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Balmoral Physio is now part of the Response Physio & Sports Therapy group

Our resident expert physio in Milton Keynes Matt Search features this week as we look at the 10 shoulder conditions we see the most in our network of clinics…take it away Matt!

The shoulder is the most versatile and dynamic joint in the body, providing great ranges of movement, which in turn, allows for a wide variety of tasks to be performed.

To allow for such a diverse range of movement the shoulder relies on a ball and socket joint which is much shallower than our other ball and socket joint, found in the hip. As a result, it relies much more heavily on passive (ligament) and dynamic (muscle) stability to help support the shoulder structures. These factors, therefore, predispose it to be more at risk of injury on repetitive movements, sustained use in poor positions and from traumatic injuries.

Read on below to find out which shoulder conditions we see the most in our clinics at Balmoral Physio.

1: Sub-Acromial Pain Syndrome

Previous known as an ‘impingement syndrome’, this is a condition that often encapsulates one or more potential issues with the tissues of the shoulder, although there may not be any structural damage. By definition, a syndrome is a collection of symptoms with no know structural diagnosis. In the case of an impingement syndrome in the shoulder, the structures between the top of the shoulder (the acromion) and the humeral head become pinched at a certain point of movement, usually at the horizontal (or 90 degrees).

Anyone of any age can acquire this complaint, but it is most common in the middle-aged population especially those who perform sedentary job roles that require a lot of computer use. The underlying causes for this can be many but typically involve factors such as sustained postures, repetitive motion in an awkward or poor position or sudden awkward or traumatic loads (such as suddenly reaching behind your seat when driving).

Physiotherapists treating this condition will often look to help facilitate improvements in postural variability and endurance and improve muscular strength through a progressive exercise programme (depending on the chronicity of the condition). Manual therapy such as soft tissue or joint mobilisation may help further to restore motion and reduce pain symptoms.

2: Rotator Cuff Tendinopathy (Supraspinatus)

The rotator cuff (RC) is a group of 4 important muscles that as the name suggests, support and stabilise the head of the arm and keep it in the middle of the socket like a cuff, as well as help deal with rotation of the shoulder joint. Although any of the four muscles – and more relevantly, their tendons – can become damaged, the most commonly affected is supraspinatus. This is primarily due to the location of the tendon that runs between the head of the arm and the acromion on the shoulder blade.

Commonly (though not always) in ‘impingement’ syndromes it is often this supraspinatus tendon that becomes pinched, which in turn leads to it becoming thickened and inflamed. As with the first condition, rotator cuff tendons most commonly occur in people in their middle age (interestingly, part of the reason for this is that often the tendon structure tends to thicken and stiffen slightly in the people over 40). Another common group to develop these conditions are people who repeated strain their arms (i.e. people attending the gym) and again high strain on top of poorly positioned shoulders is often the underlying cause.

It typically demonstrates, what is known as an arc of pain on movement, which is where there is pan on lifting the arm from 70 to 120 degrees and then eases off again toward the top of the movement. A physiotherapist will often find the focal pain source if feeling around the front of the shoulder with the arm rotated behind the back.

To treat this condition rest from the irritable activity/positions is important to reduce the irritation and settle the swelling. Shoulder repositioning education and muscle rebalancing is often a suitable treatment plan in helping to settle these conditions.

Should this condition be worse or not improve with the normal physiotherapy programme, then an injection maybe a suitable next step to help reduce the chronic swelling in the joint. It is important to note that in the absence of any structural changes in the tissues of the rotator cuff despite evidence of it being affected, the term used to describe the symptoms would be Rotator Cuff Related Pain Syndrome

3: Sub-acromial Bursitis

This is a condition where the shock absorbing fat pad between the head of the humerus and the acromion becomes pinched and inflamed. Bursa are small sacs of fluid that help to reduce friction between different structures, and it is important to note that these are commonly irritated in our daily routines with no pain experienced – a little bit like when your palm develops callouses after gripping or carrying something.

Again, this is commonly induced through persistent poor shoulder positions and activities such as using a mouse at work or changing gears in the car. It is very similar symptom-wise to a rotator cuff tendinopathy but specific clinical examination can help to identify whether this structure is causing the pain.

Conservative (i.e. physiotherapy) management for this type of problem again involves offloading and avoiding the irritable positions and activities. A physiotherapist may also perform some manual therapy to the tissues to help alleviate symptoms further. If the condition is more chronic and intense such that it will not settle with conservative treatment, then a local steroid injection is often very successful for such an injury.

4: Frozen Shoulder (Adhesive Capsulitis)

Often the term ‘frozen shoulder’ is a frequently claimed diagnosis when a patient describes limiting shoulder movement. It is a common diagnostic term to refer to restriction of range of the shoulder when there can actually be several different underlying causes for such a restriction, and only rarely is it a true frozen shoulder.

Frozen shoulder / adhesive capsulitis refers to a condition where the capsule around the shoulder joint inflames and thickens. Typically, it is more common for the non-dominant side to become affected, and it is not uncommon for the dominant side to be affected later in life. The cause for this is still unknown.

It typically goes through 3 phases each phase lasting from 3 to 6 months:

  • The inflaming phase – this is the painful phase where the joint starts to lose range and is notably painful on all movements in any direction. At this time there is an increase in capillary (blood vessel) growth. Also, the fold in the capsule (found under the armpit) starts to adhere and this section is necessary to ‘unfold’ on general arm movement but cannot.
  • The restricted phase – this second phase is where it loses some of its sensitivity, but the restriction persists.
  • The recovery phase – gradually, over the final months the shoulder started to regain its lost range.

It is important to optimise the recovery of this condition that a specialised programme of mobility and strengthening exercises of shoulder complex is performed on a daily basis. It is advised if you think that you have a frozen shoulder that you consult with your physiotherapist who can help to clarify the diagnosis and provide you with the correct rehabilitation programme to help with the recovery of this condition.

5: The ‘Unstable’ Shoulder

Although the shoulder is the most dynamic joint in the body for certain people the shoulder joint can be even more ‘loose’ than normal leading to feelings of apprehension or notable instability. Typically, this will have occurred from a previous trauma to the shoulder or that this person is generally more flexible or even hypermobile (often conditions where the normal structurally stable collage tissue in the ligament type tissues are more elastic than they should be).

These types of conditions are often identified in the 20’s or 30’s but if into sport as a child can often be picked up at this time. Often individuals suffering shoulder instability notice associated popping and clunking to the joint and will find their symptoms prevent them from performing tasks with their arm out to their side. Throwing or gymnastics are often the most provocative activity for an unstable shoulder.

Primary treatment for these types of conditions will often involve physiotherapy shoulder stabilisation exercises. Muscle balance and strengthening work is also a vital component to the rehabilitation as these tissues are not just movers in this case but have a more predominant role in helping to stabilise the shoulder than they normally would.

If rehabilitation is not able to help stabilise the shoulder enough further medical assessment is often required and if suitable tightening the shoulder capsule through minor surgery may be a suitable next step.

6: Shoulder Dislocations

Dislocations of the shoulder are an injury where the head of the upper arm bone comes out of the socket. This occurs either from a traumatic injury or if as mentioned above you have a certain amount of joint laxity that predisposes the shoulder to this type of complaint.

Symptoms of this type of injury usually include intense pains in the shoulder once dislocated, an inability to move the arm and a deformation of the shoulder – a bump in the front or back of the shoulder depending on the direction of the dislocation (there are many different types depending on the direction of dislocation and any injury to the surrounding structures that might have occurred).

Treatment for this condition involves relocating the shoulder. This should be performed by a professional who can check your vascular and neurological integrity of the joint. Once it has been relocated pain medication and rest will help the recovery and over time, progressive rehabilitation to regain the shoulder strength and muscle balance then required and as it.

7: Muscle Strain

We consider this to be one of the most common injuries that everyone will experience at one time or another. Repetitive loading, particularly at high frequencies or during exertion, of the arm can strain one or several muscles around the shoulder becoming strained.

As it starts to heal the tissues need stretching and then later re-strengthening. If the soft tissues do not heal within 5-7 days, then it is recommended to see a physiotherapist who can help assess and provide the right treatment and rehabilitation to resolve the issue.

8. Fractures

Unless in extremely rare circumstances, all fractures are typically occurred from some traumatic injury. They are often obvious but require an x-ray to confirm, particularly if there was a closed fracture (where the bone parts stayed close together). Common fractures of the shoulder include the neck of the humerus and the collar bone (clavicle).

Timeframes for healing of a bony injury will often be between 8 to 12 weeks. The injured area is typically immobilised for the first 6 weeks with a gradual rehabilitation programme set out by a consultant’s and guided by a physiotherapist for the next 6 weeks.

9: Arthritis

Arthritis issues with the shoulder commonly affected in the older population (unless the person has a specific rheumatalogical complaint). often people who have injured the shoulder in the past will often find that the affected joint will become more arthritic compared to the non-injured side.

Athritis is where the joint changes shape over time, the cartilage thins and eventually the bon structure starts to change. These conditions cannot be reversed, but with regular exercise to maintain muscle strength and optimise joint mobility will help to keep the shoulder functional and to reduce symptoms.

If you feel that you have symptoms deriding from a potential worn joint, then contact your local physiotherapist to help you manage and optimise this condition.

10: Referred Pain

The last condition in this series is not directly a shoulder problem, but as it is very common, I felt that it was worth mentioning here, and that is referred pain. Often there are conditions that will mimic shoulder symptoms or refer pain into and through the shoulder but does not originate from this structure.

Most common symptoms often stem from the neck and are caused from sustained poor positions, for example prolonged slumped sitting whilst working in front of a computer. Clues that this may be a referral problem is that the symptoms spread and often radiate from the neck to the shoulder and travel don the arm. There may also be some nerve related symptoms such as pins and needles in the arm or hand.

If you suspect that you have symptoms stemming from a neck problem referring into the shoulder then contact your local physiotherapist who can assess your condition, offer suitable treatment and provide a suitable rehabilitation programme for you.

Thanks Matt!

We hope you have found this information regarding the 10 shoulder conditions we see the most very helpful. Share this with someone who you think needs to see this – we’ve helped you out by posting it on our Facebook and Instagram pages too. And do get in touch if you are struggling with your shoulder and let’s talk about how we can help!

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