Shoulder Conditions

‘Frozen shoulder’; shoulder adhesive capsulitis

The main shoulder joint is formed between the ‘ball’ at the top of the upper arm bone (humerus) and the ‘socket’ that is part of the shoulder blade (glenoid cavity). The joint is surrounded by a bag or ‘capsule’ that has an inner lining that produces a lubricant fluid to help shoulder movements. ‘Frozen shoulder’ describes a stiff, painful shoulder occurring in middle-age that may come on after minor trauma or spontaneously. The capsule and its reinforcing ligaments (‘elastic bands’ that are placed to prevent overstretching of the joint) are affected and the joint gradually stiffens with scar tissue forming within the joint. Patients complain of pain on lifting the arm into the overhead position or placing the arm behind the back. A proper diagnosis is needed as shoulder pain can also come from the neck or arise from structures being pinched at the shoulder. The pain tends to settle in approximately two years without treatment but the stiffness can remain unless the joint is stretched.

Physiotherapy can help the condition to settle more quickly with mobilising and stretching techniques, applied at the right stage of the condition, with an explanation of the condition, reassurance and home exercises. A steroid injection, or a series of injections, may be given if the pain is persistent.

Acromioclavicular joint pain

The acromioclavicular joint sits at the top of the shoulder and is formed where the collar bone (clavicle) meets the bony prominence (acromion process) that sweeps upwards from the shoulder blade. A fall directly onto the shoulder or landing on an outstretched arm while playing squash, for example, can jar the joint leading to pain at the cap of the shoulder with tenderness to touch and pain at the extremes of shoulder movements. Placing the arm across the body at shoulder height, as if putting on a scarf, will increase the pain and this helps with the diagnosis.

The pain may settle in a week or so without treatment but if it persists, physiotherapy can help with a specific massage technique called ‘frictions’ to the ligaments spanning the joint and mobilisations to ease a little movement and to stop the joint stiffening. Ultrasound can also be helpful in promoting healing and easing the pain. Occasionally a steroid injection is needed, especially if osteoarthritis is present, and if the joint is very unstable an orthopaedic opinion should be sought.

Acute subacromial bursitis

The subacromial bursa sits like a flattened balloon containing fluid under the hard cap of bone at the shoulder where it acts to lubricate shoulder movement and to protect the tendons lying underneath. Occasionally the bursa can become suddenly very inflamed, swollen and painful, especially noticeable on attempting to lift the arm away from the side.

There is no known cause but it can be associated with a ‘burst’ of a nugget of calcium in one of the underlying tendons, usually supraspinatus. The pain will usually settle in approximately three weeks without treatment but pain relief maybe needed with prescribed medication, TENS or an anti-inflammatory injection of steroid into the bursa to help the inflammation and pain to settle.

Chronic subacromial bursitis

The subacromial bursa sits like a flattened balloon containing fluid under the hard cap of bone at the shoulder where it acts to lubricate shoulder movement and to protect the tendons lying underneath. It can be involved in impingement syndrome and is a relatively common cause of lingering pain at the shoulder. It has a close relationship with the rotator cuff tendons and the shoulder joint itself and problems may coexist. Prolonged inflammation within the bursa can cause scarring between its layers and may lead to a frozen shoulder.

Patients usually complain of a dull ache in the deltoid muscle overlying the top of the arm and it may be painful to lie on that side at night. The condition produces a ‘muddle’ of signs, with several movements causing pain, and lifting the arm sideways away from the body to shoulder height may pinch the bursa causing pain.

Physiotherapy can help and the bursa can respond well to treatment with mobilisations and stretching techniques, with exercises and advice on posture to prevent the problem recurring. It can also be treated with an anti-inflammatory injection, usually steroid, after which patients should avoid the aggravating activity for up to two weeks to allow the bursitis to settle.

Subacromial bursa

The subacromial bursa sits like a flattened balloon containing fluid under the hard cap of bone (the acromion) at the shoulder, where it acts to lubricate shoulder movement and to protect the tendons lying underneath in the ‘subacromial’ space. A tendon attaches a muscle to a bone and there are four main tendons that sit under the bursa and can be involved in so called ‘impingement syndrome’. Together they form the ‘rotator cuff’ and help to stabilise the head or ‘ball’ of the humerus (the upper arm bone) against the smaller ‘socket’ (glenoid fossa or cavity) on the shoulder blade (scapula).

Subacromial impingement syndrome

The term ‘impingement’ is a sign and isn’t a diagnosis as such. Subacromial impingement syndrome can have several causes including a narrowing of the subacromial space, where the subacromial bursa and rotator cuff tendons sit in the ‘space’ under the acromion bone at the top of the shoulder, and inflammation associated with recent trauma or shoulder instability, especially in younger athletes.

In the under 35 year group, repeated movements in the overhead position can lead to the problems and there may also be tears in the cartilage, or labrum, that attaches to the socket side of the joint and makes the cup deeper for the ball – the head of the upper arm bone (humerus).

In the over 35s, the changes in the space tend to be more related to the aging process with some degeneration, that can eventually lead to rupture of the tendons in some cases. The pain will be felt on lifting the arm above the shoulder, as in putting plates into a cupboard or whilst putting on a coat, for example.

Impingement syndrome involves inflammation and swelling in the subacromial space that can develop into thickening and scarring, or fibrosis, of the tissues with tears in the rotator cuff tendons. Clinical tests can diagnose the condition which can be confirmed by ultrasound or MRI scanning techniques.

Physiotherapy can help by treating the individual tendons with a specific massage technique called ‘frictions’; mobilising and stretching the tissues at the shoulder, including tight muscles, and providing clear advice on exercises to improve strength, stability and shoulder and neck posture overall. Ice, electrotherapy or acupuncture can also be used to help with the pain. Education plays a key role in rehabilitation and preventing the condition from returning.

If the symptoms persist, an injection into the space can be helpful and a specialist referral may be the next step, especially if the shoulder becomes more weak than painful on certain movements, which could imply tendon rupture and the need for surgical repair.

Rotator cuff

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The rotator cuff is a group of four tendons that attach their shoulder muscles to the top of the bone in the upper arm and together help to stabilise the shoulder. They are: supraspinatus; infraspinatus; teres minor and subscapularis. The most commonly affected tendons are supraspinatus and infraspinatus but all the rotator cuff tendons may be involved in impingement syndrome.

Problems with the rotator cuff tendons may be due to injury or overuse and physiotherapy can usually help as outlined under the individual tendinopathy below.

Supraspinatus tendinopathy

The supraspinatus tendon sits at the top of the shoulder, just under the subacromial bursa, with which it blends, and is one of four tendons that together are known as the rotator cuff. Supraspinatus tendinopathy can be caused by overuse and it can be part of the impingement syndrome where the space may be narrowed underneath the bone at the cap of the shoulder (the acromion).

Pain will be felt particularly on lifting the arm out sideways from the body and the tendon will usually be pinched and painful at shoulder level.

Physiotherapy can help with treatment including a specific massage technique to the painful area, called frictions, and mobilisations. Activities that aggravate the pain should be avoided initially but exercises will be given that improve the strength of the supraspinatus muscle and tendon and help to stabilise the shoulder. Electrotherapy may be used, particularly ultrasound. Advice will also given on posture to help to prevent recurrence. In cases that don’t respond to this conservative management, an injection may be given, usually into the subacromial bursa that blends with the tendon, rather than directly into the tendon itself. In the case of tendon rupture, where the arm will be functionally more weak than painful, a surgical opinion will be appropriate.

Infraspinatus tendinopathy

The infraspinatus tendon lies just behind and below the supraspinatus tendon in the subacromial space and is one of four tendons that together are known as the rotator cuff. The infraspinatus muscle sits in the lower part of the shoulder blade at the back of the shoulder and it turns the arm outwards, most obviously when the elbow is bent to 90°.

Infraspinatus tendinopathy is usually caused by overuse and the pain is felt at the back of the shoulder when performing the outward movement against some resistance and on lifting the arm up as in waving to someone, when a pinch of pain may be felt at shoulder height.

Physiotherapy can help with treatment including a specific massage technique to the painful area, called frictions, and mobilisations. Activities that aggravate the pain should be avoided initially but exercises will be given that improve the strength of the infraspinatus muscle and tendon and help to stabilise the shoulder. Electrotherapy may be used, particularly ultrasound. Advice will also given on posture to help to prevent recurrence. In cases that don’t respond to this conservative management, an injection may be given, usually into the subacromial bursa that blends with the tendon rather than directly into the tendon itself. In the case of tendon rupture, where the arm will be functionally more weak than painful, a surgical opinion will be appropriate.

Subscapularis tendinopathy

The subscapularis tendon sits at the front of the shoulder and is the largest of four tendons that together are known as the rotator cuff. Its role is to turn the arm inwards and behind the back and it is important when doing any lifting movements across your chest, as in putting on a scarf. It is essential for overhead sports, such as swimming, racquet sports and throwing.

The upper part of the tendon can be involved in impingement syndrome. Pain may be felt at shoulder height when lifting the arm away from the body with the palm facing upwards at the front of the shoulder or when turning the bent arm away from the body to its full extent. Movements involving lifting the arm up and across the body may also produce a nipping pain at shoulder height.

Physiotherapy can help with treatment including a specific massage technique to the painful area, called frictions, and mobilisations. Electrotherapy may be used, particularly ultrasound. Activities that aggravate the pain should be avoided initially but exercises will be given that improve the strength of the subscapularis muscle and tendon and help to stabilise the shoulder. Advice will also given on posture to help to prevent recurrence. In cases that don’t respond to this conservative management, an injection may be given, usually into the subacromial bursa that blends with the tendon rather than directly into the tendon itself.

Partial or complete tears of the subscapularis tendon are more rare than in the other rotator cuff tendons but when they do occur, weakness will be noticed when trying to lift the arm across the body or when pressing the arm into the ‘belly’ at waist height with the elbow bent. A surgical opinion will be appropriate if rupture is suspected.

Teres minor tendinopathy

The teres minor muscle and tendon sit below infraspinatus at the back of the shoulder and attaches to the top of the bone in the upper arm. The two muscles work together to turn the arm outwards. Teres minor tendinopathy is far more rare than tendinopathy affecting the other rotator cuff tendons and its treatment is given as for infraspinatus tendinopathy above.

Tendinopathy of the long head of biceps

The biceps muscle bends the elbow and brings the hand upwards. It has two tendons, the long head and the short head, and the long head passes upwards in a groove at the front of the shoulder into the subacromial space where it can be involved in impingement syndrome.

Pain will be felt at the front tip of the shoulder on bending the elbow upwards against resistance and a nipping pain may be felt when lifting the arm forwards at shoulder height.

Physiotherapy can help with treatment including a specific massage technique to the painful area, called frictions, and mobilisations. Electrotherapy may be used, particularly ultrasound. Activities that aggravate the pain should be avoided initially but exercises will be given that improve the strength of the biceps muscle and tendon. Advice will also given on posture to help to prevent recurrence. In cases that don’t respond to this conservative management, an injection may be given into the sheath that surrounds the tendon, rather than directly into the tendon itself.




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