Shoulder pain are one of the more common reasons for physician visits for musculoskeletal symptoms. The shoulder is the most movable joint in the body. However, it is an unstable joint because of the range of motion allowed. This instability increases the likelihood of joint injury, often leading to a degenerative process in which tissues break down and no longer function well.
Shoulder pain may be localized or may be referred to areas around the shoulder or down the arm. Other regions within the body (such as gallbladder, liver, or heart disease, or disease of the cervical spine of the neck) also may generate pain that the brain may interpret as arising from the shoulder
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Frozen shoulder – (Adhesive capsulitis) is a shoulder condition marked by shoulder stiffness, pain, and reduced range of motion. You may stop moving your arm to prevent pain, but doing so can result in more shoulder stiffness. Typically, you’ll have a reduced range of motion during the early phase of this condition, but shoulder movement improves over time.
SLAP tear –A tear to a piece of cartilage that rings your shoulder socket, usually causes deep shoulder pain and reduced range of motion. Overhead movements, like throwing a baseball or lifting weights, are generally difficult and painful. As a result, you may notice a decline in your sports performance.
Subacromial bursitis – Can cause shoulder pain with overhead activities, like throwing a baseball.1 Even reaching backward with your arm to put on a coat can be difficult. Subacromial bursitis can occur when a bursa—a sac of lubricating liquid in your shoulder—becomes inflamed.
Arthritis – Is inflammation of one or more joints throughout your body, causing stiffness and pain. Range of motion movements are difficult if you have arthritis, such as reaching for a can of soup in a cabinet. Examples of shoulder arthritis include osteoarthritis and rheumatoid arthritis.
Rotator cuff tears –
That occur from overuse can result in arm weakness and pain in your upper arm. Pain may strike when you’re reaching overhead for an item high on a bedroom shelf, for example, or when you raise your arm to your side. Eventually, pain also occurs when at rest and during sleep.
Bursitis – Bursae are small, fluid-filled sacs that are located in joints throughout the body, including the shoulder. They act as cushions between bones and the overlying soft tissues, and help reduce friction between the gliding muscles and the bone.
Sometimes, excessive use of the shoulder leads to inflammation and swelling of the bursa between the rotator cuff and part of the shoulder blade known as the acromion. The result is a condition known as subacromial bursitis. Bursitis often occurs in association with rotator cuff tendinitis. The many tissues in the shoulder can become inflamed and painful. Many daily activities, such as combing your hair or getting dressed, may become difficult.
Tendinitis– A tendon is a cord that connects muscle to bone. Most tendinitis is a result of a wearing down of the tendon that occurs slowly over time, much like the wearing process on the sole of a shoe that eventually splits from overuse.
Generally, tendinitis is one of two types:
Acute. Excessive ball throwing or other overhead activities during work or sport can lead to acute tendinitis.
Chronic. Degenerative diseases like arthritis or repetitive wear and tear due to age, can lead to chronic tendinitis.
The most commonly affected tendons in the shoulder are the four rotator cuff tendons and one of the biceps tendons. The rotator cuff is made up of four small muscles and their tendons that cover the head of your upper arm bone and keep it in the shoulder socket. Your rotator cuff helps provide shoulder motion and stability.
Tendon Tears– Splitting and tearing of tendons may result from acute injury or degenerative changes in the tendons due to advancing age, long-term overuse and wear and tear, or a sudden injury. These tears may be partial or may completely split the tendon into two pieces. In most cases of complete tears, the tendon is pulled away from its attachment to the bone. Rotator cuff and biceps tendon injuries are among the most common of these injuries.
Impingement – Shoulder impingement occurs when the top of the shoulder blade (acromion) puts pressure on the underlying soft tissues when the arm is lifted away from the body. As the arm is lifted, the acromion rubs, or “impinges” on, the rotator cuff tendons and bursa. This can lead to bursitis and tendinitis, causing pain and limiting movement. Over time, severe impingement can even lead to a rotator cuff tear.
Instability –Shoulder instability occurs when the head of the upper arm bone is forced out of the shoulder socket. This can happen as a result of a sudden injury or from overuse.
Shoulder dislocations can be partial, with the ball of the upper arm coming just partially out of the socket. This is called a subluxation. A complete dislocation means the ball comes all the way out of the socket.
Once the ligaments, tendons, and muscles around the shoulder become loose or torn, dislocations can occur repeatedly. Recurring dislocations, which may be partial or complete, cause pain and unsteadiness when you raise your arm or move it away from your body. Repeated episodes of subluxations or dislocations lead to an increased risk of developing arthritis in the joint.
Fracture – Fractures are broken bones. Shoulder fractures commonly involve the clavicle (collarbone), humerus (upper arm bone), and scapula (shoulder blade).Shoulder fractures in older patients are often the result of a fall from standing height. In younger patients, shoulder fractures are often caused by a high energy injury, such as a motor vehicle accident or contact sports injury.
Diagnosis of Shoulder Pain
Following are some of the ways doctors diagnose shoulder problems:
Medical history and physical exam
Medical history (the patient tells the doctor about an injury). For shoulder problems the medical history includes the patient’s age, dominant hand, if injury affects normal work/activities as well as details on the actual shoulder problem including acute versus chronic and the presence of shoulder catching, instability, locking, pain, paresthesias (burning sensation), stiffness, swelling, and weakness.
Other salutary information includes OPQRST (onset, palliation/provocation, quality, radiation, severity, timing) and a history of issues that could lead to referred pain (pain felt at the shoulder but actually coming from another part of the body) including cervical spine disorders, heart attacks, peptic ulcer disease, and pneumonia.
Standardized questionnaires like the Penn Shoulder Score that assess shoulder pain and function can aid in eliciting the required history to make a diagnosis and monitor condition progression.
Physical examination of the shoulder to feel for injury and discover the limits of movement, location of pain, and extent of joint instability. The steps to elicit this information are inspection (looking), palpation (feeling), testing range of motion, and performing special maneuvers. Information collected on inspection are asymmetry, atrophy, ecchymosis, scars, swelling, and venous distention.
Palpation can help find pain and deformities, and should specifically include the anterior glenohumeral joint, acromioclavicular joint, biceps tendon, cervical spine, coracoid process, scapula, and sternoclavicular joint. Range of motion tests external and internal rotation, abduction and adduction, passive and active weakness, and true weakness versus weakness due to pain.
The Apley scratch test is the most useful: touch opposite scapular by reaching behind the head for adduction and external rotation and behind the back for abduction and internal rotation. Finally, there are more specific maneuvers that can home in on a diagnosis, however their accuracy is limited.
Diagnostic tests of Shoulder Pain
Tests to confirm the diagnosis of certain conditions. Some of these tests include:
Arthrogram—Diagnostic record that can be seen on an X-ray after injection of a contrast fluid into the shoulder joint to outline structures such as the rotator cuff. In disease or injury, this contrast fluid may either leak into an area where it does not belong, indicating a tear or opening, or be blocked from entering an area where there normally is an opening.
MRI (magnetic resonance imaging) – A non-invasive procedure in which a machine produces a series of cross-sectional images of the shoulder.
Other diagnostic tests, such as injection of an anesthetic into and around the shoulder joint.
Ultrasound– can show the state of the rotator cuff tendons. Intact tendons in the setting of severe restriction in movement suggests frozen shoulder.
Arthrogram – may be used with an MRI to provide further information about structures in the shoulder. A dye is injected into the shoulder and images are obtained. The dye creates a contrast on the image, making the specific location of adhesions and the reduced space typical of frozen shoulder more visible.
Treatment of Shoulder Pain
The aim of treatment for frozen shoulder is to alleviate pain and preserve mobility and flexibility in the shoulder. However, recovery may be slow, as symptoms tend to persist for several years.
Painkillers– relieve symptoms of pain. Nonsteroidal anti – inflammatory drugs (NSAIDs), such as ibuprofen, are over – the – counter (OTC, no prescription required) painkillers and may reduce inflammation of the shoulder in addition to alleviating mild pain. Acetaminophen is recommended for extended use. Prescription painkillers, such as codeine may also reduce pain. Not all painkillers are suitable for every patient; be sure to review options with your doctor.
Exercise – frequent, gentle exercise can prevent and even reverse stiffness in the shoulder.Alternating between hot and cold compression packs can help with frozen shoulder
Hot or cold compression packs – help to reduce pain and swelling. It is often helpful to alternate between the two.
Corticosteroid injections – a type of steroid hormone that reduces pain and swelling. Corticosteroids may be injected into the shoulder joint to alleviate pain, especially in the ‘painful stage’ of symptoms. However, repeated corticosteroid injections are discouraged as they could cause damage to the shoulder.
Transcutaneous electrical nerve stimulation (TENS)– numbs the nerve endings in the spinal cord that control pain and sends small pulses of electricity from the TENS machine to electrodes (small electric pads) that are applied to the skin on the affected shoulder.
A steroid injection– A steroid injection into, or near to, the shoulder joint brings good relief of symptoms for several weeks in some cases. Steroids reduce inflammation. It is not a cure, as symptoms tend to return gradually. However, many people welcome the relief that a steroid injection can bring.
Physical therapy (UK: physiotherapy) for Shoulder Pain
can teach you exercises to maintain as much mobility and flexibility as possible without straining the shoulder or causing too much pain.
Physiotherapy
Your physical therapist’s overall goal is to restore your movement, so you can perform your daily activities. Once the evaluation process has identified the stage of your condition, your physical therapist will create an individualized exercise program tailored to your specific needs. Exercise has been found to be most effective for those who are in stage 2 or higher. Your treatment may include:
Stages 1 and 2
Exercises and manual therapy – Your physical therapist will help you maintain as much range of motion as possible and will help reduce your pain. Your therapist may use a combination of range-of-motion exercises and manual therapy (hands-on) techniques to maintain shoulder movement.
Modalities – Your physical therapist may use heat and ice treatments (modalities) to help relax the muscles prior to other forms of treatment.
Home-exercise program – Your physical therapist will give you a gentle home-exercise program designed to help reduce your loss of motion. Your therapist will warn you that being overly aggressive with stretching in this stage may make your shoulder pain worse. Your physical therapist will match your treatment activities and intensity to your symptoms, and educate you on appropriate use of the affected arm. Your therapist will carefully monitor your progress to ensure a safe healing procedure is followed.
Pain medication – Sometimes, conservative care cannot reduce the pain of adhesive capsulitis. In that case, your physical therapist may refer you for an injection of a safe anti-inflammatory and pain-relieving medication. Research has shown that although these injections don’t provide longer-term benefits for a range of motion and don’t shorten the duration of the condition, they do offer short-term pain reduction.
Stage 3
The focus of treatment during phase 3 is on the return of motion. Treatment may include:
Stretching techniques – Your physical therapist may introduce more intense stretching techniques to encourage greater movement and flexibility.
Manual therapy – Your physical therapist may take your manual therapy to a higher level, encouraging the muscles and tissues to loosen up.
Strengthening exercises – You may begin strengthening exercises targeting the shoulder area as well as your core muscles. Your home-exercise program will change to include these exercises.
Stage 4
In the final stage, your physical therapist will focus on the return of “normal” shoulder body mechanics and your return to normal, every day, pain-free activities. Your treatment may include:
Stretching techniques – The stretching techniques in this stage will be similar to previous ones you’ve learned but will focus on the specific directions and positions that are limited for you.
Manual therapy – Your physical therapist may perform manual therapy techniques in very specific positions and ranges that are problematic for you. They will focus on eliminating the last of your limitations.
Strength training – Your physical therapist will prescribe specific strengthening exercises related to any weakness that you may have to help you perform your work or recreational tasks.
Return to work or sport – Your physical therapist will address movements and tasks that are required in your daily and recreational life.
Rehabilitation program
The exercises and other treatment methods are dependent on which phase of rehabilitation the patient is at. We recommend seeking professional advice before attempting any rehabilitation.
Phase 1 – Freezing
This phase is usually the most painful phase of treatment and movement becomes gradually more and more difficult. The aim of the following treatments and exercises is to help control pain and maintain movement in the shoulder joint.
NSAID’s (nonsteroidal anti-inflammatory drugs) e.g. Ibuprofen may help reduce inflammation and pain although will be of less value in later phases of treatment. Check with a doctor before taking medication and do not take ibuprofen if you have asthma.
Electrotherapy modalities such as ultrasound, TENS and laser treatment may all help reduce pain and inflammation.
Exercises should be done as long as they can be performed pain-free. Mobility exercises such as the pendulum and assisted shoulder exercises using a pole can help maintain shoulder mobility. See adhesive capsulitis exercises for more detailed information.
Shoulder stretching exercises for the muscles at the front and back of the shoulder can be done also to attempt to maintain as much movement as possible. Strengthening exercises are unlikely to be possible at this stage due to pain.
During the frozen phase of treatment is where there is the least movement in the shoulder, but on the plus side, pain tends to have reduced. This phase should be about trying to maintain strength and as much mobility as possible.
Mobility exercises such as pendulums and wand exercises should be continued. Stretching exercises for the chest muscles and muscles at the back of the shoulder should also be maintained.
Strengthening exercises can be performed to maintain muscle strength. Isometric or static contractions are exercises needing no joint movement and can be done without worrying about movement in the shoulder.Try to maintain good posture by working the upper back muscles. Poor posture could be a contributing factor in frozen shoulder helping to cause it or prevent healing.
A therapist may be able to help by performing some more advanced mobilizations on the shoulder to increase the range of movement at the shoulder joint. This is especially beneficial to patients who have very limited movement in the shoulder.
Phase 3 – Thawing
The final phase of treatment and rehab is where movement starts to return to the shoulder. This phase is all about getting the shoulder back to normal as quickly as possible by regaining full movement and strength. After a few months with little movement, the shoulder will be considerably weakened so strengthening exercises are important.
Mobility exercises and stretches can become more aggressive, but should still be within the boundaries of pain. Aim to restore full mobility in the shoulder joint.
Strengthening exercises can progress from isometric or static contractions to exercises using a resistance band, then eventually free weights or weight machines.
Work the affected shoulder first, do as many reps as you can and then do the same number on the unaffected shoulder. This will help avoid a muscle imbalance.
Include rotator cuff exercises in treatment as well as posture exercises and exercises for the deltoid and chest muscles too. The shoulder joint is a complicated joint and correct biomechanical function between the shoulder joint and shoulder blade is important as other shoulder injuries may follow if the joint is not fully rehabilitated.
Surgery of Shoulder Pain
Surgery for frozen shoulder is typically offered during “Stage 2: Frozen.” The goal of surgery is to stretch and release the stiffened joint capsule. The most common methods include manipulation under anesthesia and shoulder arthroscopy.
Manipulation under anesthesia –During this procedure, you are put to sleep. Your doctor will force your shoulder to move which causes the capsule and scar tissue to stretch or tear. This releases the tightening and increases the range of motion.
Shoulder arthroscopy – In this procedure, your doctor will cut through tight portions of the joint capsule. This is done using pencil-sized instruments inserted through small incisions around your shoulder.
Home Exercises of Shoulder Pain
Stiff or frozen shoulders are usually uncomfortable, even if the degree of stiffness is not great. That’s the bad news. The good news is that most stiff shoulders can be managed successfully by a simple exercise program conducted by the patient in the home.
Getting the shoulder moving
It is basically a question of gently and progressively getting the shoulder moving again. This program is the safest of all treatments for frozen shoulders. Although months of these specific exercises may be required, persistence almost always pays off. Even if arthritis is present, this program may help preserve and even improve the shoulder’s range and comfort. Before beginning these exercises you should consult with your physician.
There are two components to the home program for stiff shoulders. The first is a series of stretching exercises and the second relates to regular participation in a fitness program.
Your opposite arm is a great therapist for your stiff shoulder. Your “therapist arm” is always available to apply a gentle stretch in any direction of tightness. Each of these gentle stretches needs to be held up to a count of 100.
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