In physical therapy, shoulder problems are very commonly seen. The shoulder is a complex joint with high mobility, therefore is always at risk of injury. Various types of shoulder injuries can be common to certain age populations or occupation. Next to the low back, the shoulder is the next commonly assessed and treated body region. Below are descriptions of the most common shoulder disorders seen.
Anatomy
The shoulder girdle complex consists of three bones: The Clavicle (collar bone), the Scapula (shoulder blade), and the Humerus (upper arm bone). This complex is connected to the rest of the skeleton via the Sternum (breast bone) and the Rib Cage, through a series of several joints, or “articulations”. Shoulder joints are surrounded by soft tissue capsule and muscle. Ask someone to point to the shoulder joint, and chances are they will point at the Glenohumeral Joint (shoulder ball and socket), which provides a large proportion of the movement of the shoulder girdle.
Rotator Cuff Tendonopathy/Tendonitis
This refers to the primary muscle group that provides a majority of the shoulder’s stability. Causes of pain can be strain from overpowering muscle, tear (partial or complete), or Impingement. Impingement occurs when the tendons of the rotator cuff become irritated and inflamed as they pass through the Subacromial Space, the passage beneath the Acromion (bony hook extension of the scapula). Treatment involves R.I.C.E. (Rest, Ice, Compression, Elevation) in early phases, then remobilization to regain range of motion, then to guide healing with progressive loading exercises.
Dislocation and Separation
This refers to disruption of articulation, often following a significant trauma, where the capsule and ligaments are overstretched. The most common separation involves the Acromioclavicular Joint (between collarbone and Acromion). Depending on the severity of separation, these can often lead to a positional deformity, inflammation, and immobility. Treatment requires a period of immobilization and healing, then recovery of motion, muscle strengthening, with guidance and education on return to work, sport, activities of daily living.
Osteoarthritis
This is a degenerative disease process where the joint cartilage surface that lines the bone begins to wear, eventually exposing the bone surface under the cartilage. Exposed bone is painful. Inflammation is present. Imagine a smooth ice surface at the beginning of the first period of hockey. Wearing of the smooth surface of cartilage resembles the ice surface at the end of the first period. Continued wear leads to joint tightness, muscle stiffness and weakness, and added joint stress. Bone spurs form, increasing the risk of muscle damage. Treatment involves maximizing mechanical joint health by mobilizing the shoulder and progressing exercises to maintain range of motion and optimize strength.
Frozen Shoulder
An interesting condition, not very well understood. This occurs as the shoulder capsule begins to stiffen, shrink, or “freeze up” around the shoulder joint. This is clinically known as Adhesive Capsulitis. Although the exact cause is not known, in many cases this can be related to trauma, degeneration, and insulin dependent diabetes. There can be a two year recovery period as the natural course of healing follows a distinct three stage pattern: Freezing, Frozen, Thawing. Treatment requires progressive remobilization, at times moving on to manipulation, and in extreme cases, surgical release. Physical therapy can assist with pain control in the early stages, to enable an effective home management program, with eventual quicker recovery.
Once a shoulder problem is properly assessed by a physical therapist, typical treatment design involves 4-6 weeks of therapist hands on mechanical restoration of shoulder joint and muscles. Treatment planning also involves instruction of self-applied exercises, and use of other therapeutic modalities and interventions if necessary.
