SHOULDER PAIN

a. Rotator cuff

i Tendinopathy & Tears

Rotator Cuff Pathology

The shoulder joint is a fascinating, intricate joint that relies on the coordination of a huge number of muscles around the scapula (shoulder blade) and humerus (arm bone) to function normally. Unlike most joints of the body, the shoulder relies on active (muscular) structures for stability as opposed to bony congruency.

The 4 muscles primarily responsible for maintenance of shoulder stability are termed the rotator cuff:

  • Supraspinatus
  • Infraspinatus
  • Subscapularis
  • Teres Minor

Acute trauma or long-term overuse of the shoulder may lead to a variety of rotator cuff pathology including tears (partial or full thickness) and tendinopathy. Common signs and symptoms of rotator cuff pathology include:

  • Pain with overhead activity (elevation above 90 degrees) such as pressing, throwing or serving in tennis
  • Night pain
  • Pain and weakness with resisted external rotation, full/empty can testing

In my experience, many shoulder problems arise from people attempting to do too much, too soon especially in a gym environment. Key aggravating movements are often overhead press and bench press. Poor understanding of technique and appropriate load progressions are key factors that often need addressing to help people get on top of their shoulder pain.

Unfortunately, rotator cuff pathology can be quite slow to rehabilitate due to the complexity of the shoulder girdle. Sensible, monitored progression is extremely important to make this process as efficient as possible and prevent flare ups of similar pain in the future.


b. Impingement

b. External Impingement

i. Primary vs Secondary

External impingement may be caused by any one of many structures surrounding the shoulder creating an impingement of the glenohumeral joint. External impingement may be either primary or secondary. Primary impingement is characterised by abnormalities of the superior structures of the shoulder, leading to impingement of the subacromial space, often seen in older adults aged over 35 years. Secondary impingement is more common in younger individuals, where muscular imbalances, lack of control, and increases to training volume contribute to the development of the condition.

Presents like this to us: Pain at the front of the shoulder, reduced throwing performance in athletes, shoulder weakness, muscular imbalances/ dysfunctional control through range of motion, rotator cuff pathologies, noise on movement (click, catch, pop).

It feels like this at rest and with sport to you: Dependent on severity of the injury you may experience little to no pain at rest to moderate to severe pain with movement or loaded activities.

We look for this in the physical assessment: We look for reproduction of symptoms with special tests for impingement. Weakness in the shoulder musculature and poor control through range of motion may be present.

We initially manage these by implementing this: Initial management may include rest, ice and NSAIDs. Management consists of manual therapy, strength and control exercises, and restoration of the shoulder range of motion. Specific return to sport protocols will be implemented for overhead/ throwing individuals.

Longer term we look to do this to aid prevention and performance: Restoration of shoulder range, strength, neuromuscular control, endurance and power.

For a 100% return to sport clearance we need to see this: Pain free range of motion, strength equal to unaffected limb/ pre-injury level.

iii. Internal Impingement

Internal impingement is characterised by repetitive contact between the humeral head and the glenoid in overhead arm positions (end of range abduction/ external rotation) that leads to the impingement of rotator cuff tendons. This condition is often seen in throwing or overhead sports involving repetitive movements. Underlying biomechanical imbalances may increase the right of internal impingement, these include anterior glenohumeral instability, tight posterior glenohumeral capsule, muscular imbalance, and dysfunctional neuromuscular control of the shoulder.

Presents like this to us: Pain at the back of the shoulder, especially when the arm is position at 90 degrees of abduction and external rotation, reduced throwing performance in athletes, shoulder weakness, muscular imbalances/ dysfunctional control through range of motion, rotator cuff pathologies, noise on movement (click, catch, pop).

It feels like this at rest and with sport to you: Dependent on severity of the injury you may experience little to no pain at rest to moderate to severe pain with movement or loaded activities.

We look for this in the physical assessment: We look for reproduction of symptoms in overhead movements/ throwing activities. Weakness in the shoulder musculature and poor control through range of motion may be present.

We initially manage these by implementing this: Initial management may include rest, ice and NSAIDs. Management consists of manual therapy, strength and control exercises, and restoration of the shoulder range of motion. Specific return to sport protocols will be implemented for overhead/ throwing individuals.

Longer term we look to do this to aid prevention and performance: Restoration of shoulder range, strength, neuromuscular control, endurance and power.

For a 100% return to sport clearance we need to see this: Pain free range of motion, strength equal to unaffected limb/ pre-injury level.


c. Glenoid labrum injuries

The glenoid labrum is a fibrous tissue attached to the rim of the glenoid, acting to increase the stability of the glenoid.  The labrum also aids proprioception, muscular control and spreads load across the joint surface.   The shoulder capsule, glenohumeral ligaments and long head of bicep all attach to the glenoid labrum.  Labrum injuries are divided into SLAP (superior labrum anterior to posterior) and non-SLAP injuries, in addition to stable or unstable classification.

Presents like this to us: A history of catching a heavy object, or during throwing related activities. Pain with movement, on palpation of the shoulder, and on resisted bicep movements.  Over head or behind the back movements are aggravating, with catching, popping or grinding present.

It feels like this at rest and with sport to you: Dependent on severity of the injury you may experience little to no pain at rest to moderate to severe pain with movement or loaded activities.

We look for this in the physical assessment: We look for positive shoulder special tests to distinguish a SLAP lesion from other shoulder pathologies. Active movements behind the back, overhead, and resisted biceps are painful and aggravating.

We initially manage these by implementing this: The majority of SLAP lesions require orthopaedic review for surgical management in sportspeople.  In older patients (>50 years) where surgery may not be any more beneficial than conservative management, conservative treatment is recommended.   Individuals not requiring high level function of their shoulder in overhead positions are candidates for conservative management in stable injuries.  Management consists of manual therapy, exercises, NSAIDs, and restoration of shoulder range of motion.

Longer term we look to do this to aid prevention and performance: Restoration of shoulder range, strength, neuromuscular control, endurance and power.

For a 100% return to sport clearance we need to see this: Pain free range of motion, strength equal to unaffected limb/ pre-injury level.


d. Dislocation

Dislocation of the glenohumeral joint is a common traumatic injury resulting from the arm being forced into excessive abduction and external rotation. There may also be internal trauma affecting the glenoid labrum (Bankart lesion) or fracture (Hill-Sachs lesion).

Presents like this to us: Acute trauma, with a sudden onset of pain.  Injury maybe direct or indirect in nature.  Popping out sensation and associated audible noise at time of injury.

It feels like this at rest and with sport to you: Acute pain, limited range of motion and strength compared to the unaffected side.

We look for this in the physical assessment:  Loss of strength and range of motion.  Occasionally loss of sensation from axillary nerve damage.   Prominent head of humerus and gap below the acromion.

We initially manage these by implementing this: Reduction of the dislocation is recommended, with x-ray initially if available.  Orthopaedic management for Bankart lesions is required. Immobilisation in a sling, followed by progressive range of motion and then strengthening exercises follows as tolerated.

Longer term we look to do this to aid prevention and performance: Restoration of shoulder range, strength, neuromuscular control, endurance and power to reduce reoccurrence of dislocation.

For a 100% return to sport clearance we need to see this: Pain free range of motion, strength equal to unaffected limb/ pre-injury level.


e. Instability

Shoulder instability may be either atraumatic or post-traumatic. Post-traumatic instability is characterised by a specific event leading to the development of symptoms, often a forceful abduction and external rotation injury. Subluxation or dislocation of the shoulder may have occurred, and poor recovery following the event. An atraumatic instability is common in individuals with capsular laxity, seen in repetitive sports/ activities.

Presents like this to us: A history of recurring subluxations/ dislocations, shoulder pain, impingement, shoulder weakness, noise on movement (click, pop, catch).

It feels like this at rest and with sport to you: Dependent on severity of the injury you may experience little to no pain at rest to moderate to severe pain with movement or loaded activities.

We look for this in the physical assessment: We look for reproduction of symptoms in overhead movements/ throwing activities. Weakness in the shoulder musculature and poor control through range of motion may be present.

We initially manage these by implementing this: Initial management may include rest, ice amd NSAIDs. Management consists of manual therapy, strength and control exercises, and restoration of the shoulder range of motion. Specific return to sport protocols will be implemented for overhead/ throwing individuals.

Longer term we look to do this to aid prevention and performance: Restoration of shoulder range, strength, neuromuscular control, endurance and power.

For a 100% return to sport clearance we need to see this: Pain free range of motion, strength equal to unaffected limb/ pre-injury level.


f. Adhesive capsulitis

Adhesive capsulitis (frozen shoulder) is characterised by loss of shoulder range of motion, coupled with pain on movement and at night.  The cause of adhesive capsulitis is unknown; however, the condition commonly affects individuals aged 40-60 years, women more than men, diabetics, thyroid conditions, and may present in post-operative shoulders.

Presents like this to us: Depending on the stage of the condition (freezing, frozen or thawing). Freezing stage – pain with movement, at rest, at night (may last 3-12 months).   Frozen stage – progressive stiffness, pain at end of range (3 to 12 months).  Thawing – resolution of movement and symptoms (2 to 8 months).

It feels like this at rest and with sport to you: Depending on the stage of the condition (freezing, frozen or thawing). Freezing stage – pain with movement, at rest, at night (may last 3-12 months).   Frozen stage – progressive stiffness, pain at end of range (3 to 12 months).  Thawing – resolution of movement and symptoms (2 to 8 months).

We look for this in the physical assessment: Decreased shoulder range of motion, with active range equal to passive range.   Depending on stage – pain on movement/ end of range.

We initially manage these by implementing this: As the condition is self-limiting and often takes >1.5 years to resolve, education of the condition is important to set patient expectations of timeframes.  Manual therapy may help to assist symptoms, however evidence for hands on manual therapy is indicated in the thawing stage only.  Massage of surrounding shoulder musculature may assist in symptom management, however will not reduce shoulder capsule inflammation.  Maintenance exercises will be used to reduce the effects of the condition, however should only be completed within tolerance.   Orthopaedic intervention may be helpful in severe/ unresponsive instances.

Longer term we look to do this to aid prevention and performance: Restoration of shoulder range, strength, neuromuscular control, endurance and power.

For a 100% return to sport clearance we need to see this: Pain free range of motion, strength equal to unaffected limb/ pre-injury level.


g. AC Joint

Acute acromioclavicular (AC) joint injuries occur due to trauma, often a result from either a direct force onto the edge of the shoulder or from an indirect force to the AC joint (e.g. fall onto elbow driving the upper arm up and disrupting the AC joint.    The AC joint is stabilised by the acromioclavicular joint and coracoclavicular ligaments.

There are six grades of AC joint injuries used to classify severity:

  1. Sprain of AC ligaments
    1. No instability
  2. Rupture of AC ligaments and CC ligaments are intact.
    1. Clavicle is unstable to stress
  3. Complete rupture of both AC and CC ligaments
    1. Deformity present, clavicle presents elevated
  4. Distal clavicle is displaced into trapezius muscle
    1. Posterior deformity
  5. Rupture of AC and CC ligaments with disruption of deltoid and trapezius fascia
    1. Clavicle elevated, scapular displaced downward
  6. Inferior displacement of the distal clavicle
    1. Severe trauma, commonly accompanied by other injuries

A patient will typically present with a history of mechanism of injury, pain on palpation of the area and deformity depending on the grade of injury.

You can expect to have limited shoulder range of motion with increasing severity of injury.  A grade 1 injury commonly presents with pain with shoulder abduction, while grade 2 are commonly painful with all shoulder movements.  Grade 3 + demonstrate a notable step deformity, with the patient supporting the arm close to their body.

You can expect to feel immediate pain following injury, with symptoms increased with higher grades due to instability of the AC joint and shoulder.  Avoiding sleeping on the shoulder at night will occur, in addition to limiting use the hand and arm with activities of daily living. There may be some referred symptoms into the arm or neck related to trauma to surrounding shoulder musculature.

We initially manage an acute AC joint injury with rest, ice, compression and sling to immobilise the shoulder.  Taping can also be helpful to stabilise the joint.    A referral for imaging may be recommended depending on the severity of the injury.

Timeframes for return to activities is dependent on severity of injury.  Depending on the severity of the injury and requirements of the patient to return to high level overhead activities, orthopaedic review may be required.

Longer term we look to return to patients to full range of motion, strength and activity specific training as required.


h. SC Joint

Sternoclavicular joint pathologies are often the result of trauma to the shoulder resulting in disruption of the ligaments that support and maintain the joint.  Subluxation or dislocation of the joint may occur.


i. Clavicle fracture

Clavicle fracture commonly occur in the middle-third of the bone from direct or non-direct contact to the shoulder.  An acute clavicle fracture is usually very painful.

Presents like this to us: tenderness and swelling, bone deformity may be present.  Pain inhibition limiting shoulder and arm range of motion and strength on the affected side.

It feels like this at rest and with sport to you: acute pain, limiting movement to the affected side

We look for this in the physical assessment: Marked tenderness and swelling, possibly bony deformity.  Bruising around the clavicle and shoulder often suggests assoicated muscle strain or tear.

We initially manage these by implementing this: immobilisation in a sling for 4-6 weeks is recommended.  AAROM shoulder flexion exercises to a maximum of 90 degree may be completed to reduced glenohumeral stiffness.

Longer term we look to do this to aid prevention and performance: Restoration of shoulder range, strength, neuromuscular control, endurance and power.

For a 100% return to sport clearance we need to see this: Pain free range of motion, strength equal to unaffected limb/ pre-injury level.


j. Bicep

i. Tendinopathy & Tenosynovitis

The bicep, in particular the long head of biceps, is susceptible to overuse injuries.   The long head of bicep attaches to the top of the glenoid, passing through the bicipital groove.  Often injury occurs in periods of high training volume, coupled with dysfunctional training form in movements such as bench press or dips.

Tendinopathy is a general term used to describe tendon dysfunction, while tenosynovitis is the term used for inflammation around the sheath of the tendon.

Presents like this to us: tenderness on palpation of the long head of biceps tendon, pain with shoulder movements overhead or resisted elbow/ shoulder flexion.

It feels like this at rest and with sport to you: symptoms will vary depending on the degree of tendinopathy.  Commonly morning pain is reported, before symptoms reduce once warm to a degree, with aggravation following cooling down period.  In severe cases, the bicep may be easily aggravated.

We look for this in the physical assessment: tenderness on palpation of the long head of biceps tendon, pain with resisted shoulder/ elbow flexion, pain on passive stretch.

We initially manage these by implementing this: manual therapy, NSAID’s, ice, activity modification and isometric exercises

Longer term we look to do this to aid prevention and performance: Restoration of shoulder range, strength, neuromuscular control, endurance and power.

For a 100% return to sport clearance we need to see this: Pain free range of motion, strength equal to unaffected limb/ pre-injury level.

iii. Rupture & Pec Major tears

Rupture of tendons around the shoulder commonly include the long head of biceps or pectoralis major.   Rupture of the long head of biceps is more prominent in older individuals where the bicep has been placed under load.   This is often accompanied by a tearing sensation and acute sharp pain.  A clear deformity presents from a rupture, with the attachment bunching in the arm.  We look for pain on resisted elbow and shoulder flexion.   Orthopaedic review of surgery is indicated for individuals requiring power during sport.

Rupture of the pectoralis major usually occurs at the insertion in the humerus, and is commonly seen in weight lifting where the bench press is performed.  We look for pain on resisted tests, weakness, swelling, bruising and tenderness in the area.  Rupture of the tendon requires surgery, while partial tears may be conservatively managed for 4-6 weeks with strengthening and ice.


k. Nerve entrapments

Nerve entrapments to the suprascapular nerve, long thoracic nerve or axillary nerve may result in shoulder pain. The suprascapular nerve innervates the supraspinatus and infraspinatus rotator cuff muscles, and is the most common nerve entrapment of the shoulder.   Symptoms are often described as a deep pain that is poorly localised at the back/ side of the shoulder.    Symptoms may refer into the arm or neck, with associated shoulder weakness.   We look for wasting of the supraspinatus or infraspinatus muscles, with weakness on resisted tests into external rotation and abduction.  Often surgical decompression of the nerve entrapment is required.

Long thoracic nerve is characterised by paralysis of the serratus anterior and a resulting winging of the scapula.  Injury often occurs as a result of traction of the neck or shoulder, or trauma to the area.  Symptoms often present with pain and decreased shoulder elevation, and difficulty completing activities requiring scapular control.   We look for a marked winging scapula and associated poor control.    Initially we look to manage long thoracic nerve entrapment conservatively, however may require orthopaedic intervention if unsuccessful.


l. Thoracic outlet syndrome

Thoracic outlet syndrome is the compression of neurovascular structures through the thoracic outlet from the neck.  Commonly compression occurs between the clavicle and first rib, however may occur between the anterior and middle scalene, or the coracoid process and the pectoralis minor.  A history of overhead sport and activity is common.   Dysfunctional postural patterns of shoulder and scapular control can reduce the space for neurovascular structure from neck to shoulder and result in symptoms.    Patients will often report of pain in the neck or shoulder, with associated pin and needles or numbness referring into the forearm.  Weakness, fatigue or coolness in the arm of the affected side may be experienced.

We look for a reproduction of symptoms with special tests to identify structures involved. Pain and reduced range of motion of the neck may also be present.  Poor shoulder control or posture are often associated.   We look to manage this condition with correction of the compressive restriction.  Correction of posture. Shoulder and biomechanics is important.  Hands on manual therapy, education, exercise and activity modification are initially used.


m. Fractures

Fractures of the shoulder joint are less common than other shoulder conditions.  Fractures are classified on level of severity and complexity of disruption to the bone.   Commonly non-displaced fractures are conservatively managed in a sling or brace, with gradual introduction of range of motion and strengthening exercises as tolerated.   Displaced fractures will often require orthopaedic review and surgery, with rehabilitation following surgery.  We look for localised pain, weakness on resisted tests, and limited range of motion of the shoulder joint.