Kelowna Manual Therapy Centre Blog

Many chronic shoulder injuries that people have suffered through for months and sometimes up to years can have other areas in the body that may be influencing these injured areas.

The shoulder in its own right is a very complex joint.

When simplified the shoulder is a ball and socket joint of which also consists of muscles, ligaments, tendons, and bones. Most shoulder pain originates from injury to the soft tissues of the shoulder, but in some cases, especially when you experience both neck and shoulder pain, cervical disk disease or a problem with the bones or nerves in your neck may be the source of your problem. In other cases poor biomechanics involving the scapula (shoulder blade) can put undue strain on the rotator cuff muscles, tendons and ligaments. Furthermore, the thoracic spine (middle back) and chest muscles can influence how a shoulder moves and more so can interfere with the healing process.

Exercises that focus on strengthening the scapula to provide a stable attachment site for the rotator cuff muscles will help reduce pain felt in the shoulder joint. As well as mobilizations of the cervical and thoracic vertebrae will also influence how the nerves and muscles that control the shoulder blade will interact with each other.

Many acute and chronic shoulder injuries would benefit from a thorough physiotherapy assessment of the shoulder but also the other joints that influence the shoulder.

Frozen shoulder (FS) is a common condition treated by physiotherapy.  There are three classic stages to the FS: a freezing stage, a frozen stage and a thawing phase.

The freezing stage is characterized by a gradual stiffening with a increase in pain.

The pain usually starts locally around the shoulder and is progressive in nature. Early on pain tends to be felt mostly at night or when the shoulder is moved close to the end of its range of motion. Common painful movements include doing up a bra, reaching into the back pocket, shampooing hair and pulling on a shirt overhead. The pain usually progresses to a constant intense pain at rest, which is aggravated by any movement of the shoulder.

A stiff shoulder with less pain characterizes the frozen stage.

The thawing phase is characterized by a gradual return of mobility and a further decrease in pain.

In the thawing phase, forward motion of the shoulder typically returns first. The mobility of the arm out to the side and behind the back will return later. To raise the arm, an individual will hike their shoulder blade to compensate for the lack of mobility.

The FS can last from 1-2 years. Most people will regain full use of their arm, although some individuals continue to experience a lack of mobility.

FS affects women more than men and is more common in the non-dominant shoulder.

Common risk factors for FS include:

• Trauma to the shoulder
• Diabetes
• Thyroid disease
• Increased cholesterol

Physiotherapy treatment should consist of manual physical therapy, exercises for mobility and modalities to decrease pain. The manual physical therapy is directed at the neck, upper back, shoulder blade and shoulder. The manual therapy can consist of joint manipulation, joint mobilization and soft tissue techniques. Exercises for range of motion help to improve mobility and are critical to maintain progress between visits.

It is worthwhile to try a course of physiotherapy to see if therapy can help speed up the recovery process. It is important that the therapy not increase the pain. It is okay to experience a temporary increase in pain during therapy but this should decrease to its usual level within 40 minutes.  Improvements in mobility should start to be experienced in 3-4 visits, though more physiotherapy will probably be required. If no gains in mobility are noticed in the initial visits, physiotherapy may not be help, but a home exercise program should be continued. If the pain persists or if the therapy exacerbates the pain a cortisone injection may be a good choice.

It is reported that 90% of shoulder dislocations are in an anterior (forward) direction. The other 10% are posterior (backward) dislocations. An anterior shoulder dislocation is one of the most common traumatic sports injuries and is caused by a force that pushes the ball forwards in the socket. The most common causes of dislocation is a fall onto the shoulder.

After a dislocation the sooner the shoulder is reduced or “put back in” the better.

Icing and rest are critical in the next 48 hours to minimize inflammation. Gradual mobilization and strengthening can be initiated once soreness allows.  If all goes well one can resume activity over the next 4-8 weeks. Some experts no longer advocate use of a sling although one can be used for short-term comfort. There is no reduced rate of dislocation with prolonged use of a sling and immobilization.

The bad news is that younger people who suffer a dislocation have a much higher rate of recurrence; some experts report an 80-90% rate of recurrence. Individuals aged 25 years and older will typically do well with a program of physiotherapy aimed at regaining proper shoulder mechanics and strength. Individuals aged 40 and older have a smaller dislocation rate of only 10-15% and should do also well with a physiotherapy program mentioned above. Unfortunately, older people who suffer a dislocation have a higher rate of concurrent rotator cuff tear.

A consequence of dislocation can be damage to the shoulders labrum. The labrum is like a rubber ‘O’ ring that works to deepen the socket. This type of labral tear is termed a Bankart lesion. Less common are bony fractures, ligament and muscles tears.

Symptoms of a Bankart Lesion can include:

• A sense of instability i.e. “don’t trust the shoulder”
• Further dislocations
• Catching, locking, grinding, popping sensations
• Aching of the shoulder especially at night
• Loss of strength and mobility

These complaints are common to many other types of shoulder pain but if they occur post dislocation then they require further investigation by your physician.