Physiotherapists understand the shoulder and more importantly - how to get it better! The shoulder can hurt for many reasons.
Common diagnosis include:
- rotator cuff tear
- Bursitis tendonitis
- Frozen Shoulder
It can be possible to separate these conditions and use special tests to determine which pathology is likely. However, while some tests are useful we tend to go of how the pain behaves, whether there is weakness and how much the pain is an obstruction to daily living. Cuff tears are tears of the tendon and can range from small to large complex tears. A tear in the tendon refers to a region of disruption in the continuity of the tendon. Tears can be full or partial thickness (half or fully through the tendon) and may be partial or complete. Bursitis relates to the swelling of a sack of fluid just above the humeral head. Impingement relates to the compression and loading of an irritated tendon as the arm moves to the side and makes contact with the acromion. More recently, we have tended to refer to the continuum of shoulder pain as Subacromial Pain Syndrome (SAPS) because its not always possible to isolate to one structure.
Lots of people can have tears and it may not be an issue, where others can have a small tear and be in agony. It really depends on the sensitivity of the nervous system. However, making a distinction between 'cuff tears', 'bursitis', 'tendonitis' and an 'impingement' is difficult. Even if there is weakness unless the arm is profoundly weak it can be difficult. In cases of ‘impingement’ the tendon or structures around the tendon are thought to be ‘sensitised’ (bursa, ligament, bone) with movement of these structures causing pain on reaching a certain point of load or when the tendon/strutures are compressed. We tend to call 'tendonitis' - Tendinopathy because it is preferred in current day thinking as tendon pain may not be soley becaue of inflamation and thus the latin word for suffering (opathy) is more appropriate.
Significant pain can be caused by calcium deposits in the tendon. These tend to cause diffuse pain and leave a patient unsure where to put their arm. At Core Body Clinic we can use Ultrasound scanning to differentially diagnose the problem. Combined with a good history and examination this can be the best route to diagnosis.
There is growing evidence that tendons becomes de-conditioned and are therefore intolerant to loading. Small and repeated loading may injure the tendon causing movements to becomes painful, the arm gets less use, become less conditioned and less able to cope with load. Tendons are constructed from tenocytes and with de-conditioning and pain there may be reduction in continuity of the cells.
Whatever happens, our bodies try and find a way around the pain. Movement becomes stressed, compensated and we develop odd habits with altered movement and muscle pattern imbalances.
Symptoms are wide and varied. They tend to be easily differentiated from pain that is referred from the neck or from another somatic structure in the body.
- Pain when moving arm – typically some limitation, usually pain when in a certain combination of movements ie: reaching to side, hand behind back, hand over head.
- Sometimes pain at rest which is associated with positioning of the shoulder and load on the tendon.
- Rolling onto the shoulder at night – causes waking.
- Sharp sudden pain with movements – may cause throbbing after for few mintues
- May behave totally random and cause pain at inconsistent times (ie pain on one movement and then not when performing same movement).
First line is pain relief! How we do this is dependent on how the patient presents. Shoulder mobilisation and/or joint manipulation directed at the thoracic spine and neck can have a profound effect on pain enabling movement of the shoulder. Soft tissue massage and trigger point release reduce spasm and therefore correct moveemnt pattern and acquired muscle imbalance.
Simple contractions of the muscle when not in a loaded state can also help with pain - isometric contractions.
Kinesio or sport Tape to keep the shoulder moving in the correct plain is highly effective in correcting movement by facilitating the activation of approrpiate muscles and providing a continuous reminder for movement re-education.
Acupuncture can be very useful when used alongside corrective tendon exercises. If functions to reduce pain by releasing endorphins, and may also have an effect on tissue healing.
Remember, it is painful to move so there will be a change in movement habits and therefore compensated movements and muscle spasm. If we can resolve these issues we can get the shoulder moving correctly. The best way to rehabilitate a sensitive and dysfunctional tendon is to load it with exercise. We know this works well because the tendons are composed of ‘tenocytes’, to get the tenocytes back to a state where they not sensitive and able to tolerate loading without pain is to exercise them. Tendons get stronger through loading and through a mechanism called #Mechano-Transduction. It is essentially graduated movement and loading. Loading eventually needs to be HEAVY! This is the best way to get the tendon back to normal so dont be too surprised if you are asked to ramp up the weight.
Not all need surgery and most will recover with appropriate exercise, manual therapy or other modalities. It is always best to try physiotherapy as a first port of call. However, if we feel it is not going to help we wont waste time and promptly refer you on. If you have an operation you need excercise to recover. Where there is total loss of strength in a particular direction then an operation is often indicated. However, this is dependent on several factors and will depend on the individual case.
Exercise - Strength and Conditioning.
Trigger point release
Injection therapy (can be administered by a physiotherapist or Dr).
Medication (painkillers, can be obtained over the counter or from your GP).