The shoulder is a complex area of the body, comprising the glenohumeral joint (shoulder joint) which is formed by the head of the humerus and the glenoid socket of the scapula (shoulder blade). In order for it to move effectively, an extensive group of 'shoulder girdle' muscles work closely together to time the movement of both the scapula and the head of the humerus correctly and therefore produce 'normal' shoulder movement. The timing and co-ordination of this muscle firing is vital to ensure that movement patterns do not go wrong, however the balance frequently becomes upset, causing altered shoulder movement which leads to pain during activity and problems with function. The stability of the joint also relies upon the integrity of its ligaments, labrum (cartilage) and joint capsule in order to secure the ball in the socket whilst allowing normal movement to take place.
In addition, as some of the shoulder girdle muscles are also involved in movements of the neck, both these areas must always be considered together when unravelling the source of a shoulder problem, and treatment may therefore target both areas in order to be fully effective.
Rotator cuff problems
This section itself is a huge area to cover, as there are many causes and types of rotator cuff problems. The rotator cuff is a unit of 4 muscles which originate from both sides of the scapula, passing around the shoulder joint in narrow anatomical tunnels, attaching finally just below the head of the humerus.
The rotator cuff has a number of important roles – it helps to secure the head of the humerus in its socket, thereby acting as a shoulder joint stabiliser, it adjusts the position of the humerus within the socket during movement of the shoulder and, through accurate timing of its muscle firing, co-ordinates this with the timely movement of the scapula. As it has such a vital role in the movement and function of the shoulder complex as a whole, problems with this area can significantly affect function of the upper limb.
Rotator cuff tendinopathy / tendinitis
The rotator cuff tendons can become irritated ('rotator cuff tendinopathy / tendinitis') through repetitive and improper use of the muscles around the shoulder girdle, (including those of the neck), from prolonged periods of poor posture, and poor core stability of the scapula itself. Such problems may occur as a direct result of an injury to the shoulder, which causes changes to the pattern of muscle firing or, through habitual use of the shoulder girdle in the wrong way. Rotator cuff tendinopathies are common, and often develop gradually. They are prevalent in individuals who use their arms repeatedly at work or in sport, but can also affect people with desk-based jobs who develop poor postures and who may, for example, stretch one arm out for prolonged periods of the day using a mouse. Gym users who regularly lift free weights can also develop an irritation of the cuff tendons due to incorrect technique and use of heavy weights without the appropriate underlying muscle control.
Rotator cuff inflammation and poor shoulder stability may cause a 'painful arc' of movement when raising the arm above the head, which may produce a sharp pain in certain shoulder positions (impingement) and a dull aching from the front of the shoulder into the upper arm at rest.
Management of these injuries includes avoidance of repetitive or overhead shoulder movements (including the use of the mouse at the desk!), correction of rounded shoulder posture, a course of anti-inflammatories (if appropriate), and physiotherapy to retrain the normal muscle firing and control of the scapula through specific exercises and strengthening work. The rehabilitation of the cuff needs to be designed around the functional needs of the individual in terms of work, sport and recreation and therefore individually tailored rehabilitation programmes should be issued. Manual therapy treatment is often required in order to work directly into tight and overactive muscles which are contributing to the problem, including those around the neck. The use of sports taping to facilitate correct scapula positioning may also be required. In addition, acupuncture may be a useful technique to help manage the pain arising from this condition, and to address any overactive trigger points within the muscles of the shoulder girdle.
If managed correctly, this problem can be fully resolved with a return to full functional activities and sport. Chronic rotator cuff tendinopathies, in other words those that have been present for several months, may resolve more slowly and have other associated problems requiring management that have developed due to compensations during the prolonged pathology. It is therefore advised to address any rotator cuff problems as soon as they become apparent.
Rotator cuff tears
Rotator cuff tears may occur gradually over time, through repeated use or with age (degenerative), or from a single episode of injury, for example, when the shoulder is quickly pulled in one direction or when an individual falls directly onto their shoulder (traumatic). Individuals over the age of 45 are more likely than someone in their 20's to tear their rotator cuff when falling directly on their shoulder, due to the aging process of the tendons which makes them less resilient to trauma.
Rotator cuff tears may be minor, or can be 'full thickness' tears which require surgical intervention. Either way, tears to this group of muscles are significant in causing pain and loss of movement and function, and do require physiotherapy rehabilitation, whether this is solely conservative management, or post-surgical repair. The rehabilitation process depends upon the extent of the tear, loss of movement and strength, and any relevant post-surgical protocols. Physiotherapy should also work to address any muscular compensation, and focus on re-educating normal movement and control, with clear aims as to the level of activity to which the individual needs to return.
A bursa is a small fluid-filled cushion, found in numerous areas throughout the body, commonly lying between soft tissue and a bony prominence, or between two tendons that may friction one another as the body part moves. As such, they act as a buffer between one structure and another, reducing compression forces and friction. They may become inflamed if such pressures become too great, or occur too repetitively, developing what is termed a 'bursitis'. In the shoulder joint, there are around 8 bursae, and the ones which commonly become inflamed are the sub-acromial (beneath the acromion process on the outside tip of the shoulder) and the sub-coracoid bursae (beneath the coracoid process at the front of the shoulder), due to the level of activity and pressures from the soft tissues operating around these areas.
Individuals commonly report a sudden onset of pain when suffering from a bursitis. Indeed, it does seem as if the symptoms appear from nowhere. However, in reality, they are likely to have been building for some time before the pain is felt, given the way in which they become inflamed through repetitive use of the shoulder joint.
Pain may be felt sharply on certain movements of the shoulder joint (impingement), and individuals may also report a dull, deep aching from within the shoulder which may radiate into the upper arm.
Management of this problem usually initially involves resting the shoulder and avoiding any known aggravating factors, along with appropriate use of anti-inflammatories. Physiotherapists can provide advice and information regarding appropriate postures to adopt, habits to change and movement patterns to avoid, alongside retraining muscle activity and control around the shoulder joint in order to alleviate the pressures placed on the bursae. Hands-on physiotherapy treatment may also be advised, performing soft tissue techniques in order to work on tight, overactive muscles and trigger points.
Over time, chronic sub-acromial bursitis and associated scarring may require debridement surgically through a process known as a 'sub-acromial decompression'.
The term 'unstable' can be used when describing a shoulder joint that moves incorrectly, moves too much, or one that may be so unstable as to partially dislocate (sublux), or fully dislocate. Instability can also refer to the level of stability of the scapula (shoulder blade), which is controlled mainly by the muscles of the shoulder girdle and the rotator cuff. Scapular instability may in turn lead to secondary instability of the shoulder joint, given that the socket of the joint (glenoid) is formed by the scapula.
Therefore, when a shoulder joint is described as being 'unstable', it is largely an umbrella term, relating to any aspect of instability from any of the components of the shoulder complex. As such, all factors need to be considered when managing an 'unstable shoulder'. Physiotherapists are trained to look for these movement abnormalities and assess the competence of the shoulder girdle muscles, and this is vital if the instability is to be diagnosed and addressed appropriately.
As described earlier, the rotator cuff and shoulder girdle muscles are largely responsible for providing normal movement of the shoulder joint. When timing and activation of these muscle groups is poor or abnormal, the scapula moves incorrectly resulting in 'instability' of the whole shoulder girdle. This in turn can lead to pain locally around the scapula, and may begin to affect the shoulder joint itself, and the efforts of the rotator cuff muscles. The shoulder may also become painful due to irritation of the bursae, rotator cuff tendons, and/or ligaments associated with the joint, as a problem secondary to the instability. Secondary impingement, bursitis and rotator cuff tendinopathies, may therefore present as a result of a primary instability of the scapula.
Instability can also occur directly at the shoulder joint. This may be a congenitial problem, due to a biological laxity in the ligaments holding the head of the humerus in the socket. Individuals with this presentation, often display ligament laxity in other joints throughout their body, and their joints are deemed to be 'hypermobile'. Such shoulders can be prone to subluxing, or dislocating so the stabilising muscles of the shoulder girdle need to be optimised. This helps to stabilise the shoulder joint externally, when the internal ligaments alone are not supportive enough for the joint position to be maintained. Physiotherapy can help to train these muscles correctly, and long term programmes of specific rehabilitation for these types of shoulders are often needed. On occasion, despite physiotherapy rehabilitation, the shoulder joint simply cannot stabilise itself sufficiently to prevent recurrent dislocations from occurring. In such instances, referral to an Orthopaedic Consultant who specialises in shoulder problems may be required, and surgical intervention (a 'shoulder stabilisation') may be necessary.
Traumatic dislocation of the shoulder joint may occur as a direct result of an injury to the shoulder such as a fall, direct blow, or sudden wrench of the shoulder joint causing it to 'come out of joint'. These types of injury can happen to anyone of any age, although they are more prevalent in contact sports such as rugby and ice hockey, and extreme sports such as skiing, snowboarding and water skiing. Traumatic dislocations are initially managed with rest and temporary immobilisation in a sling, and later, a course of physiotherapy treatment to help restore normal movement and muscle stability around the shoulder girdle.
In many cases, physiotherapy intervention alone is successful in fully rehabilitating the shoulder joint following a traumatic dislocation. However, when the initial injury is sustained in their teens or twenties, younger patients may be more prone to recurrent dislocations, due to the laxity of the soft tissues around the joint at this age. When physiotherapy rehabilitation alone cannot stabilise a shoulder joint sufficiently, surgical stabilisation may be necessary.