Pain in the shoulder can be one of the most debilitating types of pain we deal with in the clinic. If you stop for a moment and think about the number of things you do with your upper limb, almost everything will involve your shoulder joint. The joint is formed between the “ball” of the upper arm bone and the “socket” of the shoulder blade and this may be the description you remember from the biology lessons you had to endure at school. This isn’t in fact a great description of the joint – the ball of the upper arm is only about half a ball and the socket is no more of a socket than if you hold your cupped hand out palm up like you were asking for sweets.
This arrangement results in a joint which is very mobile but the trade off for this is that the joint is in relative terms unstable. Compare the movement you have in your shoulder with the movement you have in your hip which is much more of a true “ball and socket” joint. To make up for the lack of bony stability the shoulder joint has a group of muscles around it (the rotator cuff) which provide dynamic stability and support the joint throughout its movement.
Shoulder pain can take many forms and be present for a wide variety of reasons. Getting the best treatment for your shoulder pain relies on getting an accurate diagnosis and at City Physio you can expect us to take the time to get to the root cause of your problems and we work closely with local shoulder specialists
Mark Freeman demonstrating remarkable shoulder stability
to arrange further investigations if necessary to give you the best outcome.
Shoulder dislocation
With shoulder dislocation the diagnosis is often pretty clear and it is very unusual for people to arrive in the clinic with an undiagnosed dislocation! Almost all dislocations are where the “ball” of the top of the upper arm bone moves forwards out of the “socket” of the shoulder blade. This almost always follows a traumatic episode of some description and will usually have undergone reduction (the correct term for putting the bone back in its place) in the hospital or less often at the pitch side if the injury occurred while playing sport.
After a dislocation there is quite a high risk of the joint dislocating again (indeed some studies show that the joint is more likely to dislocate again than not). The problem is that in dislocating, the upper arm bone tends to damage some of the surrounding structures and this can lead to instability in the joint and recurrent dislocation. Each subsequent dislocation event tends to make the joint a bit more unstable and does further damage to the joint so it is important that the dislocation is managed carefully in the early stages and that an appropriate course of rehabilitation is followed. Depending on the level of function that the individual is hoping to achieve after shoulder dislocation, it may be necessary to undergo surgical stabilisation in a small number of cases.
Very rarely, the shoulder dislocates backwards. This occurs almost exclusively in two instances – during an epileptic seizure and in victims of electric shock. This can sometimes be missed on the first visit to the hospital because of its rarity but must be considered with shoulder pain following either of the incidents mentioned.
To give you an idea of how often we see this type of dislocation, in 18 years of practice we have seen just two patients with posterior dislocation. One had suffered and electric shock and had remained undiagnosed for three months, the other suffered with epilepsy. Many physiotherapists will go their entire career without seeing this type of dislocation.
Shoulder Impingement and Rotator Cuff Problems
This term describes a pinching or trapping of the muscles which support the shoulder joint between the bone of the upper arm and the bone of the shoulder blade. This tends to cause pain when lifting the arm above shoulder height. Sporting activities or occupations which involve using the arm above the head work the supporting muscles of the shoulder hard and like any other muscle which is worked hard they get bigger. This does not normally cause problems but some activities also habitually put the shoulder in an awkward position. If there is not much room in this part of the shoulder the muscles start to rub between the bones when the arm is used. Over time the muscles can become damaged, causing pain an inability to perform certain activities. Physiotherapy treatment is often useful in helping this type of impingement.
You may gently stretch the soft tissues around the painful area to relieve some of the rubbing, you can re-educate some of the muscles to change the way your shoulder works or perhaps look at your sporting technique to see if anything can be done to alter the action of the muscles.
In some types of impingement, the bone which forms the top of the shoulder joint can become thickened (this is the bone which would sit underneath the epaulettes on your shirt). This may be due to previous trauma or as part of a process of wear and tear through ageing. The thickened bone rubs on the top surface of the muscles beneath it as the arm moves and can become very painful and in severe cases the muscles can rub right through and rupture.
If you have this type of impingement, whilst physiotherapy may help to relieve your symptoms we will not be able to fix the underlying cause. For this type of impingement the normal treatment is to have part of the thickened bone removed surgically to make more space for the muscles and stop the irritation. This is usually performed via “keyhole” surgery and allows a rapid return to normal activity. At City Physio we can help arrange the appropriate referral either directly to a specialist if you have health insurance or via your doctor if you do not. After surgery we work closely with the specialist to ensure your rehabilitation runs as smoothly as possible and you make a speedy recovery.
Frozen Shoulder
If you are suffering with or have ever suffered from a frozen shoulder you will know what a painful and disabling condition it can be. Sometimes developing after a trauma, frozen shoulder is most often of “ideopathic onset” which means we know that you’ve got it but we don’t know why! It is ususally described as having three stages; in the first stage the shoulder becomes increasingly stiff and very painful, in the second stage the pain diminishes but the stiffness remains and in the third stage the movement slowly returns to the shoulder.
In frozen shoulder (or adhesive capsulitis to use the more medical term) the shoulder does not just feel stiff when moved but it is physically impossible to move. People who come into the clinic and say “It hurts to lift my arm above my head- I think I have frozen shoulder” almost certainly do not! Most people will notice that they have trouble reaching into high cupboards, ladies may have difficulty reaching behind their backs to put their bra on and chaps may find difficulty reaching into a hip pocket.
The good news with frozen shoulder is that they almost always get better, so if you are suffering do take heart from this! There are a number of treatments which may benefit you; physiotherapy to help relieve the pain and maintain/restore your movement is the first course of action and you can expect a series of exercises to help with this.
If your frozen shoulder is not responding as you would like, the next step is manipulation under anaesthetic. As the name suggests, a general anaesthetic is given (you are put to sleep) and the shoulder is moved by an orthopaedic surgeon which can be very useful in restoring movement and relieving pain. As with any procedure which involves a general anaesthetic , there is an element of risk and this procedure is not undertaken lightly.
Here at City Physio, we can help you get the right diagnosis and treatment for your shoulder pain. You can contact us below and you’ll find us happy to help you.