Physiotherapy – Shoulder

The rotator cuff is a group of four muscles that surround the shoulder joint. These muscles are responsible for stabilising and maximising movement efficiency within the shoulder joint. Sometimes one or several of these muscles can become injured either through an injury or through general wear and tear. In some instances the tendon, bursa or muscle is not damaged but is irritated due to being impinged or squashed between two bony structures. Interestingly, many of us will develop signs of rotator cuff degeneration as we grow older but show no symptoms. Those who develop symptoms may need further intervention either from a physiotherapist or a shoulder specialist.

Signs and symptoms

People who have rotator cuff injuries will often have pain around the shoulder joint, extending down the upper arm. They may also have a decreased range of movement especially in lifting the arm out to the side and forwards. Depending on the severity of the injury to the shoulder muscles, the patient may also have a reduction in strength. On having an ultrasound scan this may show signs of tendon injury or tear and/or bursa inflammation. In some cases an x-ray will show a bone spur with may have developed due to mechanical wear or compression.

How physiotherapy can help

If you have sustained a rotator cuff injury, it is essential you do the correct strengthening exercises to improve the strength of the affected muscles and just as importantly the muscles around the whole shoulder girdle. This can dramatically improve pain and function. Usually small tears respond very well with physiotherapy, however larger or more degenerative tears take longer to respond and may require surgical repair.

As part of your treatment process your physiotherapist may also use a combination of other modalities including joint mobilisations, massage, acupuncture, ultrasound and taping, as well as exercise rehabilitation. Your physiotherapist can also advise you on activities to avoid and appropriate pain relief options, should this be necessary.

Shoulder impingement describes pain caused by friction from two bony surfaces within the shoulder joint. The shoulder is a ball and socket joint made up of the humerus (ball) and the acetabulum (socket). At the side of the shoulder there is a bony arch called the acromium, this is part of the shoulder blade and forms a joint to the front with the collar bone (clavicle) called the acromioclavicular joint. In between the side of the humeral head and the acromium is a gap called the subacromial space. Within this space lies soft tissue that helps protect and move the joint.

This includes one of the rotator cuff muscles, Supraspinatus, which is responsible for maintaining shoulder joint stability, and the sub acromial bursa. This fluid filled sac (bursa) helps prevent friction occurring between the humeral head and the acromium. In a normal shoulder there is enough space for the arm to lift and allow for movements of the soft tissue within the sub acromial space without friction or pain.

The acromioclavicular joint between the acromium and the collar bone can also cause irritation often after a traumatic injury such as falling onto the side of the arm, or be due to repetitive movements of the shoulder.

Subacromial impingement is more common than acromioclavicular impingement and is often caused by age. As we get older, the supraspinatus tendon can start to deteriorate causing fraying. This can be caused by overuse or natural “wear and tear”.  Other causes include inflammation of the bursa (bursitis), calcification of the shoulder joint or bony spurs appearing at the ends of the bone due to osteoarthritis.

Signs and symptoms

Often movements with the elbow by your side such as using a keyboard are painless. However when lifting the arm above shoulder height, it is common to feel pain at the front and to the side of the shoulder. These movements include brushing your hair, putting on a shirt, etc. The pain can be felt down the arm into the bicep region. Sleeping at night can be uncomfortable, especially when lying on the painful side as this compresses the humeral head into the subacromial space. If this condition worsens then the shoulder can become weakened too. 

How physiotherapy can help

It is important that your therapist is able to diagnose the correct cause of the impingement. This may require imaging tests such as x-ray or MRI to determine the cause. A good physiotherapist will take a comprehensive approach to your treatment. This may include postural advice, muscle strength and stability, joint mobilisation, soft tissue massage, electrotherapy or acupuncture. 

There are surgical options to consider if symptoms persist. These include a keyhole procedure called a decompression in which the subacromial space is increased in size by removing some of the extra bone that has formed.

The medical name for this condition is adhesive capsulitis. It is caused by severe inflammation of the capsule (connective tissue) that surrounds the shoulder joint. When the shoulder is looked at through key-hole surgery we will often see a very red inflamed and tight joint capsule. It is more common in women than men. It occurs mostly in patients over 40 years of age and more frequently in those with diabetes. It can happen following a trauma or surgery, but this is often not the case appearing in those who have sustained no previous injuries.

Signs and symptoms

A frozen shoulder can often be painful at night, it is one of the few shoulder problems that can cause problems through the night. Patients often complain of an inability to sleep on their affected side due to pain.

When compared with rotator cuff (muscle) injuries or impingement, the patient will often have a global reduction in range of movement, especially turning the arm out to the side (abduction). There are no scans or x-rays to diagnose a frozen shoulder, just symptoms and movement tests. Patients will, however, often find the symptoms will follow a fairly distinctive pattern:

• The first stage, often called the ‘freezing’ stage the patient will have a painful shoulder with increasing stiffness. 
• The second ‘frozen’ stage will mean the patient’s shoulder will become very stiff, but not necessarily painful.
• The final ‘thawing’ stage is often characterised by an increase in shoulder movement.

Typical daily activities that become difficult for those suffering with a frozen shoulder are:

• Putting the affected hand behind your back for example, to fasten your bra, or to reach inside your back pocket.
• Sleeping on the affected side
• Stretching the arm out to the side, to do activites such as closing the car door.

How physiotherapy can help

Response to treatment can be slow. It is fairly well acknowledged that Physiotherapy can be the most helpful in the frozen and thawing stage, that is, once the initial pain has subsided. Treatment would usually include soft tissue massage, joint mobilisations and stretches, acupuncture, and electrotherapies. Once movement has begun to increase strengthening rehab plays a vital role in restoring loss shoulder power which is often becomes impaired during a frozen shoulder.

In most cases a frozen shoulder will eventually get better, but this may take up to two years to resolve. Some patients are happy to manage their symptoms with painkillers and activity modification. Other options that may aid in speeding up the recovery from this condition include:

• an injection usually by an orthopaedic surgeon, which can help with pain relief but won’t restore motion
• a manipulation of the shoulder joint under anaesthetic or capsular release, followed by physiotherapy.

These are options to consider if the movement impairment is significant or too painful to manage.