Shoulder conditions and how they are treated

Read about specific shoulder conditions and how they are treated including impingement, rotator cuff injuries and shoulder instability. 

What is an unstable shoulder and how is it treated?

Put simply, an unstable shoulder is a condition which causes repeated dislocations or the feeling of apprehension and looseness to the shoulder socket when the arm is placed in certain positions. It is a common problem which may result from a specific injury to the shoulder, most often a shoulder dislocation, but also results from genetic hypermobility syndrome or developmental variations to the shoulder socket.

Often individuals suffering shoulder instability also notice associated popping and clunking to the joint and will find their symptoms prevent them from performing tasks with their arm out to their side. Throwing is often the most provocative symptom for shoulder instability.

Evidence suggests that over ninety per cent of individuals who dislocate their shoulder before the age of thirty suffer further dislocations. As such, if imaging after a shoulder dislocation demonstrates significant damage and the shoulder appears very unstable during clinical tests, surgery may be offered before trialling a course of physiotherapy exercises.

The most common form of shoulder stabilisation surgery involves tightening the torn shoulder soft tissue capsule at the front of the shoulder and anchoring it to the upper arm bone (humeral head). Depending on any associated damage, the surgeon may also repair any labral or rotator cuff tendon tears as part of the surgery. In cases of shoulder instability after a previous dislocation sometimes there has been a fracture to the front of the shoulder socket. 

Physiotherapy exercises for shoulder instability involve a progressive program of strengthening exercises to the serratus anterior, trapezius and rotator cuff muscles of the shoulder.

Rotator cuff tears

The rotator cuff is a group of four muscles which originate from the scapular and blend with the shoulder soft tissue capsule to wrap around the shoulder joint. With shoulder movements, the rotator cuff muscles contract to stabilise the upper arm in the shoulder socket and as their name suggests the rotator cuff muscles are also the prime movers of the shoulder in to rotational motions.

Unfortunately, with significant trauma or with repetitive microtrauma, the rotator cuff tendons can tear. Tears are particularly common in middle and older age individuals as the tendons weaken significantly with age. In younger individuals, rotator cuff tendon tears are normally seen in athletes involved in throwing or contact tackling sports but in older individuals the most common cause is a fall which jolts the shoulder.  

The symptoms of a rotator cuff tendon tear may be mild shoulder pain or be very severe shoulder pain and weakness. The severity of pain and weakness depends on the exact location of the tendon tear as well as the degree of the tendon tear. Rotator cuff tendon tears with significant symptoms in active individuals will often necessitate a surgical rotator cuff repair. Alternatively, physiotherapy may be the first line of treatment for individuals who do not require their shoulder for high level function or for individuals with mild symptoms.

Occasionally, a shoulder specialist may advise to undergo a shoulder injection to reduce pain and enable physiotherapy to commence to strengthen the injured tendon.

What is the best treatment for frozen shoulder?

Frozen shoulder is a condition which has three distinct stages. These stages are critical in determining the correct management for individuals suffering with frozen shoulder.

The first stage is characterised by significant pain and a gradual onset of stiffness to the shoulder movements as the soft tissue capsule of the shoulder becomes inflamed. During this phase treatment should focus on reducing pain with the use of medication or very gentle exercises. It is advisable not to exercise vigorously as this can increase the inflammation and prolong the condition.

For patients suffering with significant pain at night, or who are unable to work due to the condition, a shoulder specialist may advise an anti-inflammatory joint injection to reduce pain during this stage.

During the second stage of a frozen shoulder, the pain reduces but the shoulder joint remains very restricted due to the build-up of scar tissue in the joint capsule. During this phase, physiotherapy range of motion exercises can begin to help regain lost shoulder mobility. Often these exercises will focus initially on increasing flexibility of the shoulder in to rotation which is the most affected movement. This can be achieved by rotating away from a hand fixed on a doorframe or using a stick to guide the shoulder in to rotation.

Finally, the third stage will see a marked increase in the shoulder flexibility and further reductions in pain levels. As the shoulder range of motion increases, physiotherapy may be useful to get the last few degrees of normal motion back to the shoulder joint and may also be needed to strengthen the shoulder muscles, weakened after several months of altered use.

A small number of frozen shoulders do not begin to improve over time. In these cases, an operation known as a capsular release may be offered. This procedure involves two keyhole incisions, one at the front and one at the back of the shoulder. The scar tissue in the shoulder soft tissue capsule is heated with specialised lasers and in this way removed. Once this has been done the surgeon manipulates the shoulder while the patient is under anaesthetic to restore mobility to the shoulder.

Shoulder impingement

Shoulder impingement syndrome may be caused by a congestion in the su acromial space due to enlarged rotator cuff tendons, calcific deposits in the tendons or bursa or by bony spurs from the AC joint which lies above.

However, in the majority of cases there is no clear evidence of anatomical causes for the shoulder impingement symptoms. It is thought that in these cases the symptoms are caused by strength and flexibility problems which lead to increased strain on the rotator cuff tendons and/or compression of the bursa and tendons due to upward migration of the arm bone in the socket. Possible causes which individuals can address include:

  • Stiff middle back (thoracic spine) and stiff pectoral muscles: this limits the ability of the scapular to tilt backwards and rotate upwards to contribute to normal shoulder motion.
  • Stiff shoulder joint capsule: this can lead to the upper arm bone sitting upwards and forwards in the shoulder socket increasing the chances of it impinging the bursa and tendons against the bony arch and AC joint above the socket.
  • Weak rotator cuff muscles: these muscles work to centre the upper arm bone in the shoulder socket reducing any glide up which may lead to shoulder impingement.

Over a period of weeks and months these mechanical shoulder problems can usually be reduced with a programme of physiotherapy exercises and with treatment the majority of shoulder impingement symptoms do get better. For persistent rotator cuff problems, a consultant shoulder surgeon will be able to discuss other treatment options with you.

What is swimmer’s shoulder?

Swimmer’s shoulder describes the common problem of persistent shoulder pain which is thought to originate from the rotator cuff tendons and subacromial bursa. The problem is essentially subacromial impingement which is discussed above. However, the underlying biomechanical causes of swimmer’s shoulder may differ from that of normal subacromial impingement due to swimmer’s hypermobile spine and shoulder movements.

This hypermobility allows swimmers to perform the repetitive overhead shoulders movements without the need for large amounts of scapular rotation. Over time their movement pattern changes and may reduce the scapular movement even further leading to further work being needed at the actual shoulder joint and tendons of the rotator cuff resulting in fatigue of these structures.

What conditions may cause pain in the collar bone?

Unless pain has occurred after a serious injury, the actual collar bone (clavicle) will not be responsible for pain in this area. However, pain arising from the AC joint or SC joint can both refer pain to the collar bone.

In some circumstances, individuals may suffer with pain in this area due to a problem with their first rib. The first rib may be elevated which can cause an impingement between the first rib and the clavicle when fully elevating the shoulder which is sometimes referred to as costoclavicular syndrome.

A first rib problem may also cause a condition known as thoracic outlet syndrome. An elevated first rib or an extra first rib can ride up into the nerves as they pass through the thoracic outlet. This may cause pain in the area between the neck and the shoulder joint itself and may refer pain, pins and needles or tingling down the arm to the hand.

Other causes of thoracic outlet syndrome include tightness to the scalene muscles which run from the middle neck to attach on the first rib as well as tightness to the pec minor muscle which lies over the nerves before they enter the arm.

Treating a shoulder fracture

The treatment and recovery timeframe for treating shoulder fractures is highly dependent on the location and type of fracture sustained. The most common type of shoulder fractures involve either the upper arm bone (humerus) or the collar bone (clavicle). Less common fractures include an avulsion fracture of the insertion of the rotator cuff tendons or a fracture to the shoulder socket (glenoid).

Stable fractures of the humerus and clavicle are normally treated with immobilisation in a sling to let the fracture site heal. If initial healing has been confirmed on a check X-ray at six weeks, the shoulder can commence appropriately graded physiotherapy exercises.

Operative solutions for stabilising fractures of the clavicle include using screws and plates or threading wire around the fracture site. Upper humeral fractures can be stabilised with plates and nails and shoulder socket (glenoid) fractures can be treated with a wire mesh to fixate the fracture site while it heals. Following most operative stabilisations of the upper humerus and clavicle, gentle physiotherapy exercises will commence on day one or two after the surgery. Glenoid fractures will often require six weeks of stabilisation before physiotherapy commences.

The entire recovery timeframe may be as long as six to twelve months for an individual to regain the maximal range of motion and strength following a shoulder fracture. 

Shoulder pain diagnosis

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