Shoulder Pain Physiotherapy

Shoulder pain is a b*^%$ch I get it, I’ve had a few small episodes of shoulder pain and it wasn’t fun, let alone suffering a shoulder injury like a dislocation or a labral tear. Research suggests that up to 67% of people suffer shoulder pain in their lifetime and it doesn’t seem to get less common as we get older with people older than 50 commonly reporting episodes of shoulder pain. So why do so many people get shoulder injuries? Is it because we use it so much, maybe because it’s such a mobile joint, or are we just a bit unlucky? I think it’s a combo of the first two, with a hint of number three on occasions. Because the shoulder is required to perform movements with such a variety and such a large range of motion we need to have a shallower joint socket with more of an active stability system aka the rotator cuff. The rotator cuff works to dynamically stabilise the humerus within the shoulder joint through movement. What happens though if our rotator cuff gets a little weak or a little underused, or if we try to do a little too much too quickly, this is often where we run into trouble. Acute injuries such as a dislocation or some occasions such as rotator cuff tears can occur with more one-off acute traumas such as a traction force on the arm, falling onto an outstretched arm, or catching or lifting a heavy object. Shoulders are incredibly mobile and on occasions, unstable structures in the right positions and under the right load, keep them strong and keep everything around them mobile and you’ll do your best to keep a healthy set of shoulders.

Shoulder pain can be incredibly diverse ranging from acute to chronic rotator cuff tears, to AC joint sprains and shoulder dislocations requiring surgery. As a physio, the shoulder is always keeping me on my toes with what could be going on. Sometimes shoulder pain isn’t even caused by the shoulder, on occasions, it’s caused by the cervical or thoracic spine. All I know is it takes time to determine an appropriate diagnosis and treatment pathway.

What we will discuss:

As with pretty much everything else, the first thing we want to know is how did your concern start. Was there a mechanism of injury where something happened that caused your symptoms, or did they gradually start coming on over a few weeks or months, or maybe you decided to build a deck and now it’s really sore? Whatever you can find happened, or in some cases didn’t happen, we want to know all about it. Understanding how your pain came on will help us rule in and rule out potential differential diagnoses.

For a shoulder, I also like to have a good in depth understanding of the pain, how it feels, and what aggravates it and what makes it easier, and how the pain behaves throughout the day and at night. I find pain descriptions such as whether the pain feels achy, sharp, shooting, or grabbing, as well as whether it sits on the surface or whether it feels deeper within the shoulder joint. Aggravating factors can vary wildly between people and I’ve certainly heard some interesting ones in my time but they give us a lot of hints as to what may be causing your symptoms. Night pain is almost a dead giveaway for some cases of shoulder bursitis, I find if you have a certain set of symptoms coupled with pain lying on the shoulder at night, you have a really good chance of getting a positive result from injection therapies.

Some of the easier questions to answer include whether you have any pins and needles or numbness, whether you have a previous history of shoulder injuries or pain, and what you do for work and hobbies. The only outlier important question is whether you have any sensations of looseness, giving way, instability, clicking, or catching sensations, all of these could indicate more significant structural concerns within the shoulder following an injury such as falling onto an outstretched arm.

What we will assess:

Range of motion is where we start and we are assessing for the freedom of movement as well as for any pain produced throughout the movement. All I am looking for with these movements is do you feel any pain or do you feel any restriction, once you hit that point there are two questions – 1 – can you go through it and what happens if you do, and 2 – if that’s as far as you can go what stops you going further. I like for clients to describe what they feel throughout the movement, for example, an often reported sensation is an increase in pain between about 70deg and 100deg when you take your arm straight out the side, and then it dissipates as they go higher. This is quite a common finding among a few shoulder pain presentations.

Next, I will often deviate away from the shoulder and assess the neck and the thoracic spine for any potential causes of restriction. The thoracic spine is vital for good shoulder health, without adequate extension or rotation you will see adaptations occurring at the shoulder joint to make up for it. Consider that not too many movements you actually do just involve the shoulder joint, want to reach up to a high cupboard? You better hope that you have good thoracic extension otherwise you might need to ask your shoulder to do a little bit more work. The neck is an important one to clear, it’s not an uncommon cause of shoulder symptoms, and if you have any neural symptoms such as pins and needles or numbness any good physio should be clearing it. Assessing the range of motion of the cervical spine but then moving on to assess for stiffness and tenderness to palpation to the facet joints. If I’m suspecting involvement in the thoracic spine, I’ll also perform palpation of the spinal segments there assessing for tenderness or stiffness as well.

Special tests of the shoulder to assess for specific structures aren’t all that special after all. These tests were designed so that I could rule in or rule out certain structures with a specific diagnostic test with the aim of isolating that structure. Unfortunately, that’s not really how it works and they fall well short of the mark of being specific to certain structures and more of an “all-round test” which really doesn’t help us all that much. I may use a specific test here and there, but more often than not I tend not to utilise them because of their poor clinical utility.

Other specific tests we often perform could include an assessment of shoulder instability. This is often performed after an acute injury and we are assessing to see whether there is increased play at the shoulder joint either in the movement going forwards, backwards or downwards. Most commonly people will present with anterior or inferior instability as these are the most common dislocation directions. AC joint injuries are the other common specific tests I tend to perform, the testing battery I utilise is assessing for tenderness on palpation and pain at the AC joint on passive horizontal adduction of the shoulder, this correlates quite well with ultrasound and x-ray findings.

Otherwise, we are looking at functional movements and positions. Jeremy Lewis is a UK-based physiotherapist who developed the Shoulder Symptom Modification Procedure. It is a testing battery where we assess a functional movement and we are able to test different changes to the movement to look for at an absolute minimum a 20% improvement but realistically we are wanting a “wow that’s so much better!” type of response. I find these tests and modifications extremely useful as they can provide significant and immediate benefits to clients that we can implement in a treatment program right away.

How we treat it

Treating shoulder pain can be tough work, there are a lot of differential diagnoses and a lot of different treatment pathways to go through. Firstly, if there’s something that we think is out of the ordinary following an injury such as a fall onto an outstretched arm we may recommend you speak with your GP about a potential MRI referral to rule out anything within the joint that may be causing issues.

Barring that hands-on techniques usually work fantastically. The pathway that we opt for often comes from what we find in our objective assessment and which portion of the Shoulder Symptom Modification Procedure had the greatest benefit. For someone who responded well to increased thoracic extension, I will often target mobilisations to the thoracic spine. Whereas someone else may have responded well to a posterior glide of the humerus and so we may do a lot of work through the pectorals to release some muscle tone. Regardless of what works, hands-on techniques including mobilisations and soft tissue release usually have some great benefits.

I find dry needling is a common technique around the shoulder and rotator cuff that can have some really nice benefits as well. It can commonly be performed through the rotator cuff muscles and latissimus dorsi. Dry needling has some nice short-term effects that can reduce muscle tone and improve freedom of movement to enhance your capacity to perform an exercise program.

Exercises are the best long-term treatment option for just about any presentation of shoulder pain physiotherapists will see. A comprehensive and individualised exercise program should be addressing your predisposing factors along with correcting any problematic movement patterns to improve your efficiency of movement and reduce your symptoms. Commonly your shoulder exercise program will mainly consist of strengthening exercises for the rotator cuff, the powerhouse shoulder muscles such as the deltoids, and the muscles through the inside of the shoulder blade such as the trapezius and rhomboids. In some cases stretches can be a good addition to the program too should there be any muscle length deficits identified during your assessment.

Returning to Sport

Common sporting shoulder injuries include AC joint sprains, shoulder dislocations or subluxations, muscle tears, or tendinopathy. Returning to sport following a contact injury should be a measured process and it may change depending upon the sport you play. Determining the best pathway will be different for a front rower in rugby league versus a winger in a soccer match. Understanding the athlete and the role they play in their sport and within their team is integral. For injuries such as an AC joint sprain usually the biggest concern is the stability of the joint, once that has been cleared as sufficient it often becomes a pain tolerance issue. Some athletes may require padding strapped on top of the AC joint during play to reduce the impact forces should they be impacted directly on the area during a match.

For other injuries such as shoulder dislocations or subluxations, stability of the joint is integral. Some clients who suffer a dislocation may require surgical intervention to restore adequate joint stability and avoid recurrent episodes of dislocation or instability. Recurrent episodes of dislocations aren’t healthy for shoulders and can result in further issues such as labral tears, and chondral defects, that could compromise the longer-term health of the shoulder joint. Ensuring that the shoulder is both stable and strong prior to returning to sport to ensure that both the active and passive stability subsystems are operating well. Taping is often utilised in this client subgroup to support the shoulder joint and reduce the risk profile for dislocation or subluxation incidents.

Preventing shoulder pain

If we could just get rid of shoulder pain the world would be a much better place, right? So how can you help reduce your risk profile for suffering either an acute shoulder injury or developing a more slow developing onset of shoulder pain?

I would have to say that shoulder strength is your number one priority. I think the isolated internal and external rotation exercises that everyone does are a little overplayed. They can be great as a warm-up to get the rotator cuff firing but we need to be doing a little more than that in the long term. I think of shoulder strengthening from the perspective of we need to strengthen the shoulder to do what it does in the real world. So we need it to be able to:

Lift above head
Carry
Rotate
Lift and rotate
Carry overhead
Reach behind our back/head

We need to be able to practice and improve the capacity to perform all of these movements and functions if we truly want to work towards reducing our risk profile for shoulder pain. Getting in the gym is a great option, but some people don’t either have the time or they don’t enjoy it, so why not get around the house and do some of those jobs your spouse has been wanting you to do? Being active and using your shoulder will help develop its tolerance, just don’t go doing too much too soon.

The shoulder is pretty darn complex even without considering how we need to integrate the rest of the body into a lot of the movements. Consider a tennis serve, it seems very shoulder dominant, but if you took away the actions from the rest of the body athletes would lose a vast amount of power on their serve. So preventing shoulder pain in the athlete isn’t just about the shoulder. Athletes should be considering their sport and what they need to perform. Shoulder health in athletes often relies on thoracic and lumbar mobility, hip strength and power output, shoulder strength and endurance, and even all the way down to calves if we are looking at a tennis serve. Keep your entire body in check to help reduce your risk profile for shoulder pain or a shoulder injury if you are an athlete.

Treatment Packages

3 Week Program

Our 3-week program was designed for clients who have suffered an acute injury and want to get out of pain ASAP. This package could be suitable for clients who have suffered the recent onset of shoulder pain following an acute increase in activity, a recent diagnosis of bursitis, a lower-grade AC joint sprain, or an injury sustained at the gym.

Our 3-week program is inclusive of the following:

3xweekly 45min physiotherapy consults
$40 equipment allowance for bands, trigger point balls, foam rollers etc.

Total cost: $940

Package price: $770

6 Week Program

Our 6-week program is designed for clients who have sustained a higher-grade injury. This could include clients who have a longer period of shoulder symptoms (often around 1 month or longer), higher-grade AC joint sprains, ongoing bursitis, or a rotator cuff tear.

Our 6-week program is inclusive of the following:

2xweekly 45min physiotherapy consults
$80 equipment allowance for bands, trigger point balls, foam rollers etc.

Total cost: $1280

Package price: $1050

12 Week Program

Our 12-week program is designed for clients who have sustained higher-grade injuries such as a shoulder subluxation or even a dislocation pending potential surgical opinion, or persistent shoulder pain either due to bursitis or other causes.

Our 12-week program is inclusive of the following:

2xweekly 45min physiotherapy consults
$150 equipment allowance for bands, trigger point balls, foam rollers etc.

Total cost: $2550
Package price: $2050