Shoulder disorders: physiotherapy can help

Shoulder disorders are commonly seen by physiotherapists. The shoulder complex is a complicated area. It consists of the:

• glenohumeraljoint• acromio-clavicularjoint• sterno-clavicularjoint• scapulothoracicarticulation.

Thereisminimalbonysupportwhichenablesalargerangeofmovementtooccurthroughtheupperlimb.Thisleadstoproblems as in essence, the shoulder complex is controlled by soft tissue.

Thegleno-humeraljointhasoftenbeendescribedas a watermelon on a saucer. This is not far from the truth. Therotatorcuffmusclesneedtoworkingoodsynchronisation, withsupportiveligamentsforeffectiveshoulderfunction.

Afullsubjectiveandobjectiveassessmentoftheshoulderandsurroundingareascanbealengthyprocessbutis essentialforgoodclinicaloutcomes. Therearethreemainsubdivisionsintowhichshoulder disorders nearly always fall:

1.impingement/rotatorcuffinjuries2. instability3.adhesivecapsulitis/capsularrestrictions.

Itisalsoimportanttoconsiderotherfactorswhenassessinga shoulder disorder. This includes:

• referredpain(fromthecervicalorthoracicspine)• sportingtechniqueincludingequipmentchanges/ modifications,eg.tennisracquetchange• biomechanicalandposturalissues.

Ifthesefactorsarenotaddressedtheywillaffectthehealingprocess and the patient’s outcome.

Athoroughsubjectiveandobjectiveassessmentisimportant. Experienceinorthopaedicshouldertestsisvital.Shoulderrange ofmovement,scapulathoracicrhythm,strength,impingementand stability tests should be an essential part of your assessmenttoassistdiagnosis.Ifnecessary,imagingwillalsoassistdiagnosis.Researchshowsthemajority ofshoulderproblemswillsettlewithexercise,modifiedrestandre-education.Althoughosteoarthritisisuncommoninthegleno-humeraljoint,subtlechangesinthebonemaybepresentthatcanpredisposetospecificconditionsdeveloping. Acromial spurs are an example of this.

Earlydiagnosisandphysiotherapytreatmentwillproducequickerimprovementsandbetteroutcomesinthemajorityofclients.Diagnosisandtreatmentmustbetailoredtotheindividualclient.

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Medical management• Non-steroidalanti-inflammatorydrugsareoften beneficialintheacutestageandshortperiodsofrest canhavesomevalue• Cortico-steroidinjectionsintotheshoulderjointor surroundingareascanbeverybeneficialtoreducepain, inflammationandallowrehabilitationtoprogress• Surgerymaybeindicatedforfullthicknessrotatorcuff tears,impingementduetobonyspursandlabralrepairs in instability problems.

PhysiotherapyPhysiotherapyplaysalargeroleinshoulderdysfunction.Delaysinreferralcanmeanfurtherdamagetothejointsleadingtoincreasedriskofsurgeryandmoreinvasive treatments.Accurateandthoroughdiagnosisalongwithgoodexerciseprescriptionwillsettlethemajorityoftheseshoulder disorders, especially if seen early.

Therotatorcuffisanimportantgroupofmusclesforthe stability of the shoulder complex. They act to stabilise theheadofhumerousintheglenoidfossa.Forthisreasontheywilloftenformpartoftherehabilitationprogram. The physio will also look closely at scupulohumeral control whichisthequalityofthescapulamovementasthearm ismoved.Specificexerciseswillbeprovidedtooptimisethis control if necessary.

Maintaininggoodfunctionofthesurroundingjoints oftheshoulderwillassistrecovery.Mobilisationofthe lowercervicalandthoracicspinecaninsomecases, produceinstantimprovementsinshoulderrangeandpain.

Thisisbecausegoodfunctionandposturechanges inthespinewill‘de-load’theshoulderjointandtissues.

Gradual hydrotherapy and exercise rehabilitation can beusefultoimproverangeofmovementandstrength especiallyifaclientisfindinglandtreatmenttoopainful.

Physio In Practice

Theglenohumeraljoint—wheretheheadofthehumerus(upperarm bone)attachestotheshoulderblade—isclassifiedasaball-and-socketjoint.Howeveritismoreakintoagolfballsittingonateeasthesocketisquiteshallowanddoesnotactuallyencapsulatemuchoftheball.Thesternoclavicularjoint—wherethecollarboneattachestothesternum—istheonlyjointthatconnectstheentireupperlimbtothemainskeleton.Thisdesignallowstheshouldertobethemostmobilejointinthebody,butmakesitpronetoinjurydue to the lack of inherent stability and the reliance on muscles andligamentsforsupport.

SymptomsTraumaticshoulderdisordersresultingfromfallsorimpactrangeinseverityfrombruisesandminormuscleandtendonstrainstofracturesanddislocations.Theseverityandfrequencyofpainoftenrelatestotheseverityoftheinjury,soifthepainisconstantandsevere,itislikelyyourshoulderinjurywilltakelongertoheal.However,ifyourpainismildanddoesnotsignificantlyrestrictyourmovement,itislikelythatwithpropermanagement,yourshoulderwillreturntonormalquitequickly.

Non-traumaticandoveruseinjuriesoftheshoulderareverycommon. Heavyorrepetitivemovements,particularlyinawkwardpositions,greatlyincreasetheriskofshoulderinjury.Disuse,poorpostureandpreviousinjurycancausetightorweakmusclesaroundtheshoulderwhichcanleadtoinjury.

Intheearlystages,painmaybelimitedtospecificmovementsoronlyevidentafteradayofheavyorrepetitivework.Iftheconditionisallowedtoprogress,theinflamedstructuresintheshouldercancauseimpingementduringmovement,resultingingreaterpain anddecreasedrangeofmotion.Thelongerthisprocesscontinues,themoretheaffectedtendonscan‘wearout’andinlongstanding,untreated cases, this can potentially cause the tendon to rupture. Inmoreadvancednon-traumaticoroveruseshoulderconditions,symptomswillincludepainatrest,difficultywithmovementslikereachingaboveyourheadorbehindyourbackanddisturbedsleep.

Physio 4 You

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What can you do?Thebestinitialtreatmentis‘relativerest’fromactivitiesthatworsenthesymptoms.Thisdoesnotmeanrestingcompletely,rathermodifyingorlimitingaggravatingactivities.Somerelativerest examples include:

• placingyourcomputermouseasclosetoyourselfaspossible tolimitreaching• carryingitemsclosetoyourbodyanduseabackpack where possible• avoidingliftinganythingaboveyourhead• takingregularbreaksorfrequentlychangeyouractivity, ifyouareunabletomodifyaggravatingactivities• applyinganicepackaftertraumaticinjuriesorifyourshoulder painhasflaredup• applyingaheatpackwhenexperiencingshoulderstiffness.

What can physiotherapy do?A physiotherapist can determine whether the shoulder disorder isbeingcausedbymusculoskeletalfactorsorifthereareotherreasons for the pain. Your physiotherapist will then undertake athoroughassessmentincluding:

• postureanalysistoassesswhetheryournormalsitting orstandingpositionisstressingyourshoulder• examinationofyourshoulderrangeofmovementandbiomechanics• jointandmuscletestingtomeasurepain,restriction, weaknessandtightness• assessmentofotherareasofthebodytodetermineother factorsthatmaybecausingpain• organisingimagingsuchasx-ray,ultrasoundorMRIscans.

Atailoredtreatmentplanwillthenbedesignedtosuityourwork and recreational lifestyle. This will typically include a combination of:

• massagetostretchtightmuscles• jointmobilisationstoregainlostrangeofmotion• strengthwork• stretches• posturalcorrection• taping.

Shoulderdisorders