Physiocure

Tag: Shoulder Pain

  • Shoulder Pain

    Shoulder pain is a common problem which lot of regular or athletic population face during their life time. However, identifying the source of this shoulder pain can get better insights to the resolution of the problem.

    shoulder pain
    shoulder pain

    Understanding shoulder pain

    This requires knowledge of the structures involved the activity which lead to the pain and the present or past history of events.

    For example, a regular individual who complains of shoulder pain may have Sub acromial impingement syndrome or rotator cuff syndrome or a cervical disc prolapse, it’s the occupation, lifestyle presenting posture of the individuals, and many other factors point out to the cause of pain and the provisional diagnosis.. At the same time it is important to judge and understand that the shoulder pain could be referred from the heart ache as well.

    SHOULDER INJURIES IN SPORTS:-

    • The shoulder is a frequent site of injury in competitive athletes. Shoulder injuries
      comprise between 8% and 13% of all athletic injuries.
    • These injuries may result from repetitive overhead activities (in swimmers, baseball pitchers, tennis players, and javelin throwers) or direct trauma (in football and rugby players).
    • Within a given sport, most shoulder injuries are position specific. In baseball, shoulder injuries are more common among pitchers. In swimming, shoulder injuries are most common in those who compete in butterfly, freestyle, and backstroke events.
    • In addition to the nature of the sport and the position played, shoulder injuries in the athlete depend on the anatomic variants specific to each athlete, their age, conditioning, level of play, level of overhead activity, techniques used, and the length of participation in their respective sport.

    THE SHOULDER COMPLEX AND ITS FUNCTION:-

    • The shoulder Complex is made up of these 4 joints which are run by over 30 different muscles. the sternoclavicular (SC),acromioclavicular (AC), and glenohumeral (GH) joints, as well as the scapulothoracic articulation..
    • Over a period of years, there certain wear and tears occuring around these joints which disrupt the normal working harmony of these joints and the muscles
    • The primary goal of the shoulder complex is to position the hand in space for activities of daily living.
    • Secondarily, during overhead athletic activities such as throwing and serving, the shoulder functions as the “funnel” through which the forces from the larger, stronger muscles of the legs and trunk are passed to the muscles of the arm, forearm, and hand, which have finer motor skills.
    • The ability to execute these actions successfully comes from a balance in mobility and functional stability of the shoulder complex.
    • The majority of the stability at the shoulder is determined by the soft tissue structures that cross it. The ligaments and capsule form the static stabilizers and function to limit translation and rotation of the humeral head on the socket of the shoulder joint.
    • The muscles make up the dynamic stabilizers of the shoulder joint and impart stability in a variety of ways. During muscle contraction, they provide increased capsule ligamentous stiffness, which increases joint stability.
    • They act as dynamic ligaments when their passive elements are put on stretch . Most importantly, they make up the components of force couples that control the position of the arm and the shoulder blade, helping to appropriately direct the forces crossing the shoulder joint .
    • Proper scapula (shoulder blade) motion and stability are critical for normal shoulder function. The scapula forms a stable base from which all shoulder motion occurs, and correct positioning is necessary for efficient and powerful arm movement.
    • Abnormal scapula alignment and movement, or scapula thoracic dyskinesis, can result in clinical findings consistent with instability and/or impingement syndrome.

    WHAT DO SYMPTOMS POINT OUT TO?

    • Weakness may appear as a true loss of power, suggesSai RCfting a neurological disorder, or as a sudden and surprising inability to abduct the shoulder – perhap sdue to a tendon rupture. Between these extremes there is weakness in performing only certain movements and weakness associated with pain.
    • Instability symptoms may be gross and alarming(‘my shoulder jumps out of its socket when I raise my
      arm’); more often they are quite subtle: a click or jerk when the arm is held overhead, or the ‘dead arm’ sensation that overtakes the tennis player as he or she prepares to serve.
    • Stiffness may be progressive and severe – so much so as to merit the term ‘frozen shoulder’.
    • Swelling may be in the joint, the muscle or the bone; as a patient its difficult to know the difference.
    • Deformity may consist of asymmetry of the arm, squaring of shoulders, winging of the
      scapula or an abnormal position of the arm.
    • Loss of function is usually expressed as difficulty with dressing and grooming, or inability to lift objects or
      work with the arm above shoulder height.

     

    These are the most common signs and symptoms and each points towards involvement of specific structures in the shoulder which help aid our diagnosis.

    WHAT SHOULD U EXPECT DURING YOU EXAMINATION?

    • once you contact us, we might have a brief chat about your problem on the phone.
    • on the first visit, you should get all your investigations as well as referal papers.
    • on the first visit maximum time goes in understanding how did the pain start and a brief history is taken, all the reports are read and an examination pertaining to your shoulder pain is performed.
    • then i usually explain all my clients the course of treatment, all of this will take around 20 min.
    • next the treatment is started on the first visit itself.

    WHAT TREATMENT PRINCIPLES BASED ON DURING SHOULDER PHYSIO?

      • In most patients, rehabilitation after a shoulder injury should initially focus on pain control and regaining the coordinated motion throughout all components of the shoulder complex.
      • Once motion is regained, attention is shifted to strengthening and re-educating the muscles around the shoulder to perform their normal tasks.

    • To reproduce the precision with which the shoulder complex functions, the muscles need to be re-educated through “learned motor patterns.”
    • These patterns position the shoulder complex in “predetermined” ways and activate the muscles in precise synchronization to maximize recovery of function.
    • Associated conditioning of the lower extremities and trunk muscles is extremely important because over 50% of the kinetic energy during throwing and serving is generated from the legs and trunk muscles.
    • Therefore, rehabilitation of all components of the kinetic chain is required before the successful return of competitive or strenuous overhead athletic activities.

  • Subacromial Impingement Syndrome

    After coming across the normal thought process of most patients visiting our clinic, we decided to put forward a small write up to make a layman understand that “not all shoulder pains are frozen shoulders”.

    It is estimated that 30% of people will experience shoulder pain sometime during life (Lewis 2009b, p. 259). ‘The incidence of shoulder pain increases substantially with age, and for people over 65 years of age shoulder pain is the most common musculoskeletal problem’ (Taylor 2005, cited in Lewis 2009a, p. 236).

    Shoulder pains can be classified into variety of different diagnoses like Sub acromial Impingement, Rotator cuff syndrome, Cervical radiculopathy, AC joint strain/arthritis and many more. In this article we will be discussing about the Sub Acromial impingement Syndrome(SAIS).

     

    WHAT IS IMPINGEMENT?

    Shoulder muscles get pinched between the bones that form your shoulder leading to shoulder pain. This is medically diagnosed as an Impingement. This impingement can be due to structural faults in the bones or tendons or muscles or due to faulty biomechanics .

    To understand the above medical diagnoses let us first understand the anatomy and the factors which cause this kind of pain.

    ANATOMY AND BIOMECHANICS OF SUB ACROMIAL AREA:-

    The shoulder joint:-

    This joint is formed of 3 bones namely the humerus or the arm bone, the clavicle or the collar bone and the scapula or the shoulder blade bone. There are total 4 joints between these bones and your rib cage which form the shoulder namely

    • Glenohumeral joint( GHJ) connecting the arm bone, collar bone and shoulder blade at the corner of your shoulder;
    • Coracoacromial joint( CAJ) between the collar bone and the shoulder blade;
    • Scapulothoracic joint (SCJ) between the rib cage and the shoulder blade and
    • Acromioclavicular (ACJ) joint between the shoulder blade and collar bone again.

    Other than these 4 joints, ti Understand SAIS, we need to understand the area at the tip of the shoulder formed by the GHJ & the ACJ, called the Subacromial area. Other than bones it has a bursa, tendon of the muscle Supraspinatus & biceps, which are mainly affected in SAIS

    The subacromial bursa (SAB)

    • A bursa is a sac filled with nourishing fluid cells and some fat tissue. It normally is present between the bones which end up forming a joint as its main role is to prevent friction between these bones. The shoulder has 7-8 bursae of which “subacromial bursa(SAB)” is the largest.
    • There are a group of muscles called the rotator cuff (RC) muscles which maintain our shoulder joint compact. There many other muscles which cross the shoulder joints.
    • The SAB separated the RC muscle ends which form tendons to attach on the bone from another major muscle called the deltoid.
    • The SAB also separates an important ligament called the coraco acromial ligament from these muscles thereby preventing friction between these muscles and ligaments on the bone.
    • The SAB has wiring as well that is nerves which cause the sensation of pain when there is something wrong with this bursa.

    DIFFERENT CAUSES OF CHRONIC SHOULDER PAIN IN PEOPLE OVER 40 YEARS OLD ARE (Codsi, 2007, p. 473).

    Below is a list of diagnoses which comprise a range of pathologies which can cause shoulder pain

    The common causes Other causes of pain are:

     

    		 Causes of referred pain:

     
    • SAIS,
    • Rotator Cuff Syndrome( RCS),
    • Adhesive capsulitis,
    • Arthritis of the GHJ and/or ACJ
    • Fracture,
    • Chronic posterior dislocation,
    • Infection,
    • Calcific tendinitis,
    • Biceps tendinitis,
    • Fibromyalgia,
    • Shoulder instability.
    • Cervical disc disease,
    • Pancoast tumor,
    • Thoracic outlet syndrome,
    • Hepatic disease
    • Diaphragmatic irritation

     

    THE PATHOLOGY OF SAIS:-

    Impingement syndrome is a generic term used to describe RC lesions, from early inflammation through degeneration to partial/complete tears). Number of hypotheses has been suggested for the etiology of SAIS: structural factors (like acromial shape), hypermobility and instability of the GHJ, internal impingement, capsule contraction, and RC tendinitis (Lewis, Green & Wright 2005, p. 385; Ainsworth & Lewis 2007, p. 208).

    Intrinsic theories

    • These theories are based on changes occurring inside the tendons of the muscles attached in this subacromial space.
    • The changes occur either due to limited blood supply, constant/repetitive compression which eventually cause negative changes in the basic structure of the tendon leading to wear and tear.
    • Intratendinous degeneration or tendinosis might occur as a result of the combination of limited vascularity in CODMAN’S CRITICAL ZONE and external compression of the tendon structures in the subacromial space’
    • Because of these intrinsic changes within the tendon, they indirectly affect its strength. These wear and tear changes cause the tendon to develop cartilage like properties at the attachment site making them susceptible to tears which also cause changes in the shape of the bone acromion where they attach.

    Extrinsic theories

    • Nho et al. (2008, p. 988) suggest the influence of age and activity on the shape of the acromion, as well as environmental causes such as age, co-morbidities (like diabetes mellitus and smoking) and overuse in impairing the healing processes of the tendon.
    • It seems that superior translation of the humeral head plays a significant role in the pathology (Lewis 2009a, p. 239).
    • Chronic impingement can lead to bursal inflammation, tendonitis and can eventually cause degenerative changes and tears of the cuff tendons if not treated (Lin, Weintraub & Aragaki 2008, p. 627; Nho et al. 2008, p. 988).
    • The height of the subacromial space, from the head of the humerus to the coracoacromial arch, is only 1.0–1.5 cm as seen on radiographs. Changes of this space occur in subjects with healthy shoulders;

    STAGES OF PATHOLOGY:-

    Neer described three stages of impingement

      Stage 1 Stage 2  Stage3
    Age Less than 25 25-40 More than 40
    Signs: Swelling or redness Tendinitis/bursitis Bone spurs, tendon tears.
    Symptoms Sub acromial pain

    Tenderness

    Painful arc

    Muscles are strong but painful

    		 Range of motion restriction in capsular pattern Weakness in movements like abduction and external rotation

    Squaring of acromion
    Treatment Reduce pain

    Swelling

    Proximal control exercises

    		 Work on improving range of motion Based on the tear.

    SIGNS AND SYMPTOMS:-

    • Although impingement symptoms may arise following trauma,
    • The pain more typically develops insidiously over a period of weeks to months.
    • The pain is typically localized to the front or side of the tip of the shoulder and radiates to till the mid portion of the arm.
    • Patients experience pain at night, exacerbated by lying on the involved shoulder, or sleeping with the arm overhead.
    • Normal daily activities such as combing one’s hair or reaching up into a cupboard become painful.
    • Weakness and stiffness may also be encountered, but they are usually secondary to pain.2

    EXAMINATION:-

    A thorough physiotherapy objective examination includes:-

    • Testing of the neck including ROM, palpation and provocation tests are done to rule out referred pain.
    • The shoulder girdle is examined for atrophy, weakness and for shoulder blade and arm muscles asymmetry
    • Active and passive shoulder ROM is assessed (where in we find that limited Active shoulder movements but passive movements are full
    • strength in all planes is tested once the pain is in control.
    • Tests for impingement and instability are performed, as well as a detailed neurovascular assessment is done.

    INVESTIGATIONS:-

    X-ray:- On an X-ray a loss of subacromial space may be seen indicating of SAIS, but it should not be used solely for diagnosing SAIS.

    Other imagings used are US and MRI.

    Presence of a tear on MRI does not necessarily correlates with symptoms, especially in the older population (Matava, Purcell & Rudzki 2005, p. 1411).

     

    MANAGEMENT:-

    There is no one recipe for treating this kind of shoulder pain. Systematic Research on Exercises and manual therapy effects in Impingemnt says:-

    1. Exercises are effective in reducing pain (also stated by Senbursa, Baltaci & Atay 2007, p. 920; Trampas & Kitsios 2006, p. 125; Michener, Walsworth & Burnet 2004, p. 163)
    2. Home exercise is effective as supervised exercise.
    3. May be better effect if combined with manual therapy (also stated by DeSantis & Hasson 2006, p. 78; Trampas & Kitsios 2006, p. 127; Faber et al. 2006, p. 21; Senbursa, Baltaci & Atay 2007, p. 915; Michener, Walsworth & Burnet 2004, p. 162).
    4. Acromioplasty with postoperative exercise can improve symptoms.
    5. Functional shoulder brace may be effective in reducing pain and increase strength.
    6. Faber et al. (2006, p. 21) found that combination of exercise and manual therapy is most effective in improving function.
    7. Senbursa, Baltaci & Atay (2007, p. 915) found that improvement in function, strength and decrease in pain is significantly higher with manual therapy compare with self-training in patients with impingement syndrome. Combining manual therapy with supervised exercise may be even more beneficial (Senbursa, Baltaci & Atay 2007, p. 920).
    8. DeSantis and Hasson (2006, p. 86) found that MWM might be effective as a treatment for patients with SAIS in improving function, AROM and decreasing pain.
    9. The findings challenge the belief that posture and its concomitant muscle imbalance comprise an etiologic factor in SAIS’ (Lewis, Green & Wright 2005, p. 385).
    10. Kibler (2006, p. 42) states that there is clear link between impingement and scapular dyskinesis and thus must be addressed.

    1. Lewis, Wright and Green (2005, p. 72) found that correcting posture (scapula + thorax) with taping, increase Flexion and Abduction ROM and delayed the point at which pain was first experienced, but didn’t change pain intensity. The purpose of the tape was to extend the thoracic spine, and retract, depress and posteriorly tilt the scapula (Lewis, Wright & Green 2005, p. 82).
    2. Multiple SR (Green, Buchbinder & Hetrick 2003; Michener, Walsworth & Burnet 2004; Van Der Heijden 1997 cited in Kuhn 2009, p. 155) concluded that using US is of minor value in the treatment of shoulder pain; therefore using US is of no value for treating impingement syndrome.
    3. ‘There is no data for or against the use of cold or heat as a modality; thus, their use must be optional at this point’ (Kuhn 2009, p. 155).
    4. Cumpston et al. (2007, p. 1-2) in their SR concluded that there is some evidence that glyceryl trinitrate patches are more effective than placebo in the short term (first week of symptoms), and not clear on the long term effect. In addition, headaches were found to be common side effect in one of the studies. There is insufficient evidence to assess its effectiveness in treating rotator cuff disease (Cumpston et al, 2007, p. 15).
    5. Faber et al. (2006, p. 7) in their SR found conflicting evidence regarding improvement in function after steroid and analgesic injections.
    6. Regarding functional limitations a SR from 2006 reported ‘strong evidence that extracorporeal shock wave therapy (ESWT) is no more effective than placebo’ (Schmitt et al. 2001; Schmitt et al. 2002; Speed et al. 2002 cited in Faber et al. 2006, p. 21).
    7. Bal et al. (2009, p. 31) showed that there is no distinct advantage of using low level laser therapy (LLLT) in combination with 12 weeks home exercise program compare to exercise alone, in relation to pain and function among people with SAIS.
    8. Faber et al. (2006, p.21) in their SR found that laser is not superior to placebo in regard to functional limitations.
    9. CT evaluated the effectiveness of PEMF in the acute phase of SAIS, found that there isn’t additional benefit to PEMF in that stage (Aktas, Akgun & Cakmak 2007, p. 1234).
    10. They also found that patients that treated by both nerve block and standard rehab ( ice, pendulum, electrical stimulation, accessory joint play, strengthening, stretches etc) reported significantly less pain during physiotherapy sessions and had better final results compare with standard therapy alone.

    These 20 points on various types of treatments preferred for SA impingement or RC impingement are based on systematic research studies and are usually followed at our Physiocure once the patient is examined and diagnosed correctly.

    CONCLUSSION:-

    Rotator cuff disorders and subacromial impingement are well connected and can predispose to one another. Many theories have been suggested to try and explain the pathoaetiology of these disorders, but it is still a mystery to some extent. To date there is still a debate whether the cause is more due to extrinsic or intrinsic mechanisms, but it seems that the intrinsic theory is gaining momentum in recent years.

    Regarding management, there are many tools that can be used; none of them is a “gold standard” treatment and most of them are lacking clear clinical benefit. However, it seems that combination of treatments including some “fancy” manual therapy techniques can contribute to cope with the challenge of treating this pathology.

    Finally, if conservative approach has failed, surgical treatment can be considered.

    REFERENCES:-

    1. Aktas, I, Akgun, K & Cakmak, B 2007, ‘Therapeutic effect of pulsed electromagnetic field in conservative treatment of subacromial impingement syndrome’, Clinical Rheumatology, 26, pp. 1234-39.
    2. Bal, A, Eksioglu, E, Gurcay, E, Gulec, B, Karaahmet, O & Cakci, A 2009, ‘Low-level laser therapy in subacromial impingement syndrome’, Photomedicine and Laser Surgery, 27, no. 1, pp. 31-6.
    3. Buchbinder R, Green S, Youd JM. Corticosteroid injections for shoulder pain. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD004016. DOI: 10.1002/14651858.CD004016.
    4. Cleland, J 2007, Orthopeadic Clinical Examination: an evidence based approach for physical therapists, Saunders, Philadelphia, USA.
    5. Codsi, MJ 2007, ‘The painful shoulder: When to inject and when to refer’, Cleveland Clinic Journal of Medicine, 74, no. 7, pp. 473-88.
    6. Coghlan JA, Buchbinder R, Green S, Johnston RV, Bell SN. Surgery for rotator cuff disease. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD005619. DOI: 10.1002/14651858.CD005619.pub2.
    7. DeSantis, L & Hasson, SM 2006, ‘Use of Mobilization with Movement in the Treatment of a patient with Subacromial Impingement: A Case Report’, The Journal of Manual & Manipulative Therapy, vol. 14, no. 2, pp. 77-87
    8. Dorrestijn, O, Stevens, M, Winters, JC, van der Meer, K & Diercks, RL 2009, ‘Conservative or surgical treatment for subacromial impingement syndrome? A systematic review’, Journal of Shoulder and Elbow Surgery, 18, no. 4, pp. 652-60.
    9. Faber, E, Kuiper, JI, Burdorf, A, Miedema, HS & Verhaar, JAN 2006, ‘Treatment of Impingement Syndrome: A Systematic Review of the Effects on Functional Limitations and Return to Work’, Journal of Occupational Rehabilitation, 16, no. 1, pp. 7-25.
    10. Haahr, JP & Andersen, JH 2006, ‘Exercises may be as efficient as subacromial decompression in patients with subacromial stage II impingement: 4-8 years’ follow-up in a prospective, randomized study’, Scandinavian Journal of Rheumatology, 35, no. 3, pp. 224-8.
    11. Kibler, WB 2006, ‘Scapular Involvement in Impingement: Signs and Symptoms’, Instructional course lectures, 55, pp. 35-43.
    12. Lewis, JS 2009a, ‘Rotator cuff tendinopathy’, British Journal of Sports Medicine, vol. 43, pp. 236-41.
    13. Lewis, JS 2009b, ‘Rotator cuff tendinopathy/subacromial impingement syndrome: is it time for a new method of assessment?’, British Journal of Sports Medicine, vol. 43, pp. 259-64.
    14. Lewis, JS, Wright, C & Green, A 2005, ‘Subacromial Impingement Syndrome: The Effect of Changing Posture on Shoulder Range of Movement’, Journal of Orthopaedic & Sports Physical Therapy, 35, no. 2, pp. 72-87.
    15. Michener, LA, McClure, PW & Karduna, AR 2003, ‘Anatomical and biomechanical mechanisms of subacromial impingement syndrome’, Clinical Biomechanics, 18, pp. 369-79.
    16. Michener, LA, Walsworth, MK & Burnet, EN 2004, ‘Effectiveness of Rehabilitation for Patients with Subacromial Impingement syndrome: A Systematic Review’, Journal of Hand Therapy, vol. 17, no. 2, pp. 152-64.
    17. Senbursa, G, Baltaci, G & Atay, A 2007, Comparison of conservative treatment with and without manual physical therapy for patients with shoulder impingement syndrome: a prospective, randomized clinical trial’, Knee Surgery, Sports Traumatology, Arthroscopy, 15, no. 7, pp. 915-21.
    18. Trampas, A & Kitsios, A 2006, ‘Exercise and Manual Therapy for the Treatment of Impingement Syndrome of the Shoulder: A Systematic Review’, Physical Therapy Reviews, vol. 11, pp. 125-42.

     

  • Frozen Shoulder

    Frozen Shoulder is a condition causing severe shoulder pain and difficulty in moving the arm in different directions leading to disability in daily life.
    The three hallmarks of frozen shoulder are:
    1. Gradual shoulder stiffness
    2. Severe pain (even at night)
    3. Near complete loss of range of movement at the shoulder.

    Laboratory tests and x-rays are usually normal.

    There are 3 different stages of Frozen Shoulder:
    Stage 1: The Painful stage
    This stage usually lasts for 3 to 9 months. The pain experienced is severe in nature causing difficulty in performing simple movements like reaching the back pocket of trousers or front pocket of a shirt.

    Stage 2: stiffening phase
    This phase usually lasts for 4-12 months, where the difficulty in moving the arm gets worst. Overhead activities like combing hair and other self-grooming activities like wearing a shirt may be restricted.

    Stage 3: thawing phase
    This phase lasts for 5-26 months. There is minimal pain but a significantly limited shoulder mobility. In this phase there may be gradual recovery of movements which can be further improved by mobility and stability physio rehab.

    The few known causes for frozen shoulder are:
    Existing medical problems like diabetes,
    hormonal problems eg. post menopause or biochemical changes at the shoulder.
    History of repetitive shoulder injuries,
    post-surgery,
    stroke, or
    history of wrist fracture.

    How Physio helps with Frozen shoulder?
    On the 1st visit based on your symptoms and complains we first identify which stage of frozen shoulder you are in.
    We at PhysioCure, we first identify the stage of frozen shoulder and the treatment program is designed as per your goals. You will be counselled about the process and duration required for the treatment program. The rehabilitation focuses on reducing pain and improving overall shoulder mobility. A combination treatment usually involves electrotherapy, manual therapy and/dry needling, taping along with the rehab exercises.
    Usually the rehab lasts for 1 month to 6 months depending on the severity and the patient compliance with the programme.

    How does diabetes affect frozen shoulder?
    Due to increased glucose level in the blood, the soft tissues around the shoulder tend to become stiff leading to worsening of symptoms. It is usually common in both the sexes. A direct correlation is unknown, but controlling blood glucose along with physiotherapy will lead to better recovery.

    Is Physio necessary inspite of taking steroid injections?
    While steroid injections help to reduce the swelling inside the joint, it does not play an active role to help regain the shoulder mobility. This is where physiotherapy helps. With our customized rehab program you should be able to acknowledge the improvement within 4 weeks.

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