Updated: Mar 17
The shoulder is a wonderful joint. A healthy normal range of movement of the shoulder girdle is exceptional. The articulation of the humerus (upper arm) in its socket or fossa, and that articulation with the clavicle (collar bone) and acromion process of the scapular (shoulder blade), enable the many movements of flexion, extension, abduction, adduction, circumduction, protraction and retraction, and internal and external rotation.
There are thus, many muscles involved in shoulder movement, that maintain its stability and integrity, all of which should work together (ideally in the correct firing pattern), to enable its efficient and smooth movement; more on this later. However, muscles alone cannot ensure the correct function of the shoulder. There are of course ligaments, tendons, bursae and articular capsules that need to work in harmony and smoothly to ensure such mobility while maintaining stability.
If the ball of the upper arm is not kept centred, and abnormal stress is placed on surrounding tissues (muscles, tendons, bursae and ligaments); this combined with age related degeneration and other health risk factors, can overtime leave the shoulder prone to a reduction in range of movement, pain and subsequent injury.
Common Causes of Shoulder Pain and Injury
There are many different causes of shoulder pain. Repetitive and/or forceful overhead sporting activities, such as swimming or throwing a baseball, may cause pinching of the rotator cuff or biceps tendons.
Of course, trauma such as falls or motor accidents can also injure the shoulder in a variety of ways and degrees. However there are a number of other causes of shoulder pain that should be considered. In approximately 2-5% of the general population, and significantly, between 30 and 50% of the population with diabetes who experience shoulder pain, will experience Frozen Shoulder. This will commonly be experienced as a gradual onset of significant pain and subsequent reduced range of movement; especially movement of the arm away from the body (laterally raising/abducting the arm) that appears to be completely unprovoked.
Occasionally, poor sitting posture may also place increased stress on the shoulder and cause pain. Posture at a desk with arms or specifically one dominant arm outstretched reaching for the mouse or keyboard, put strain a constant and repeated strain on the rotator cuff muscles, tendons and ligaments, as well as forcing an anterior head carriage in to the equation. All of this places unnecessary stress on the postural musculature of the neck, thoracic spine and shoulder, causing altered movement patterns and secondary injury to tissues-without even realising you are doing it!
Common shoulder problems include:
Biceps Tendonitis: The biceps tendon attaches your biceps muscle in your upper arm to the front of the shoulder. Many people consider the long head of the biceps tendon to act as a fifth rotator cuff tendon, offering stability to the front of the shoulder. This tendon can get pinched by the bony anatomy of the shoulder blade or by ligaments that attach to the collarbone and shoulder blade, causing tendonitis. Overloading the biceps by lifting something heavy may cause biceps tendonitis (also called shoulder tendonitis). Strengthening the biceps helps prevent injury.
Shoulder Bursitis: A bursa is a fluid-filled sac that helps body structures glide smoothly over one another. There is a bursa that lies between the humerus bone and the shoulder blade. This bursa can be pinched in the shoulder, leading to pain.
Rotator Cuff Tendonitis: The rotator cuff is a group of four muscles that help support and move the shoulder. Their primary role is to help hold the ball of the arm bone in the socket while the arm is moved. The rotator cuff tendons attach to the arm bone in an area that lies directly underneath a bony prominence of the shoulder blade. The tendons can get pinched underneath this bone and become inflamed and sore.
Strengthening the rotator cuff therefore is an excellent way to help prevent common rotator cuff injuries including tendonitis, rotator cuff tears, and shoulder impingement syndrome.
Age-related changes in rotator cuff tendons leave them less elastic and more susceptible to injury. There is also a gradual loss of muscle mass that occurs with ageing, which can be counteracted with strengthening exercises.
Frozen Shoulder: Frozen Shoulder typically goes through three stages
Stage 1: The painful / freezing stage: Gradual onset pain which increases in severity – often causing waking in the night and increasing difficulty with everyday activities due to reducing range of motion and pain.
Stage 2: The restricted / frozen stage: The pain levels off or gets slightly better but the shoulder continues to get more and more restricted.
Stage 3: The resolution / thawing stage: The pain gradually goes away and the movement comes back to normal.
The timespan to move through these stages is variable. One high-quality epidemiological study showed that the average length of time for a Frozen Shoulder (without any treatment) is 30 months.
DIAGNOSIS & TREATMENT OPTIONS
There are a number of different evidence-based diagnostic techniques and treatment options for the treatment of shoulder injuries. Here we will look at:
Rotator Cuff Tendinopathy and Frozen Shoulder.
The Rotator Cuff Muscles
If you have developed shoulder pain as a result of trauma like a fall or a car accident, you should seek medical attention immediately. Also, if your shoulder pain has lasted for more than two to three weeks and is accompanied by significant functional loss, a visit to a physiotherapist or sports therapist is recommended.
Your rotator cuff is the main stabiliser of the shoulder joint, and is actually the collective term of 4 separate muscles surrounding the shoulder joint. Each attaches to the tuberosities of the humerus (upper arm), whilst also fusing with the joint capsule (the surface of the socket covered in cartilage). The resting tone of these muscles act to compress the humeral (upper arm) head into the glenoid cavity (the socket).
The supraspinatus muscles are located at the top of the shoulder and (along with other muscles) abducts the shoulder - it raises the upper arm and moves it away from the body.
The subscapularis muscles are the largest of the rotator cuff muscles. They are triangular in shape and sit on the inside surface of the shoulder blades - they primarily internally (medially) rotate or inwardly twists the humerus (upper arm), as in the movement of if slamming a door shut. It also stabilises the shoulder girdle and assists in the downward motion of the arm from being high above the head.
The infraspinatus muscles sit on the back of the shoulder blades - they externally rotate the shoulder/bring your arm behind your back (fist outwards). Imagine the movement initiated at the start of throwing a ball, where the arm is drawn outwardly rotating and back.
Teres minor starts from the posterior- lateral border of the shoulder blades and attaches to the greater tubercle of the humerus (bony prominence of the upper arm). It is also responsible for externally rotating the arm (turning outwards such as throwing a ball).
Though each rotator cuff muscle has a primary function of movement at the shoulder, they all work together to stabilise the shoulder joint.
Strengthening all the muscles of the rotator cuff is important, but premature strengthening can delay healing and cause more pain. For specific advice regarding injury-appropriate rotator cuff strengthening, it is highly recommended that you consult the professional advice of an experienced musculoskeletal physiotherapist or Sports therapist.
Rotator Cuff Tendinopathy Treatment
The majority of people with shoulder pain have pain and weakness related to the rotator cuff. In fact, about 50% of shoulder patients have rotator cuff related shoulder pain. The vast majority of these respond very well to specific rehabilitation exercises. A very small proportion need to have more invasive treatment like corticosteroid injections or surgery.
It is very important that you try physical therapy exercises before considering surgery. The research in this area is very clear. Since 2005, five high quality research trials have shown that exercise is as effective as surgery for rotator cuff related shoulder pain. Furthermore, two excellent trials have shown that physical therapy exercise reduces the need for surgery by up to 80%.
PRICE - Protection, Rest, Ice, Compression, Elevation
If the onset of pain is due to an impact or trauma to the rotator cuff muscles, an initial short period of rest is recommended. This should last two to three days. During this period, you can apply ice to the shoulder to help control inflammation and provide symptomatic relief. Ice can be applied for 10 to 15 minutes every 2 waking hours.
You can also start gentle pendulum exercises during this time as in the illustration to the
right. By keeping the shoulder mobile, you can avoid a frozen shoulder (adhesive capsulitis), which is discussed further here.
After a few days of rest, shoulder exercises can be started to help improve the range of motion of the joint and improve the strength of the rotator cuff muscles
As stated earlier, the rotator cuff helps stabilise the ball in the socket when you lift your arm, so strength here is important. However, there is a general rule of thumb in the treatment and rehabilitation of injuries to the shoulder; and that is LENGTHEN BEFORE YOU STRENGTHEN, so some gentle stretching exercises should be performed to reduce tension in the muscles supporting the shoulder. These may be found in the article entitled Back and Neck Pain - Is your Poor Posture to Blame?
Similarly, before embarking on strengthening exercises, be sure that you have sought the advice as to which of the rotator cuffs are injured, and to what degree. It is then important to begin with ISOMETRIC STRENGTHENING EXERCISES, which require a contraction of the muscle/s involved WITHOUT any range of movement (a static hold.)
The following series of exercises are intended as a guide for the inital stages of rehab. Please consult your Sports therapist/Physiotherapist for progressions when appropriate.
Some Isometric exercises to help strengthen the rotator cuff muscles are below.
ISOMETRIC EXTERNAL ROTATION
Stand sideways against a wall with your upper arm close to your side and elbow at a right angle.
Push the elbow to the side against the wall. Hold for 8-10 seconds and relax for 4 secs. Repeat 8-10 times.
ISOMETRIC INTERNAL ROTATION
Stand in a doorway with you elbow close to your body and bent at a right angle. Place your hand against the wall.
Push your hand inwards against the wall. Hold for 8-10 secs and relax for 4 secs. Repeat 8 times.
Stand with your upper arm close to your side, elbow at a right angle and the back of your hand against a wall.
Push the back of your hand against the wall. Hold 8-10 secs and relax for 4 secs. Repeat 8-10 times.
ISOMETRIC SHOULDER EXTENSION
Stand facing away from wall as shown with elbow bent.
Place a pillow or towel between elbow and wall.
Push against wall.
Do not hold breath.
Maintain the contraction for few seconds and release.
Repeat for 8-10 times.
ISOMETRIC SHOULDER FLEXION
Stand facing a wall - the opposite of shoulder extension.
Keep your upper arm close to the side with elbow at a right angle.
Push your fist against the wall, holding the position for 8-10 seconds and relax for 4 secs. Repeat 8-10 times.
Isometric contractions and stretching should be performed daily, and a gradual increase in range of movement should be aimed for, by performing the pendulum exercise.
Active assisted range of motion.
As pain reduces, the aim is to start increasing the range of movement. This is done at first, in a passive or assisted manor.
You can use your unaffected arm to assist with the
following movement, or you might find a cane/broomstick/pulley system helpful to move the injured arm.
Holding a broom stick with both hands, use the injured limb to raise the broom stick away from body (towards your injured side) until you can no longer raise it, now use the non injured limb to help move through further range of motion but it is important to continue to try an use your injured limb
This exercise can be done either lying down (A) or sitting down (B). Clasp hands together and lift arms above head. Keep your elbows as straight as possible. Maintain the elevation for 10-20 seconds, then slowly lower your arms.
Slowly increase the elevation of your arms as the days progress, using pain as your guide.
Repeat 10-20 times per session.
Finally, as range of movement increases with reduced pain, some scapular setting exercises are advisable.
Active training of the scapula muscles.
Two exercises are shoulder shrugs and pinching your shoulder blades (scapular retraction)
Scapular Retraction: Pinch the back of the shoulder blades together using good posture.
Shoulder Shrugs: Pull shoulders up and back and hold.
Frozen Shoulder Diagnosis & Treatment
There are three criteria in the diagnosis of frozen shoulder:
A typical history of gradual onset pain and loss of movement in the shoulder – often with waking in the night due to pain.
A clinical examination demonstrating a true passive restriction in the movements of the shoulder.
Normal bony morphology i.e. an X-Ray that demonstrates that there is no other reason for the restriction.
What is the treatment for Frozen Shoulder?
There are a number of different evidence-based treatment options for the treatment of Frozen Shoulder: physiotherapy, image-guided corticosteroid injection, arthrographic hydrodistension and capsular release surgery. Different treatment approaches are suitable at different stages of the condition and for different people.
As with all soft tissue injury it is advisable to seek the advice of a physical therapist who will be able to more clearly identify the structures that are injured or require lengthening or strengthening. Visit our online booking system here