Shoulder Pain

In this section you will find information on the five main causes of shoulder pain: shoulder impingement, rotator cuff tears, frozen shoulder, shoulder instability/dislocation and acromioclavicular joint (ACJ injuries). If you have any further questions or would like to book an appointment, please get in touch.

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.

ACJ injuries

The ACJ or acromio-clavicular joint is the joint at the top of your shoulder that connects your collarbone to your shoulder blade. This is quite a commonly injured joint, and generally is caused by a fall onto the point of your shoulder, or by a force directly onto the shoulder like in a rugby tackle. Injuries to this joint can range from the very mild to complete ruptures of all the ligaments. Your physio will do a few tests in the physical examination, and have a feel around your shoulder to diagnose this problem. They may also send you for an Xray to confirm the diagnosis and exclude any fractures. All but the most severe of ACJ injuries are treated conservatively with rest, physiotherapy and pain relief. Sometimes you may wear a sling for a short period to help with your pain. Physiotherapy will initially aim to improve your range of movement and decrease your pain. Once you can move your arm freely you will need to do some strengthening exercises before you return to sport. Recovery can take anywhere from 3-12 weeks depending on the severity of your injury.

The ACJ can also be affected by arthritis in the middle aged to older patient. This tends to be of gradual onset and may make movements of the shoulder painful. You may have swelling and the joint will be tender to touch. An Xray will help with the diagnosis of this problem. ACJ arthritis is generally caused by overuse, but if you have had a severe injury in the past this is likely to contribute to early onset of this problem. Physiotherapy can help to increase your range of movement and decrease your pain. They will also advise you on appropriate exercises to improve your movement and strength. You may also benefit from taking anti-inflammatory medication, or having an injection into the joint to decrease pain and inflammation. There are surgical options for when the pain does not improve with conservative measures, and the arthritis is severe.

Another problem that can occur to the ACJ is an overuse injury often caused by heavy weightlifting. This is called clavicular osteolysis. This is often characterised by a gradual increase in pain which is aggravated by heavy gym work, and is usually in people under the age of 40. This is common in bodybuilders or athletes that place a large amount of stress on their shoulders. It can also occur in people who have very heavy, repetitive jobs. It is essentially a stress fracture of the outer end of your collar bone, and therefore requires a period of relative rest. Physio can help with your pain and range of movement, and then to help strengthen the muscles around the shoulder that are often neglected during weight training. Anti-inflammatory medication or steroid injections can also help with pain, but should not be used as an excuse to continue training in the same manner. If these measures don’t settle the pain then your physio may refer you to see a shoulder surgeon.

In this section you will find information on the five main causes of shoulder pain: shoulder impingement, rotator cuff tears, frozen shoulder, shoulder instability/dislocation and acromioclavicular joint (ACJ injuries). If you have any further questions or would like to book an appointment, please get in touch.

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.

ACJ injuries

The ACJ or acromio-clavicular joint is the joint at the top of your shoulder that connects your collarbone to your shoulder blade. This is quite a commonly injured joint, and generally is caused by a fall onto the point of your shoulder, or by a force directly onto the shoulder like in a rugby tackle. Injuries to this joint can range from the very mild to complete ruptures of all the ligaments. Your physio will do a few tests in the physical examination, and have a feel around your shoulder to diagnose this problem. They may also send you for an Xray to confirm the diagnosis and exclude any fractures. All but the most severe of ACJ injuries are treated conservatively with rest, physiotherapy and pain relief. Sometimes you may wear a sling for a short period to help with your pain. Physiotherapy will initially aim to improve your range of movement and decrease your pain. Once you can move your arm freely you will need to do some strengthening exercises before you return to sport. Recovery can take anywhere from 3-12 weeks depending on the severity of your injury.

The ACJ can also be affected by arthritis in the middle aged to older patient. This tends to be of gradual onset and may make movements of the shoulder painful. You may have swelling and the joint will be tender to touch. An Xray will help with the diagnosis of this problem. ACJ arthritis is generally caused by overuse, but if you have had a severe injury in the past this is likely to contribute to early onset of this problem. Physiotherapy can help to increase your range of movement and decrease your pain. They will also advise you on appropriate exercises to improve your movement and strength. You may also benefit from taking anti-inflammatory medication, or having an injection into the joint to decrease pain and inflammation. There are surgical options for when the pain does not improve with conservative measures, and the arthritis is severe.

Another problem that can occur to the ACJ is an overuse injury often caused by heavy weightlifting. This is called clavicular osteolysis. This is often characterised by a gradual increase in pain which is aggravated by heavy gym work, and is usually in people under the age of 40. This is common in bodybuilders or athletes that place a large amount of stress on their shoulders. It can also occur in people who have very heavy, repetitive jobs. It is essentially a stress fracture of the outer end of your collar bone, and therefore requires a period of relative rest. Physio can help with your pain and range of movement, and then to help strengthen the muscles around the shoulder that are often neglected during weight training. Anti-inflammatory medication or steroid injections can also help with pain, but should not be used as an excuse to continue training in the same manner. If these measures don’t settle the pain then your physio may refer you to see a shoulder surgeon.