If you are having problems with your shoulder, the chances are it is having quite a negative impact on your ability to do the things that you need to do to live a normal life. The shoulder is a complex joint and you need to be sure you get the best available advice on what is causing your problem. Often overlooked is the link between neck and shoulder problems and if the route cause is your neck and only your shoulder gets examined, the problem will never get fixed.
Nicky Snazell Clinic has the expertise you need to diagnose and treat your shoulder problem, whether it’s local to the shoulder or has a neck overlay as well.
Pectoralis Major Inflammation
Biceps Long Head Tendinitis
Rotator Cuff Injury
The Interplay of Shoulder Muscles
The Sporty Shoulder
Impingement Syndrome of the Shoulder can be caused by Osteoarthritis
Rotator Cuff Tear – Have you had a fall lately?
Rotator Cuff Arthroscopic Surgery
Conservative Rehabilitation for Supraspinatus Tear
Adhesive Capsulitis ( Also known as Frozen Shoulder)
After an acute trauma, do you have severe pain with a ‘popping-out’ sensation in the shoulder?
If so, you may have a dislocated shoulder.
Shoulder dislocation is a very common traumatic injury that can occur across a wide range of sports. In 95% of cases it is an anterior (front) dislocation, where the head of the humerus (the upper arm bone) is forced forwards when the arm is turned outwards, and held out to the side (abducted). Posterior dislocation only accounts for 3% of cases.
With a bankart lesion, the shoulder joint is particularly prone to dislocations due to its high mobility, and lack of stability. Dislocation can cause a labral tear – the labrum is a cup-shaped ring of cartilage, deepening the glenoid fossa into which the arm bone sits. There can be a lot of damage to soft tissue after dislocation.
Provisional diagnosis is by your physio, GP, and X-ray, and follow up treatment should include a time for immediate rest with a sling, then progressive physiotherapy mobilisations. Also, try soft tissue treatment for bruising with electrotherapy modalities and massage.
PECTORALIS MAJOR INFLAMMATION
The pectoralis major muscle is a large, powerful muscle at the front of the chest. We need this muscle to rotate the arm inwards, to pull a horizontal arm across the body, to pull the arm from above the head down, and to pull the arm from the side upwards. The weakest spot is where it inserts into the humerus. In weight training, the bench press is the most common reason for injury.
Provisional diagnosis is by a physiotherapy assessment, and treatment can include: initially, ice, and relative rest of the muscle. See a sports therapist or physiotherapist for massage, ultrasound, laser, and a rehab prescribed programme.
Do you have pain at the front of your shoulder? Does it hurt to lift a straight arm out in front of you?
If so, you may have one of the following conditions:
BICEPS LONG HEAD TENDINITIS
The biceps muscle splits into two tendons at the shoulder. The long tendon runs over the top of the humerus (arm bone), and the head attaches to the top of the shoulder blade. A rupture of this tendon is rare in young athletes, but common in older ones. Inflammation of this tendon is a fairly com-mon complaint, especially with swimmers, rowers, throwers, golfers, and weight lifters.
Provisional diagnosis is by physiotherapy assessment and ultrasound scan, and if tendonitis is confirmed, the treatment of choice can include: initially, relative rest, massage, sports therapy, stretching and strengthening exercises, and a full rehabilitation programme. Electrotherapy – such as pulsed shortwave or MRT – can help reduce inflammation faster.
If the patient is older or a partial tear is also seen on the scan, an orthopaedic opinion may well be needed. If the tendon goes on to tear, the surgeon will need to be consulted in case a repair operation is needed. Furthermore, if pins and needles (or numbness and weakness) are present, a full assessment of the cervical and peripheral nerves is needed.
ROTATOR CUFF INJURY
Rotator cuff tendinitis describes the inflammatory response of one or more of the four rotator cuff tendons, due to impingement or overuse, and leading to more and more micro-trauma that can then lead to a tendon rupture.
The inflamed thickening of the tendons often causes the rotator cuff tendons to become trapped under the acromion – like a carpet stuck under a door – causing sub-acromial impingement. Failure to heal then leads to further damage, resulting in a tendinopathy. Early treatment of tendinitis, therefore, is necessary in order to prevent the development of more chronic and serious conditions.
Treatment can include: postural exercises to lessen the impingement and local electrotherapy, such as laser, ultrasound, deep oscillation, or MRT.
Do you have pain when lifting your arm sideways? Does it get worse against resistance?
If so, you may suffer from the following:
Contraction of the supraspinatus (SS) muscle leads to abduction (lifting up sideways) of the arm at the shoulder joint. It works so hard during the first 15 degrees of its arc, and beyond 15 degrees the deltoid muscle supports the abducting of the arm, helping out strongly. When you get inflammation of this tendon, it leads to supraspinatus tendinitis. You will get shoulder pain with movement from the inflammation, and pain at night, as well as weakness in the shoulder and arm. There is also the possibility of tenderness and swelling in the upper front part of the shoulder, and in some severe cases, a difficulty to raise the arm to shoulder level – a painful arc from 60 to 120 degrees.
I learnt some useful diagnostic shoulder tests from two hunky shoulder surgeons, Roger Hackney and Vinod Kathuria, and the tests have rather strange names: Neer’s impingement, Hawkins-Kennedy, and the Empty Can Test, the latter of which indicates a problem with SS.
TREATMENTS FOR ROTATOR CUFF TENDINITIS
NSAIDs (non-steroidal anti-inflammatory drugs) are often prescribed for the management of acute inflammation, providing you have a strong stomach. Ice packs, gels, and creams – either NSAID or herbal – can help reduce pain and inflammation and should be applied to the painful area for 15 minutes at a time, at regular intervals throughout the day. Electrotherapy – as in ultrasound, pulsed shortwave, deep oscillation, and laser – all help, as do gentle shoulder mobilisations, massage, and postural exercises. Sport specific rehab exercises guide you back to full fitness.
The provisional diagnosis is by physiotherapy assessment, and a diagnosis of the degree of damage is carried out via an ultrasound scan.
THE INTERPLAY OF SHOULDER MUSCLES
The supraspinatus is just one of four rotator cuff muscles, its partners in crime being infraspinatus, subscapularis, and teres minor. The infraspinatus is a thick triangular muscle, which occupies the chief part of the infraspinatous fossa (a sculptured dent in the back of the shoulder blade). As one of the four muscles of the rotator cuff, the main function of the infraspinatus is to externally rotate the humerus (back hand in tennis) and stabilise the shoulder joint.
The subscapularis is a large triangular muscle that fills the subscapular fossa (the front of the shoulder blade) and inserts into the lesser tubercle (bony knob) of the humerus, as well as the front of the capsule of the shoulder joint. The orthopaedic assessment will include specific tests to move the shoulder into specific positions in order to detect pain, indicating a tear. The name of these tests are the Gerber lift off, the bear hug, and the belly press! There is no singular imaging device or technique available for a satisfying and complete subscapularis examination, but the combination of MRI and ultrasound scans work well, ultimately seeing it in surgery.
The rotator cuff muscles are a group of muscles that work together to provide the glenohumeral (shoulder) joint with dynamic stability, helping to control the joint during rotation. The scapula (shoulder blade) plays an important role in shoulder impingement syndrome. It is a wide, flat bone lying on the posterior thoracic wall that provides an attachment for three different groups of muscles – and it looks like the Star Trek Enterprise.
The subscapularis, infraspinatus, teres minor, and supraspinatus intrinsic muscles attach to the surface of the scapula and rotate the glenohumeral joint, along with humeral abduction (sideways). The extrinsic muscles include the biceps, triceps, and deltoid muscles, and these attach to the nobbly bits of bone called the coracoid process, the supraglenoid tubercle of the scapula, the infraglenoid tubercle of the scapula, and the spine of the scapula. It’s as if these muscles all have their own coat hook, like in kid’s changing rooms, and these muscles are responsible for several actions of the shoulder joint.
THE SPORTY SHOULDER
The third group of muscles with funny names are mainly responsible for both the stabilisation and rotation of the shoulder blade. They are the trapezius, serratus anterior, levator scapulae, and rhomboid muscles, and they attach to the medial, superior (upper), and inferior (under) borders of the scapula. Each of these muscles has their own role in shoulder function, and must be in balance with each other in order to avoid shoulder problems, like the tension on kite strings. Abnormal scapular (shoulder blade) function is called scapular dyskinesis.
The arm bone must be slid down and turned to avoid jamming up; the shoulder blade, during a throwing or serving, has to elevate the acromion process (the spoon-shaped bit overhanging the humerus head). If the scapula fails to properly lift the acromion, impingement may occur during the cocking and acceleration phase of an overhead activity. I see this a lot with my patients and describe it like the rubber stopper wedged under my door, stopping it from closing.
The two muscles most commonly inhibited/being lazy during this first part of an overhead motion are the serratus anterior and the lower trapezius. These two muscles act as a force couple within the glenohumeral (shoulder) joint to properly elevate the acromion process. If a muscle imbalance exists, shoulder impingement may occur, and this can usually be diagnosed by history and physical exam. During a physical exam, I twist or elevate the patient’s arm to test for reproducible pain (using the Neer sign and Hawkins-Kennedy test). These tests help localise the problem to the rotator cuff, however, the Neer sign may also be seen with subacromial bursitis, which is when the bursal sac gets inflamed and swollen, like a wet, thickened carpet jamming in the door.
You can inject lidocaine and a corticosteroid into the bursa – I used to in hospital and I still do in my current clinic – and while it can be a quick fix, it is a very unpleasant injection to receive. If there is an immediate improved range of motion and a decrease in pain, this is considered a positive ‘impingement test’. It not only supports the diagnosis for impingement syndrome, but it is also therapeutic, and other treatments include electrotherapy, postural exercise, and dry needling.
Plain X-rays of the shoulder can be used to detect joint problems, including acromioclavicular arthritis, osteoarthritis, and calcification. However, ultrasonography, arthrography, and MRI must be used in order to detect any rotator cuff muscle pathology/problems. MRI is the best imaging test prior to arthroscopic surgery. Impingement syndrome is usually treated conservatively, but sometimes it is treated with arthroscopic surgery or open surgery. I have seen a lot of these operations, and they can be done with a local anaesthetic.
Non-surgical treatment includes rest from painful hobbies, as well as physical therapy and electrotherapy treatments to maintain a pain free range of movement, improving posture and gaining a gradual pain free strengthening of the shoulder muscles. As discussed before, in order to improve overall pain and function, treatment can also include: joint mobilisation, Acupuncture, soft tissue therapy, therapeutic taping, rotator cuff strengthening, and rehab education regarding the cause and mechanism of the condition. TENS, deep oscillations, NSAIDs, and ice packs may also be used for pain relief. If nothing is helping and you do not have a muscle tear, then injections of corticosteroid and local anaesthetic may be used for persistent impingement syndrome. The total number of injections is generally limited to three, due to possible side effects from the corticosteroid.
I have watched Mr Hackney do this operation on several occasions, and also, on occasion, Mr Kathuria as well. A number of surgical interventions are available – depending on the nature of the pathology and the age of the patient – and surgery may be done arthroscopically (through a scope) or as open surgery. The impinging structures in the subacromial space may be widened by resection of the distal clavicle (the collar bone) and the excision of osteophytes (bony spikes) on the under-surface of the acromioclavicular joint. Damaged rotator cuff muscles can be surgically repaired, and this may be the only way a shoulder can function again. My mother had this surgery, and while she had a lengthy recovery, she also had excellent results.
Muscles attach to bone by tendons, and the inflammation of these tendons is called shoulder tendinitis, a type of tendinopathy. Tendinitis (also tendonitis) means the inflammation of a tendon, and the term tendinitis should be reserved for tendon injuries that involve acute injuries with inflammation.
Chronic tendinitis, chronic tendinopathy, or chronic tendon injury all refer to damage to a tendon at a cellular level (the suffix ‘osis’ means chronic degeneration without inflammation). Damage is caused by microtears in the tendon, and an increase in tendon repair cells. This may lead to reduced tensile strength. I remember Mr Hackney correcting me about tennis elbow – he said it is degeneration, not inflammation. He was referring to degenerative changes in the collagenous matrix, hypercellularity, hypervascularity, and a lack of inflammatory cells. The term tendonITIS (inflamed) is different to tendinOSIS (meaning wear and tear).
Corticosteroids are drugs that reduce inflammation, and they are injected along with a small amount of a numbing (haha) drug called lidocaine. They can make a tendon very weak; I used to fear a ‘twang’ sound after my injection as if one of my guitar strings were going, so I never carried out more than two jabs in any one tendon. Research shows that tendons are weaker following corticosteroid injections and far more likely to rupture.
By definition, anything that ends in ‘itis’ means ‘inflammation of’. Tendinitis is still a very common diagnosis, though research increasingly documents what is thought to be tendinitis and usually turns out to be tendinosis. Prof Gunn would say that the tendons get damaged due to an increased pull from muscle contractures, and that these muscle contractures present due to supersensitive nerves innervating them.
Tendinitis of the rotator cuff usually occurs over time, and it can be the result of poor posture, keeping the shoulder in one position – such as when on the computer – and not moving it over a period of time. You could be sleeping on the shoulder every night or having your arm bent up over your head. Or you could be doing a lot of activities that require extending the arm over the head at 90 degrees and above. Rotator cuff tendinitis can be developed from cleaning windows, painting ceilings, and manual jobs, as well as playing sports that require extending the arm over the head. This is why the condition may also be referred to as swimmer’s, pitcher’s, or tennis shoulder.
Often, we don’t know why rotator cuff tendinitis occurs, but mostly, over time you are able to regain the full function of the shoulder without any pain. It can affect one or more muscles in the shoulder, and without treatment, it can become a chronic problem.
Diagnosis is by physiotherapy assessment, MRI, and ultrasound scan, and to reiterate, treatment can include: rest from painful activities, ice, sports therapy/physiotherapy, ultrasound, laser, massage, and progressive exercises for posture and muscle imbalance.
This is a form of tendinitis that is characterised by deposits of hydroxyap-atite (a crystalline calcium phosphate) in any tendon of the body, but most commonly in the tendons of the rotator cuff (shoulder), causing pain and inflammation. The condition is related to and may cause adhesive capsulitis (frozen shoulder), and three main theories have emerged in an attempt to explain the mechanisms involved in tendon calcification.
The first theory is the theory of reactive calcification and involves an active cellular process, usually followed by spontaneous resorption by phagocy-tosing multinucleated cells (cell eating), showing a typical osteoclast (bone cell munching) phenotype. The second theory suggests that calcium depos-its are formed by a process resembling endochondral ossification (making bone), and the mechanism involves regional hypoxia (low oxygen), which transforms tenocytes (tendon cells) into chondrocytes (cartilage cells). The third theory involves ectopic bone formation from metaplasia of mesen-chymal stem cells (cells not as yet assigned to be anything) – which are normally present in tendon tissue – into osteogenic (bone) cells.
As no single theory is satisfactory to explain all cases, calcific tendinopathy is currently believed to be multifactorial – G.O.K. (God only knows!). I’d like to add a quick mention here of extracorporeal (sound waves) shock-wave therapy, as after a four day conference in Nice I was sick of hearing about how amazing it was! I have to admit that the highlight was escap-ing for a trip to Monte Carlo. However, it is excellent for calcific tendinitis, though it is not useful in other types of tendinitis, as it is aggressive and will cause more inflammation.
IMPINGEMENT SYNDROME OF THE SHOULDER CAN BE CAUSED BY OSTEOARTHRITIS
The symptoms of impingement syndrome include pain, weakness, and a loss of movement at the affected shoulder. The pain is often worsened by shoulder overhead movement, and it may occur at night, especially if the patient is lying on the affected shoulder. The onset of the pain may be insidious if it is due to a gradual process such as an osteoarthritic spur, and other symptoms can include a grinding or popping sensation during movement of the shoulder. I often hear crunching in shoulders with OA wear and tear.
When the arm is raised, the subacromial space (the gap between the ante-rior edge of the acromion and the head of the humerus) narrows, through which the supraspinatus muscle tendon passes. Anything that causes fur-ther narrowing impinges the inflamed tendon, resulting in impingement syndrome. This can be caused by bony structures such as subacromial os-teoarthritic spurs (bony projections from the acromion, the spoon-shaped part of the shoulder blade where the humerus pushes up against), and also osteoarthritic spurs on the acromioclavicular joint. Thickening or calcifica-tion of the coracoacromial ligament will worsen the impingement.
It is useful to get an X-ray to see how arthritic the shoulder is.
ROTATOR CUFF TEAR – HAVE YOU HAD A FALL RECENTLY?
The pathology of tears is common between 40 and 70 years of age, though many patients that have full-thickness tears don’t have symptoms, account-ing for nearly 40% of rotator cuff injuries. In comparison, patients over the age of 60 with partial and full-thickness tears account for 60% of rotator cuff tears. The supraspinatus is the most commonly injured, and repeti-tive microtraumas, subacromial impingement, tendon degeneration, and hypo-vascularity (reduced circulation) can lead to a weak, torn muscle, unable to resist shearing forces. Surgery may be needed. My mother had two tendons sewn together last year following two falls. It was a long, slow recovery, but her arm is amazing now.
ROTATOR CUFF ARTHROSCOPIC SURGERY
The rotator cuff requires adequate time to heal by means of conservative (no surgery) treatment or surgical intervention. This slow rehab can last anything from four months to one year, depending on the treatment. Ini-tially, the aim of the treatment is to decrease pain and inflammation by reducing activity and resting the limb. Once the healing process has begun, the focus of physical therapy then changes to increasing pain free strength and range of motion, until full power and movement is attained. Pain re-lief is essential as it can be a very painful rehabilitation. Deep oscillations, TENS, massage, and electrotherapy are all useful.
CONSERVATIVE REHABILITATION FOR SUPRASPINATUS TEAR
If the tear of the supraspinatus muscle is small, healing without surgical intervention may take between four and nine months, and range of motion (ROM) and pain free exercises are important.
The cycle of rehab is as follows: regain ROM – regain strength – increase range – increase strength. The type of strengthening exercises used during rehab should progress initially from isometric (no movement, just resisted statically), followed by concentric (resistance through movement), and lastly, eccentric (working the muscle whilst it is lengthening). The exercises are integrated into the treatment to provide a return to full functional activities.
Initial Three Weeks: Patient typically in a sling, doing very little in the way of exercise:
- Isometric strengthening.
- Shoulder shrugs.
- Pendulum activities.
- Supine (lie on your back) exercises, consisting of abduction (lift out sideways) and external rotation to protect the injured tendon.
- Anti-gravity strengthening.
- Progress exercises to full range of movement (ROM) with resistance.
Do you have pain down your arm or in your shoulder? When you move your neck, does this pain change?
If so, you may have one of the following conditions: cervical radiculopathy or spondylosis and osteoarthritis (see neck section).
If you try to push yourself off your chair, does it hurt in your upper arm?
This can happen when you push something far too heavy and get arm pain in your upper arm. The elbow also gets tender and stiff.
The triceps muscles are located at the back of the upper arm, and they act to straighten the elbow and resist the bending of the elbow. Typical actions that can overload the triceps – and in severe cases rupture the tendon – include pushing an excessively heavy object or breaking a fall on your hands.
Treatment can include: RICE (rest, ice, compression, and elevation) for two days, ultrasound, laser, sports therapy, and physiotherapy rehab programmes.
ADHESIVE CAPSULITIS (ALSO KNOWN AS FROZEN SHOULDER)
This is a painful and disabling disorder of unclear cause in which the shoulder capsule – the connective tissue surrounding the shoulder joint – is inflamed and stiff, greatly restricting motion and causing chronic pain. Pain is unpleasant, constant, worse at night, and irritated by cold weather. Sudden movements or bumps can provoke even more pain and cramps. It is thought to be caused by injury or trauma to the area and may include an autoimmune and hormonal component.
Treatment may be painful and longwinded, and it can consist of: physical therapy, Gunn IMS with cervical (neck) treatment, shockwave, manipulation, medication, massage therapy, or surgery, as a last resort. A surgeon may also perform manipulation under anaesthesia, which breaks up the adhesions and scar tissue in the joint to help restore some range of motion. Pain and inflammation can be controlled with TENS, Acupuncture, a stiff drink, or analgesics and NSAIDs.
People who suffer from adhesive capsulitis usually experience severe pain and sleep loss for a long time due to pain that gets worse when lying still in restricted positions. It can also lead to depression, can add to problems in the neck and back, and can cause irritability and weight loss due to long-term lack of deep sleep. You may also have extreme difficulty concentrating, working, dressing, or doing housework.
It usually resolves over time even without surgery, and most people will regain about 90% of their shoulder motion. One sign of a frozen shoulder is that the joint becomes so tight and stiff that it is nearly impossible to raise the arm. The movement that is most severely inhibited is the external rotation of the shoulder, and the stiffness and pain can worsen at night, with the pain being dull or aching.
Your physical therapist, osteopath, or chiropractor may suspect a frozen shoulder if a physical examination reveals limited shoulder movement. Frozen shoulder can be diagnosed if limits to the active range of motion (the range of motion from the active use of muscles) are the same or almost the same as the limits to the passive range of motion (the range of motion from a person manipulating the arm and shoulder).
An arthrogram or an MRI scan may confirm the diagnosis, though in practice this is rarely required.
The normal course of a frozen shoulder without treatment has been described as having three stages:
- Stage One: The ‘freezing’ or painful stage. This may last from six weeks to nine months, with a slow onset of worsening pain as the shoulder gets stiffer.
- Stage Two: The ‘frozen’/sticky/adhesive stage. This is marked by a slow improvement in pain, but the stiffness remains. This lasts from four to nine months.
- Stage Three: The ‘thawing’ or recovery, when shoulder motion slowly returns towards normal and pain is not so much of a problem. This generally lasts from five to 26 months.
Adhesive capsulitis is primarily a clinical diagnosis, though imaging may be used to exclude other causes. Arthrography is usually regarded as the gold standard for imaging diagnosis, though ultrasound and MRI may help in diagnosis by assessing the thickening of the coracohumeral ligament. Another ultrasound finding can be that of ‘hypoechoic’ material (more blood vessels), surrounding the long head of the biceps tendon at the rotator end. In very painful cases, local injection can help.
Osteopaths, chiropractors, and physiotherapists may suggest treatments such as shockwave, massage therapy, daily extensive stretching, and Gunn IMS dry needling. If these treatments are unsuccessful, however, more invasive painful techniques will be needed. These could include: manipulation under general anaesthesia to break up the adhesions, distension arthrography, and surgery (athroscopy) to cut the adhesions (capsular release).