can begin to degenerate and tear. Your physio will be able to diagnose the problem with a physical examination. They may refer you for an Xray and/or ultrasound scan to confirm the diagnosis, and exclude other causes of the pain. Initially they will try to reduce your pain and increase your movement using techniques like joint mobilisation, massage, acupuncture, taping, and stretching of the shoulder. If it fails to settle down then they may advise you to have a cortisone injection to decrease the inflammation. In severe or persistent cases they may refer you to see a shoulder surgeon. It is very important to strengthen the rotator cuff muscles once the pain has improved, so your physio will give you an exercise programme and progress you through the stages of your rehabilitation. If you don’t address the strength and muscle balance issues it is likely the pain will return once you start increasing your activity levels again or return to sport.

Rotator cuff tear
The rotator cuff is a group of muscles and tendons that stabilise the shoulder joint, and help to rotate the arm. Our shoulders are capable of a larger range of movement than any other joint in our body and the rotator cuff plays an important role in allowing this. Unfortunately, a rotator cuff tear is not an uncommon problem, and injury can make daily tasks painful and more difficult. Tears to these muscles and tendons can come in various degrees of severity, and treatment will be different depending on the type and size of your tear. In the younger population they are more commonly caused by an accident such as falling onto your arm or shoulder. In the middle aged to elderly population it can be either from an accident or from repetitive overuse. Your physio will ask you a few questions, and do a physical examination. If they suspect a tear they may refer you for an ultrasound scan to confirm the diagnosis. Physiotherapy is usually the first step in the treatment for rotator cuff tears, as most will get better with physiotherapy. Your treatment may involve massage, joint mobilisation, acupuncture, taping, and stretching. As the pain settles your physio will get you to do some strengthening exercises as your muscles will have become weak during the injury recovery. You may need to take some anti-inflammatory or pain relief medication, or you may be advised to have an injection of cortisone (a strong anti inflammatory). In severe cases or tears in younger people, particularly when there has been a fall or injury, surgery may be required. Your physio or GP can refer you to the appropriate surgeon if necessary. After surgery you will require an extended period of rehabilitation guided by your physio.

Frozen shoulder
Otherwise known as adhesive capsulitis, this is a painful condition that can cause severe restriction of shoulder movement. The cause of a frozen shoulder is not well understood, but it often occurs for no obvious reason. Frozen shoulder causes the ligaments surrounding the shoulder joint to become inflamed, and then contract and form thickened scar tissue. Often, frozen shoulder occurs with no associated injury or obvious cause, or it can happen after a shoulder injury or surgery. It most commonly affects patients between the ages of 40 to 60 years old, and it is twice as common in women as in men.

There are three stages in the process of frozen shoulder:

1. Painful or Freezing Stage – This stage typically lasts 6-12 weeks. Patients usually have a lot of pain and the onset of restricted movement.
2. Frozen or restricted stage – The frozen stage can last 4-6 months. During this stage, the pain usually improves, but the stiffness worsens.
3. Thawing stage – The thawing stage can last more than a year. The thawing stage is gradual, and motion steadily improves over a lengthy period of time.

Treatment for frozen shoulder primarily involves pain relief and physio to try and restore the shoulder range of movement. Your physio will do a lot of stretching exercises with your shoulder, and may also use massage, or acupuncture to help release the tight muscles around the shoulder joint. You will also need to work on a home exercise program to maintain improvements. It works best if caught early, before the shoulder has completely stiffened up. A steroid injection can help reduce the pain and inflammation so that physiotherapy can be more effective.

Shoulder instability/dislocations
The main shoulder joint is known as the gleno-humeral joint and is a ball and socket type joint. The ball is the end of your arm bone (humerus), and the socket is a part of your shoulder blade called the glenoid. There is also some cartilage connected to the socket that helps stabilise the joint; this is called the labrum. Around the labrum there are a series of ligaments that encapsulate the joint, and this is termed the capsule.  A shoulder dislocation is where your humerus is forced out of the socket, often damaging the labrum, and overstretching the capsule in the process. Sometimes the joint will have to be relocated manually, often in the emergency department or on the sports field. Other times the joint may only pop out for an instant and then back in on its own. Either way it is important to have your shoulder examined afterwards, and Xrays are often indicated. You may be referred to a specialist (sports physician or orthopaedic surgeon) who can refer you for more advanced imaging to examine the tendons, ligaments, and labrum more closely. Depending on what you have damaged in your shoulder you may be advised to try a period of physiotherapy to strengthen your shoulder muscles and stabilise the joint. This can solve the problem as your shoulder relies heavily on muscular stability so strong muscles make a big difference. If you have recurrent dislocations or certain types of damage inside the joint, then you may be advised to have surgery. After surgery you will require a lengthy period of rehabilitation, guided by your physiotherapist.