Shoulder pain is the sensation of discomfort in the shoulder and upper-arm area. Shoulder pain is one of the most common upper limb complaints which a person will seek medical advice for. It is common to have neck pain as well. Shoulder injuries often overlap with neck pain. You may feel the pain constantly or only when moving the shoulder. Shoulder pain can be caused by any of the muscles, tendons or joints, so let’s look at the different types of structures in the shoulder.
The shoulder is one of the most challenging areas for any sport medicine practitioner. The structure of the shoulder is complex. Conditions are difficult to diagnose and rehabilitation can be a lengthy process.
The major muscle in the front of the the shoulder is the anterior deltoid. The posterior deltoid muscle makes up the muscle group at the back. On the outside of the shoulder is the mid-fibers of the deltoid muscle. These are the superficial muscles i.e. those you can see.
Muscle strains are often called ‘muscle pulls’ or ‘pulled muscles’ because of the way these injuries occur, with the muscle tissue forcibly stretched until it is torn. Depending on the number of muscle fibers that are torn, muscle strains are classified as first degree (least severe), second degree (moderate severity) and third degree (most severe) strains. This rarely happens to the superficial shoulder muscles but does happen to the rotator cuff muscles deeper down.
Causes of shoulder pain
Shoulder pain is one of the most common upper limb orthopaedic complaints which a person will see medical advice for. It is the most mobile joint and as a result of the increased mobility, stability is sacrificed. This makes it predisposed to injury, especially traumatic injury or overuse injuries i.e. repetitive movements like a swimming stroke. Shoulder pain may be caused by:
- Trauma – dislocations, fractures, labrum injuries, muscle or ligament strains, and sprains
- Overuse – Tendon inflammation, labrum injuries and athritis
- Instability – Impingement of rotator cuff muscle (swimmer’s shoulder)
- Autoimmune – Adhesive Capsulitis (Frozen Shoulder)
- Referral from other joints – Acromio-clavicular joint, sterno-clavicular joint, neck
- Visceral referral – Diaphragm, gallbladder, heart, top part of lung and spleen
- Nerve impingement – Usually in the neck
- Referral from rotator cuff injury (trigger points, strains, tendinopathies or tears)
- Glenohumeral joint surface injuries
- Fracture of neck of humerus
- Neuritis (viral)
– Rotator cuff strain
– Rotator cuff tendinopathy
– Shoulder dislocation
– Shoulder subluxation
– Labral tear
– Referred pain from neck or back
– Fracture of the clavicle
– AC joint sprain
– Muscle tear (pectoralis major or biceps)
– Rotator cuff tear
– Calcific rotator cuff tendinopathy
– Frozen shoulder (Adhesive capsulitis)
– Biceps tendinitis
– Nerve entrapment (Suprascapular/long thoracic)
– Fracture (scapula, humerus, coracoid)
– Levator scapulae syndrome
– Shoulder arthritis
– Brachial plexus injury
– Neuropraxia (burners/stingers)
Our professional experience on shoulder pain
Shoulder injuries are common in just about all sports, especially in contact sports. It can be extremely debilitating, affecting many activities that are usually taken for granted. Washing, dressing, putting clothes on, carrying children, reaching into cupboards to name but a few. When left untreated many shoulder problems can progressively worsen and become chronic.
The shoulder can, due to its extreme necessity to most activities, compensate heavily when injured. Pain can subside, but the dysfunction is still there. We often hear individuals just excluding certain activities. Some patients stop reaching overhead because it is too painful even years after the original injury. We rarely find persons with both strong scapula muscles and rotator cuff muscles (holds shoulder in place) due to the high rate of shoulder injuries. Big shoulder muscles (i.e deltoids) don’t mean you have stable shoulders!
We commonly see and treat the following shoulder pain conditions:
- Shoulder dislocations and subluxations
- Rotator cuff strains and tendinopathies
- Impingement syndrome of rotator cuff muscle (swimmer’s shoulder)
Symptoms of a shoulder injury
Mild Shoulder Symptoms
Mild pain and stiffness with shoulder movements
Reduced range of movement
Pain reaching behind back
Pain lifting or carrying
Difficulty sleeping on the shoulder
Pain into the upper arm or neck
Moderate Shoulder Symptoms
Moderate to severe pain
Unable to move shoulder
Locking or catching
Unable to lift or carry objects
Unable to put weight on the shoulder
Sharp electrical pain into the upper arm or neck
Numbness, pins and needles
Dangerous Shoulder Symptoms
Severe shoulder pain with traumatic incident
Bleeding in armpit/inner arm or bruising down the arm without trauma
Loss of total strength and function in a particular movement
Major injury with severe pain followed by redness, bruising and loss of function
Young children with severe dysfunction of the shoulder
Shoulder Injury & Pain Treatment
- Acute injury treatment
- 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)
- Shoulder sling
- Compression Bandage or Sleeve
- Supportive strapping and taping
- Biomechanical Analysis
- TENS and electrical stimulation
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.
- Significant tendon and muscles tears (grade III – full ruptures) can often require surgically repairing
- 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
Rotator cuff tear (Strain)
Anatomy of the shoulder
The shoulder joint is a ball and socket joint which consist of five joints 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 work in unison when the arm is lifted to stabilise 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 rotator cuff tears?
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.
Rotator cuff tears are the most common cause of shoulder disability and pain!
Symptoms of a rotator cuff tear
- 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)
Shoulder Injury Treatment
You know when an injury occurs. There may be pain, swelling, bruising or even bleeding. The first and best thing to do is to apply the 5 step PRICE regime; a tried and tested treatment for reducing pain and swelling to minimize the effects of the immediate injury. It also prepares the body for the next stage of treatment. Many sports injuries such as muscle strains, sprains and fractures heal faster when the PRICE-regiment is used immediately following an injury.
Protect the injured joint, muscle, nerve or tendon from getting worse by using strapping or a brace. Splints can also be used to prevent movement of the injured area and provide support in an effort to minimize the tissue damage. Immediately protect the area until you are able to get to a medical professional.
Protection also includes resting the limp using crutches for the legs and a sling for the arm. We use it to ‘immobilize’ your limbs, by restricting movements and preventing you to use it. Warning: relocating a dislocated shoulder by pulling on it can pinch a nerve or block a blood vessel
Forcing yourself to go on when there are signs of an injury is not only damaging to the tissue but also unwise.”No pain, no gain” does not apply here. It prevents healing from taking place. Rest is important to allow the injured muscle, tendon or ligament to reattach and heal. Avoid any activity or movement that produces or brings on the pain for the first 3 days. After that, you need to start moving or other problems will develop.
If you are unsure what to do, rather contact us and we can guide you.
Cold provides short-term pain relief by limiting the bleeding around the injured tissue. The bleeding from ruptured arteries and veins will cause an increase of pressure surrounding the injured tissue which will also decrease the blood flow around the injured tissue. The first priority is to stop the bleeding as fast as possible. Wrap an ice pack or ice cubes in a towel, wet the towel and place on the skin. Never apply ice directly to the skin (it can cause burns). Apply the ice for 15 minutes on, 20 minutes off. Repeat 5 times per day for the first 3 days.
Initially the ice will cause the superficial arteries and vein to constrict and close up. This will prevent the blood seeping out into the surrounding tissue. You will also experience a redness and ‘warm’ feeling after the ice as been applied. This is when the body reacts by sending cells to clean up the injured tissue and start repair.
Warning: Never apply heat (and heat rubs) to an acute injury in the first 48 hours. The heat encourages bleeding and could be detrimental if used too early.
Using a Compression bandage, elastic strapping, neoprene sleeve or brace will reduce the bleeding and swelling which occurs when cells and other substances rush to the site of an injury. Applying compression will also help to prevent the blood from pooling in you limbs and reduce the pain. Take care not to have the bandage too tight, as it will restrict blood flow.
Resting with the injured part above the level of the heart is the best means of relieving swelling. In order to effectively use gravity, the injured area must be above your heart to assist in the drainage of excess swelling. For example lie on your back with your foot resting on a chair to drain your legs.
What you need to look out for
If the pain gets worse within the first 24 hours, we recommend you give us a call and we can give you advise on how to proceed.
- Severe swelling (not going down)
- Visible deformity
- Unable to move
- Severe bleeding
- Redness and puss oozing from skin
- Open wound
If I do nothing, will it heal by itself?
In our experience patients walk through our doors daily that left their injuries untreated. These patients’ injuries take longer to heal, not to mention the lingering pain and compensatory problems that have developed. It is important to remember that symptoms lasting longer than two weeks are much harder to heal.
If you are unsure what to do, rather call us and we can guide you.
Patients that don’t opt for treatment can develop the following:
- Abnormal Scar tissue formation which causes abnormal movement patterns leading to a cascade of compensatory mechanisms.
- Joint stiffness due to immobility and causes abnormal joint movement, stressing adjacent joints even more.
- Muscle weakness which leads to other muscles working harder to perform that muscle’s function and putting more strain on the surrounding muscles.
- Joint laxity that can lead to unstable joints.
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.