RUBBING SHOULDERS The type of injury behind an aching shoulder determines the best course of treatment.
Shoulders can be a pain. One day your arms move freely and reach overhead and do everything you ask of them, then, as if from nowhere, they stop working.
And when they get sore, oh boy do they get sore. A nagging dull ache at the outside of the shoulder, where your regimental crest would be if you were a soldier. And it aches. Then you go to reach the tea from the kitchen cupboard and the ache becomes sharp for a while, then goes back to aching and stops you from sleeping that night, and probably for a week.
What causes that? Why does something that always seemed to move so well decided to become a problem all of a sudden?
Well, the answer is complicated. There are numerous possibilities, and you could have a combination of all of them, so let’s start with an anatomy lesson then look at the three most likely causes: rotator cuff tendonitis, impingement syndrome and frozen shoulder.
The shoulder is essentially a ball and socket joint. I say essentially, because it’s a big ball in a not very big or deep socket. If you make a fist with one hand, and rest it in the palm of your other hand, without closing your fingers, that’s roughly how the shoulder joint fits together. Now as you can imagine, a joint that open has plenty of movement available to it, but is pretty unstable. Which explains why it’s possible to swim backstroke, but also relatively easy to dislocate a shoulder. In order to provide some stability to the shoulder, we have a group of five small muscles that come from various points around the shoulder blade, and attach just below the head of your humerus (the ball at the top of your arm). These muscles are called the rotator cuff, and as the name implies, they form an active sleeve around the joint helping the ball to move around, but stay stable on, the socket.
The first, and most common cause of shoulder pain – rotator cuff tendonitis – comes from damage or irritation to these rotator cuff muscles. The small tendons of the rotator cuff muscles pass through quite confined spaces, and if everything is not working in the correct pattern, or some form of trauma is suffered, the tendons become damaged. Think of an old shoe lace that frays over time and eventually breaks.
The second common cause of shoulder pain is somewhat similar; impingement syndrome is where one of the rotator cuff tendons – the supraspinatus – gets squashed by the arch of bone at the top of your shoulder blade. People who do a lot of overhead activity often suffer with impingement, particularly if they have a hooked bone at the outer end of their shoulder blade.
Frozen shoulder is a painful and debilitating condition that in the early stages can mimic rotator cuff tendonitis or impingement. The correct name for frozen shoulder is ‘adhesive capsulitis’ which translates as ‘sticky, inflamed capsule’. There are three phases to a frozen shoulder: the freezing phase, where the joint capsule becomes progressively more inflamed and adhesions form that tighten the normally mobile structure; in the frozen phase, the shoulder is stiff, but not excessively painful unless you try to reach towards the end or your range of movement; finally the resolving or unfreezing phase is when the shoulder spontaneously improves.
Adhesive capsulitis is thought to be an auto-immune reaction to trauma around the shoulder, is most common in women age between 40 and 70, and can last for up to five years, after which time most people recover 90 percent of their movement.
Rotator cuff injuries, impingement syndrome and frozen shoulder are all painful complaints that present very similarly and therefore need to be assessed and accurately diagnosed. Treatment of rotator cuff and impingement injuries revolve around settling the inflamed structures through rest and local treatment, and improving the stability and strength around the shoulder muscles. Interestingly, there is a growing body of opinion and evidence to suggest that hanging monkey-like from a bar could be very beneficial to patients with these types of complaints. In severe cases, injection or even surgery might be necessary, but if caught early, most people will get good relief from physiotherapy.
Treatment for frozen shoulder focuses on maintaining and improving what range of motion there is, and keeping strength up, so that when the shoulder starts to recover, the patient is able to take advantage of the increasing range of movement. In some cases, steroid injection or manipulation under anaesthetic may be required, where the joint is stretched as far as possible to break up the adhesions and restore movement.
If you have shoulder pain or restricted movement, you should contact your chartered physiotherapist or GP for assessment. As with all injuries, the sooner it is diagnosed, the better.
Andrew O’Brien is a chartered physiotherapist and the owner of Wannarun Physiotherapy and Running Clinic at Westport Leisure Park. He can be contacted on 083 1593200 or at www.wannarun.ie.