We never really think about how much we use our shoulders in daily life until we experience shoulder pain. Your day is probably filled with reaching, lifting, stretching, picking things up and other activities that involve your shoulders. As a result, shoulder pain can reduce your quality of life in a big way. Almost every type of shoulder pain can be alleviated and treated with physical therapy. If you’re living with severe shoulder pain, don’t hesitate to give us a call and schedule a consultation with a physical therapist.
What is Shoulder Pain?
“Shoulder pain” is really just a generic term for something that makes your shoulder area hurt. The shoulder is a complicated ball and socket joint that includes your collarbone (clavicle), your upper arm bone (humerus) and the shoulder blade itself (scapula). The shoulder has ligaments and muscles attached to it from your back, chest, and arm. An injury or debilitating condition to any of those attachments, bones, ligaments or muscles can lead to “shoulder pain.”
The only question is, how serious is the pain? Some types of shoulder pain are so severe that it can completely restrict your movement — for months at a time. If it is an ongoing pain that doesn’t seem to be getting better, you should seriously consider physical therapy for pain relief and to help you recover.
Causes of Shoulder Pain
Acromioclavicular Joint Injuries
The acromioclavicular (AC) joint is the place where the acromion process of the scapula meets the end of clavicle. Injuries can occur at this location due to traumatic experiences or overuse. Most traumatic experiences happen in males under the age of 35 and are typically associated with falling on the shoulder during athletic events. The ligaments holding the joint together are often stretched and damaged during the traumatic experience resulting in shoulder separation. Overuse syndromes result from the breakdown of cartilage at the joint causing the bones to rub together.
Symptoms most commonly associated with AC joint injuries include pain in the shoulder, swelling and tenderness over the AC joint, decreased strength and range of motion of the affected extremity, popping sounds associated with movement of the shoulder, and pain when lying on the affected shoulder.
Physical therapy will assist in gaining range of motion and strength, encouraging appropriate movements of the affected extremity to avoid further damage, reducing pain, and ultimately, getting you back into life!
Osteoarthritis (OA) of the shoulder is common in both men and women who have participated in repetitive tasks for many years. The cartilage-lined surfaces of both the humeral head and the glenoid fossa of the scapula, the two bones that make up the shoulder, become worn-down and result in the bones rubbing together. Often, bone spurs, protrusions of bone, are also associated with OA and can lead to tearing of the rotator cuff muscles.
Symptoms associated with OA of the shoulder include pain during activities that is typically relieved with rest, decreased range of motion and strength in the shoulder, and difficulty sleeping especially on the affected side.
Skilled Physical Therapists and Physical Therapist Assistants will instruct in gentle strengthening/stretching exercises, perform manual therapy to increase range of motion, and use modalities to reduce pain.
Adhesive Capsulitis (Frozen Shoulder)
Adhesive Capsulitis (Frozen Shoulder) results from scar tissue in the shoulder that limits motion and causes pain. The cause of adhesive capsulitis is debatable, but some people believe it is caused by inflammation of the joint or an autoimmune disease, a condition where the body attacks itself. This condition typically affects women more than men. Of these women, the average age is 45 years old or above.
Symptoms of frozen shoulder are categorized by four phases:
Phase 1: Pre-Freezing - pain is present for 1-3 months, motion is becoming limited into all planes due to pain, and sleep is becoming progressively more difficult
Phase 2: Freezing - symptoms are present for 3-9 months with motion very limited into all planes due to stiffness and pain.
Phase 3: Frozen - symptoms are present for 9-14 months. At the beginning of this phase, there is a substantial amount of pain. Toward the end of this phase, pain begins to reduce allowing for more motion of the shoulder.
Phase 4: Thawing - symptoms are present for 12-15 months. Pain is decreasing at a rapid rate, sleep is improving, and motion is almost back to normal with significantly less pain noted.
Physical therapy is beneficial in all stages of frozen shoulder. Beginning with light stretching and strengthening exercises and modalities to reduce pain, the patient will progress into moderate to aggressive stretching and strengthening to gain motion, strength and reduce pain. Once the pain begins to subside, physical therapists will focus on gaining normal activity of the shoulder allowing for more everyday use without pain.
Bursitis occurs when bursa (fluid-filled sacs) become irritated and inflamed. Bursa serve as a cushion between tendons and bones to reduce friction. With inflammation, the bursa become painful during movement. Shoulder bursitis can be caused by repetitive motions particularly in an overhead plane, incorrect posture, muscle weakness, direct trauma such as falling on the shoulder, bone spurs (overgrowth of bone), autoimmune diseases, and surgery.
Symptoms of bursitis include pain with or without touching the affected area, difficulty sleeping especially on the affected side, limited motion due to pain, and decreased strength as a result of limiting motion to prevent pain.
Symptom reduction will be easily attained by beginning skilled physical therapy sessions. Focus will be placed on pain reduction through use of modalities such as ultrasound, postural education, light strengthening and stretching exercises, and manual therapy to promote increased range of motion.
Shoulder dislocation is defined as a displacement of the humeral head from the glenoid fossa of the scapula. The humeral head, a ball-shaped surface at the top of the arm bone, is held inside the glenoid fossa, a concave surface of the shoulder blade, by soft tissue structures called labrum, ligaments, muscles, and tendons. If a dislocation occurs, both the soft tissue structures and the bones can become damaged. In mild cases, this condition can be treated conservatively with physical therapy. However, most cases require surgery to repair the damaged structures of the shoulder joint.
Symptoms of dislocation include pain, inability to move the arm, and an awkward appearance of the shoulder.
Conservative treatment in mild cases would include modalities to reduce pain, strengthening and stretching exercises, manual therapy to increase range of motion of the shoulder, and postural education.
Post-surgical treatment would include patient education of the protocol used during recovery, strengthening and stretching exercises, manual therapy to increase range of motion, postural education, and return to sports or activities of daily living training.
Shoulder impingement refers to the repetitive compression or “impingement” of the rotator-cuff tendons. A common location for impingement is the subacromial space, the space where tendons, ligaments, and bursa reside under the acromion process of the scapula. Impingement is caused by repetitive, overhead movements, a traumatic injury such as falling on an outstretched arm, osteoarthritis/bone spurs, muscle imbalances and weakness, and poor posture.
Symptoms of shoulder impingement include restricted movement of the affected extremity due to pain and muscle weakness, pain during sleeping especially on the affected side, and difficulty performing dynamic movements due to pain.
Physical therapists and physical therapist assistants will assist with pain management via strengthening and stretching exercises, manual therapy to increase range of motion, modalities for pain relief, postural education, and training to return to sports, occupations, and activities of daily living.
Shoulder Labral Tear
The labrum of the shoulder refers to a ring of cartilage that surrounds the glenoid fossa of the scapula and helps to hold the humeral head inside of the glenoid fossa to produce the ball-in-socket shoulder joint. The labrum can be torn in both non-traumatic and traumatic experiences. Non-traumatic tears occur due to muscle weakness and shoulder instability that put stress on the labrum. Traumatic tears result from a single incident such as falling on an outstretched arm. Labral tears can produce symptoms or be pain-free. If conservative treatments such as physical therapy do not eliminate symptoms, surgery may be required.
Symptoms of a labral tear include pain on top of the shoulder, popping or clicking sounds during movement due to instability of the shoulder joint, and muscle weakness.
Physical therapy will include postural education, strengthening and stretching exercises, modalities for pain relief, manual therapy to improve range of motion, and education for returning to sports, occupations, and activities of daily living. If surgery is required, physical therapists will follow a protocol to gradually improve range of motion and strength while reducing symptoms.
Thoracic Outlet Syndrome
Thoracic Outlet Syndrome (TOS) is caused by compression of structures in the thoracic outlet, a place just above your first rib, and behind the collar bone that results in various symptoms that can impair the upper extremity function. There are four main types of TOS with various symptoms:
Arterial TOS: pain in hand, coldness, numbness and tingling
Venous TOS: pain and swelling in the arm, change in arm coloration (bluish), numbness and tingling into hands
True Neurogenic TOS: pain, numbness and tingling in upper extremity and neck, headaches, cold intolerance, hand coldness and color changes
Disputed Neurogenic TOS: pain, numbness and tingling in upper extremity and neck, headaches, cold intolerance, hand coldness and color changes, tests may come back normal (hence the term “disputed”)
Physical therapists can help reduce pain and symptoms by performing gentle manual therapy like mobilizations to reduce nerve symptoms, postural education, strengthening and stretching exercises, and education for activity modifications to place less stress on the structures involved with TOS.
Total Shoulder Replacement
Total shoulder arthroplasty (TSA) is a surgical procedure that involves replacing part or all of the shoulder joint. The humeral head is replaced with a metal ball and the glenoid fossa that the humeral head sits in is replaced with a plastic cup. Another type of total shoulder arthroplasty is called a reverse total shoulder arthroplasty. This procedure involves reversing the metal ball and plastic cup and is typically the method of choice when the rotator cuff muscles are damaged by allowing the deltoid to take over the functions of the rotator cuff muscles.
TSA is performed when the motion of the shoulder is lost due to osteoarthritis, rheumatoid arthritis, severe shoulder fracture, rotator cuff disease, and osteonecrosis of the shoulder.
Prior to surgery, physical therapy will address range of motion and strength limitations to allow for an easier and quicker recovery. Following surgery, physical therapy will address limitations and pain via strengthening and stretching exercises, manual therapy to improve range of motion, modalities to reduce pain, postural education, and training for returning to work, hobbies, and activities of daily living.
Rotator Cuff Tear (non-surgical and surgical)
The rotator cuff is a group of four muscles that help keep stability in the shoulder joint. Injuries to the rotator cuff is common due to repeated overuse of the arm. Typically, tears occur later in life due to falls or straining the shoulder. However, younger individuals can tear their rotator cuff through traumatic injuries during sports or hobbies. If a tear does not dramatically limit the motion of the shoulder or cause pain, surgery may not be required. Tears are classified as full-thickness, extending from the top to the bottom of the rotator cuff muscle/tendon, or partial-thickness, affecting some portion of the rotator cuff muscle/tendon without completely tearing. These classifications determine the protocols used during physical therapy.
Symptoms of a torn rotator cuff include pain over the top of the arm or down the outside of the arm, shoulder weakness, and loss of motion.
Non-surgical approaches: physical therapists will educate you on modifications during arm movement to reduce discomfort, teach you strengthening/stretching exercises, perform manual therapy to improve range of motion, use modalities to reduce pain, and teach postural education.
Surgical approaches: specific protocols from the orthopedic surgeon will outline progressions of exercises and passive range of motion used by physical therapists to safely gain correct use of the upper extremity. Strengthening and stretching exercises, modalities to reduce pain, manual therapy to increase range of motion, and postural education will aid the healing process following surgical repair.
Rotator Cuff Tendinitis
A group of four muscles make up the rotator cuff of the shoulder. They work together to help raise, rotate and stabilize the shoulder. With repetitive motions and overuse, the tendons can get inflamed and irritated. This is referred to as rotator cuff tendinitis. Due to the pain felt by tendinitis, an individual will develop poor posture, decreased range of motion, and decreased strength. However, these factors can also contribute to the development of tendinitis.
Along with decreased range of motion and decreased strength, a person may also notice difficulty sleeping on the affected side, pain when reaching behind the back, and pain when reaching across the body. At times of rest, the pain may subside.
With correct education on erect posture, gentle strengthening and stretching exercises, modalities to reduce pain, and manual therapy to increase range of motion, the symptoms of tendinitis will begin to dissipate. Physical therapists will also encourage rest of the extremity and non-repetitive movements below 90 degrees of shoulder flexion, the motion of lifting the arm overhead in a forward plane.
Proximal Humerus Fractures
Most humerus fractures occur at the proximal (end closest to the shoulder) end of the bone. The fractures result from traumatic injuries such as a fall or a vehicle accident. Immediate attention is required with this injury in order to maintain complete function of the shoulder joint. Some humerus fractures require surgical intervention to reset the bone and attach hardware to help with healing. Other humeral fractures will heal correctly without surgical intervention. It is best to consult your orthopedic surgeon to make this decision.
Symptoms of a humeral fracture include pain, swelling, bruising, severely restricted movement of the shoulder, numbness and tingling throughout the extremity, and deformity of the upper arm. If surgery is required, symptoms afterward will include pain, swelling, lack of strength and range of motion, and possible numbness around the incision site.
Physical therapists will use modalities to reduce swelling and pain, manual therapy to increase range of motion, strengthening and stretching exercises, and education for safe return to function.
Biceps tendinitis is a common injury to the shoulder. Inflammation occurs at the long and short head attachments of the biceps muscle at the front of the shoulder. Most cases result from overuse of the shoulder, weakness of the rotator cuff, tightness in the shoulder joint, poor body mechanics, an abrupt increase in exercise routine, and age-related body changes.
Symptoms of biceps tendinitis include pain in front of the shoulder during use of the arms, tenderness during palpation of the area, radiating pain into the neck or down the arm, dull pain following activity, weakness of the shoulder joint, catching and clicking sensations, and difficulty with activities of daily living.
Physical therapy is a great adjunct for a quick recovery! Therapists use modalities to decrease pain, manual therapy to improve range of motion, strengthening/stretching exercises, and education for safe return to prior function.
A biceps rupture occurs when the biceps muscle pulls away from the bone. Men are affected more than women. Due to wear and tear of the biceps muscle, the injury typically occurs between the ages of 40 and 60 years old. The biceps muscle attaches at the shoulder and the elbow. At the shoulder, the muscle splits into two tendons: long head and short head. Though this injury typically occurs at the shoulder, the tendon can also rupture at the elbow.
When a biceps rupture occurs, symptoms include sharp pain in the upper arm or elbow, hearing a pop or snap at the shoulder or elbow, bruising or swelling in the upper arm or elbow, weakness, tenderness to palpation, muscle spasms in the shoulder or arm, and a bulge in the lower part of the upper arm.
In most cases, this injury can be treated with physical therapy. Therapists utilize modalities to decrease pain, manual therapy to increase range of motion, strengthening and stretching exercises, and education for safe return to prior level of function. If the injury leads to long-lasting symptoms that affect the function of the arm, surgical intervention may be required to repair the rupture.