Anatomy of the shoulder
The shoulder joint is a ball and socket joint which consist of five joint if the whole shoulder girdle is taken into account. The main joint is the glenohumeral joint which is the ball and socket joint. The acromio-clavicular joint connects the collar bone to the shoulder blade and the sterno-clavicular joint connects the collar bone to the breast bone.
The shoulder joint is the most mobile joint in the body and due to the increase in range of movement it is also one of the least stable joints. As the shoulder joint is not very deep, a labrum can be found around the joint to increase the congruency of the joint similar to that in the hip.
As passive stability in the shoulder is limited due to the mobile nature of the joint, the dynamic stability proved by the muscles are of the utmost importance. The is where the all important rotator cuff performs its most important function: Keeping the joint in its socket thus preventing the shoulder from dislocating with movement.
The muscles of the rotator cuff are the supraspinatus (think of it as the top one), the subscapularis (the front one which also rotates internally), the teres minor and infraspinatus (the back ones which rotates the shoulder externally).
The rotator cuff muscles works in unison when the arm is lifted to stabilize the joint and this is known as concavity compression. In individuals with chronic shoulder pain these muscles can be dysfunctional and not work together which increases the pain.
What causes a shoulder muscle injury?
Overstretching a muscle is a very common cause for muscle pain, also known as myalgia. The overstretching of a muscle results in a strained muscle. A muscle strain can also be called a muscle tear or a pulled muscle. The muscle damage can vary from a Grade I strain (mild), Grade II strain (moderate) to a Grade III strain (severe and complete rupture). The muscle fiber damages results in muscle pain and or muscle soreness, with reduced muscle function. Decreased function includes muscle weakness, stiffness or tightness.
Rotator cuff tears can be caused by:
- Degenerative changes: Can be caused by auto-immune diseases (Rheumatoid arthritis), diabetes Melitus or smoking
- Over-use/repetitive strain injuries: Micro-trauma from repeated loading as found in cricket bowlers or tennis players
- Traumatic injuries: Falling on the arm, a unexpected traction force and shoulder dislocations/subluxations
- Non-traumatic injuries: Normal age related degeneration and weakening of the tissue.
Why do the shoulder muscles ache after an injury?
Fiber damage or tissue damage of the muscle occurs when the tissues tear. This can either be from the muscle or the tendon attaching the muscle to the bone. The tearing of the muscle fiber can also injure the blood vessels which causes bleeding in the area, or bruising, and pain caused by irritation of the nerve endings in the area.
Most muscle strains happen during high-speed and high load activities like sprinting or running. The most relevant muscle strains injuries can be in your hamstrings (hamstring strain), quadriceps (quadriceps strain), calf (calf muscle tear), and groin strain (adductor strain). These are the most common, but this can happen to almost all muscles.
Strain from sustained positions can also cause a muscle strain. Long periods of sitting in a posture can overstretch muscles in the back and neck which can then be strained. Back, shoulder and neck muscle strains are very commonly related to postural strain. Text neck has become a common condition due to postural fatigue while overusing your phone.
Muscle pain can also be caused from micro-tears in the muscles related to exercise. DOMS or delayed onset muscle soreness describes the pain or stiffness after vigorous exercise which can last anywhere from 24-72 hours depending on the amount of damage.
Symptoms of shoulder muscle pain
- Severe pain at time of injury (if traumatic)
- Progressive and unbearable pain (if non-traumatic)
- Pain at night especially if lying on shoulder
- Pain with reaching overhead (getting items out of cupboard)
- Painful arc of movement when taking arm from the side
- Weakness and disability of the shoulder
- Loss of movement and function of the shoulder
- Keeping your arm in the front and close to the body (sling position)
How do we diagnose a shoulder muscle injury?
How we test
Physiotherapists are able to test and determine if the cause of your pain is coming from the muscle, joint, ligament, or nerve. This will be the first step, before we start doing any other investigation.
Muscles are tested both in its ability to contract and stretch. This together with the current function and possible bruising gives the therapist an indication of the grade of the strain. A complete rupture doesn’t always result in you not being able to use that muscles as many muscles around it will compensate to assist this injured or torn muscle.
X-rays
In some cases we may refer you for an X-ray to exclude any shoulder pathology, but this is rare. X-rays show only the bones (and not the soft tissue) and will not give us an indication of how the muscle are doing. X rays will only be indicated if we suspect a stress fracture, avulsion fracture, fracture or joint damage (as in osteoathritis).
MRI
A MRI is a very expensive scan which can only be referred by a specialist and in the shoulders case this is usually by the orthopeadic surgeon. This can show us all the soft tissues and often will be able to show us if there is an underlying labrum injury. (However please read our facebook post/blog on conservative management of labrum injuries).
Sonar
This will be the investigation of choice, as the soft tissue (muscles, ligaments and nerves) can be visualised. A sonar would show the depth, length and direction of the muscle tear enabling us to treat you optimally. The sonar might also be able to show the top of the labrum, but would however not allow us to see into the joint.
Why is my shoulder muscle pain not going away?
The shoulder is very often affected by referral pain. This commonly comes from the neck and is related to a cervical disc injury. The muscle might not be the primary problem in this case as well as it may be the joint as in osteoarthritis or it may be a labrum injury inside the joint.
We often see rotator cuff injuries not rehabilitated very well and as a result the pain never goes away. Not every theraband exercise is a rotator cuff exercise and it takes some very specialised knowledge to get a shoulder muscle working again. Shoulder pain can debilitate almost all activities you do with your hands and that is why very specific rehab is required from a professional who knows the shoulder in and out.
Physio treatment for a shoulder muscle injury
The shoulder is very often affected by referred pain. This commonly comes from the neck and is related to a cervical disc injury. The muscle might not be the primary problem in this case as well as it may be the joint as in osteoarthritis or it may be a labrum injury inside the joint. A shoulder muscle treatment starts of with a very detailed assessment.
We often see rotator cuff injuries not rehabilitated very well and as a result the pain never goes away. Not every theraband exercise is a rotator cuff exercise and it takes some very specialised knowledge to get a shoulder muscle working again. Shoulder pain can debilitate almost all activities you do with your hands and that is why very specific rehab is required from a professional who knows the shoulder in and out.
Acute Shoulder Muscle Strain Treatment
- Early Injury Treatment – Rest, ICE, compress, elevate and LOADING (early loading improves outcomes but it requires a professional to guide you)
- Avoid the HARM Factors – Overuse, stopping harmful movements and taking anti-inflammatories too early
- Brace or Support – A sling or strapping
- TENS Machine – To control pain by using electrical stimulation.
Sub-acute Shoulder Muscle Strain Treatment
- Sub-Acute Soft Tissue Injury Treatment
- Acupuncture and Dry Needling
- Soft Tissue Massage
- Kinesiology Tape
- Supportive Taping & Strapping
- Electrotherapy & Local Modalities
- Heat Packs
- Medications
Types of shoulder treatments
- Acute injury treatment
- Ultrasound
- Medications
- Soft tissue massage
- Electrotherapy treatment
- Laser (Low Level Laser therapy)
- Acupuncture & Dry Needling
- Heat packs (Thermal therapy)
- Kinesiology Tape
- Rigid Strapping or taping
- Neurodynamics (Nerve tissue mobilizations)
- Dynamic Strapping
- Strengthening exercises
- Guided loading protocol
- Stretches (Static, dynamic and ballistic)
- Moon boot
- Brace
- Compression Bandage or Sleeve
- Supportive strapping and taping
- Biomechanical Analysis
- Gait Analysis
- TENS
Later Stage Shoulder Muscle Treatment Options
- Foam Roller
- Stretching Exercises
- Strength Exercises
- Closed Kinetic Chain Exercises
- Eccentric Exercises
- Neurodynamics
- Proprioception & Balance Exercises
- Agility & Sport-Specific Exercises
Other assessments to prevent shoulder injuries
- Biomechanical Analysis in order to see how the rest of the body affects the shoulder
- Joint Mobilisation Techniques to allow muscles to move easier
- Throwing Analysis to look for technique problems
- Functional movement Screening
- Video Analysis
- Prehabilitation
Physiotherapy goals for a shoulder muscle injury
- Reducing pain and muscle tension in the scapular and neck area in order to promote the motility of the scapula. This to ensure the correct position of the glenoid. The muscles targeted are the M. pectoralis minor, upper trapezius and M. levator scapulae.
- Improving the wrong humeral head position in order to restore scapulo-humeral mobility.
- Strengthen the muscles that stabilize and move the shoulder, the upper part of the M. serratus anterior and the intact rotator cuff muscles.
- Regain proprioception and movement automatism by neuromotor rehabilitation
Both nonoperative rehabilitation and postoperative rehabilitation of the rotator cuff involves the following principles.
- Reduction of overload and total arm rehabilitation
- There should be no compensatory actions in the upper extremity.
- It is advised to quickly use the elbow, forearm and wrist in order to strengthen them. Especially during long immobilization.
- Mobilization of the scapulothoracic joint and submaximal strengthening of the scapular stabilizers are indicated. The injured tissues should not be inappropriately stressed or loaded.
A technique which is used early in the rehabilitation phase is the scapular protraction and retraction resistance exercise. It involves a side-lying position and specific hand placement to resist scapular protraction and retraction without stress applied on the glenohumeral joint. This exercise begins at low resistance. The glenohumeral joint must be in slight abduction and forward flexion during scapular motion.
- Restoration of normal joint movement and stable joint movement
- Posterior capsular mobilization and stretching techniques are often indicated and applied to improve internal rotation ROM.
- Promotion of muscular strength balance and local muscular endurance
Recovery time
Shoulder pain has many causes and EARLY diagnosis and treatment is the best way to recover quickly.
Simple shoulder muscle pain can usually improve within a week or two of injury if you manage your injury properly. However, muscular pain or spasm lasting more than a few days is normally protective spasm overlying a more significant neck injury, which should be professionally investigated. It may not be just a simple shoulder muscle strain!
Most sufferers of shoulder pain will recover within 4 to 6 weeks. However, this time can vary greatly as it depends on both the nature of your injury and the shoulder muscle treatment plan that you develop with your physiotherapist.
How can I prevent recurring shoulder muscle pain?
If you have suffered shoulder pain in the past, you are unfortunately more likely to suffer in the future and worsening bouts. The most common cause of recurrent shoulder pain is insufficient rehabilitation. A constant shoulder muscle ache is not ok and is impossible to prevent if it never fully healed.
Follow the advice of your physiotherapist, who will establish a treatment plan to help you achieve your short-term goals and help prevent a recurrence. We see many people for a shoulder muscle treatment and prevention sessions.
While there are no guarantees, it is well known that active individuals who exercise and adopt safe lifting postures at home and at work are at a reduced risk of developing shoulder pain.
Discuss with your physiotherapist the specific postures and activities that you perform on a daily basis. They will aim to help you to understand how to position yourself and move with the lowest risk of injury based on your injury type and potential weaknesses.
What else could the shoulder pain be?
Rotator cuff tears must be differentiated from rotator cuff tendinopathy and from bursitis (subacromial bursitis). Arthrography or ultrasonography can make this distinction. A shoulder muscle ache can be caused by mean different conditions.
Additional differential diagnosis to look out for are:
- Acromioclavicular injury
- Glenoid labrum tear : Slap lesion, Bankart lesion
- Cervical pathology: Cervical nerve root injury, Cervical Radiculopathy, Cervical Spondylosis
- Subacromial Impingement
- Osteoarthritis, Rheumatoid Arthritis
- Shoulder Instability
- Subscapular nerve entrapment
- Scapulothoracic bursitis
- Adhesive Capsulitis
- Biceps Tendonitis
- Calcific Tendonitis Shoulder
When is shoulder surgery necessary?
After a consultation we can assess the need and possibility of surgical intervention. You will be refer to a specialist if it is in your best interest. We are the first step in a shoulder muscle treatment.
- Significant tendon and muscles tears (grade III – full ruptures) can often require surgical repair
- Damage to the shoulder joint itself and the labrum (such as a SLAP lesion or Bankart’s lesion)
- Patients that have suffered a severe dislocation, or recurrent dislocations of the shoulder joint
- Patients with chronic degeneration of the shoulder joint surfaces
The type of surgery performed will determine the recovery time frames and the management strategy determined by your orthopaedic surgeon. Our extensive experience in rehabilitating shoulder injuries post-surgery means we can work to get you pain free in the shortest and safest possible time frames. We tailor a sport specific rehabilitation program to get you back to where you want to be.
