- Shoulder Pain Key Facts
- What are the main causes of Shoulder Pain?
- What increases the chances of getting shoulder pain?
- How is shoulder pain diagnosed?
- Do you need a scan or investigations for your shoulder pain?
- Do you need to consult an orthopaedic surgeon for your shoulder pain?
- Our best advice and tips for Shoulder Pain
- I have seen a specialist or surgeon and they have recommended surgery, what should I do now?
- The latest research on Shoulder Pain Summarised
Shoulder Pain Key Facts
Shoulder Anatomy and Function
The shoulder joint complex is the most mobile joint in our body.
The shoulder is made up of three articulations or joints.
- These are the glenohumeral joint, which comprises of the ball of the humerus which connects with the scapula or shoulder blade, the acromioclavicular joint or AC Joint which connects the clavicle/collarbone to the scapula and the sterno clavicular joint which connects the clavicle to the sternum or breastbone.
- The clavicle is essentially the bridge between the arm and the rest of the body and the AC joint and SC joints are what keeps our arm attached to the body.
- The glenohumeral joint is the mobile portion of the shoulder complex which allows us to move our arm with a great degree of freedom.
One of the trade-offs for being so mobile is that the shoulder lacks stability that other joints like the hip are afforded with its deeper socket into which the ball inserts.
To enable greater stability, the shoulder has a strong hood of muscles which essentially wrap around the humeral head known as the rotator cuff.
This cuff assists with stability as well as initiating movements of our arm in all directions.
Interaction with surrounding structures
Our joints and muscles don’t just move in isolation.
They need the joints above and below to be mobile and functional as well.
The joints above and below the shoulder include the thoracic spine, the neck and the joints of the arm.
If we are to move the shoulder joint efficiently, we require mobility of these adjacent joints.
Thoracic spine mobility will allow the scapula to move more efficiently.
Similarly, the neck or cervical spine can have a significant effect on the motion and function of the shoulder.
The nerves that supply the messages of sensation and muscular function to the shoulder, originate from the neck.
If there is compromise to these nerves via an issue with a disc or any of the joints of the neck, this may present as pain in the shoulder region.
It is important that if there are co-existing issues with the neck and the shoulder that you have both areas thoroughly and expertly assessed by a medical practitioner or physiotherapist.
What are the main causes of Shoulder Pain?
Strain, overuse or tightness of muscles
Like any area of the body, overuse or doing things that you are unaccustomed to may result in trauma to the muscles of the shoulder.
You might be pulling weeds or shrubs out of the garden, painting the walls and roof of your spare room or throwing the cricket ball to your kids in the nets for the first time in ages.
This may result in your muscles getting sore for the days following your unaccustomed activity.
Often this is not a big issue and your physiotherapist can advise you the best way to recover from this overuse.
However, there are occasions where a muscular strain may result and this needs to be managed appropriately to ensure you can get back to doing what you love, sooner.
Our work often requires us to do repetitive tasks or sustain postures for extended periods of time.
This may result in fatigue of the muscles of the neck, upper back and shoulders and as a result, these muscles may become tight and stiff.
There are some simple remedies for this including gentle massage and the application of a heat pack or wheat bag.
This can encourage those tight muscles to relax and the pain to reduce.
If these symptoms are persistent, your physiotherapist can help with strategies to correct your work postures as well as address any short term discomfort you may be experiencing.
Falls may result in significant injuries to the shoulder complex including fractures to the bones of the shoulder.
Fractures are where a bone breaks either partially via a “greenstick fracture” where the bone bends like a green stick (most common in children and adolescents) through to larger fractures completely through the cortical structure leading to instability of the bone and joint.
Injuries to the bones are characterised by significant pain and bruising due to the rich supply of blood and nerve vessels to the bone.
Some of the more common fractures are:
- Clavicle Fractures
- The collar bone may be injured with a fall on the outstretched arm or a direct blow to the side of the arm where the force is directed along the line of the collarbone.
- There is often a “step deformity” where there is a visible difference along the line of the collarbone where it dips into a “step” shape at the fracture site.
- You can immobilise the shoulder to protect the fractured collarbone by tucking the forearm into the bottom of the patient’s shirt to create a makeshift sling.
- Clavicle fractures MUST be assessed by a medical professional, in a hospital emergency department if necessary.
- Humeral Neck
- The top of the upper arm bone known as the humerus can be injured during a fall and a fracture at this site requires immediate medical investigation.
- Management of a humeral neck fracture may include surgical intervention to restore structural integrity of the bone and shoulder joint.
- These fractures are common in the elderly more than young people.
- Scapular fractures
- Direct trauma to the shoulder blade may result in the bone being injured and a fracture occurring.
- These are more commonly managed conservatively (without requiring surgery) but they need to be assessed by a medical professional to ensure safe recovery.
- Rotator Cuff tears
- These may be traumatic from a fall or sporting injury or more long term degenerative due to gradual overuse of the muscles of the cuff.
- Pain is experienced on the outside of the upper arm and the front of the shoulder area especially when the arm is lifted away from the body.
- This is when the soft tissue structures such as the bursa or tendons become squashed between the bones, in particular the humeral head and the acromion when the arm is taken away from the body.
- There is often a painful arc of motion where the pain coincides with the movement that results in the tendon and underlying bursa being squashed between the humerus and the “roof” of the shoulder but then the pain eases when the arm continues past this point overhead.
- There are a number of structures within the space between the “roof” of the shoulder or the acromion and the head of the humerus.
- There is a tendency to compress these structures including the rotator cuff tendons and the associated bursa when the arm is lifted up and overhead.
- This is a lack of structural integrity of the glenohumeral joint whereby the joint lacks control and the humeral head translates or slides more than normal and the shoulder dislocates or partially dislocates or subluxes.
- This may be due to a traumatic event such as a sporting injury where the ball of the joint slides out of the socket and requires relocation.
- Subluxations are partial dislocations which may be due to loosening of the capsule and ligaments following a dislocation or may be due to more gradual weakening of the supporting structures over time.
- The most common direction that a shoulder dislocates or subluxes is forwards or anteriorly and only in this one direction.
- In some cases though, there may be more than one direction that the shoulder tends to slide out of the joint. This may be anterior, posterior (backwards) and/or inferior (down). When there are multiple directions of instability, this is known as multidirectional instability (MDI).
- MDI may be caused by a traumatic event however is more commonly due to a history of repetitive micro trauma (e.g. swimming, gymnastics, tennis) and is more common in young females. MDI patients may experience multiple dislocations per day and may require surgical intervention to tighten the capsule to reduce the frequency of the dislocations.
- Is a joint disease that may affect any synovial joint which refers to a joint which has a capsule surrounding the connection between two bones.
- Osteoarthritis may lead to erosion of the joint surfaces leading to a painful and stiff joint which progresses over years.
- In severe cases where the joint has deteriorated to the extent that motion is significantly reduced and pain is severe, osteoarthritic shoulder joints may require a joint replacement however this is generally considered as a last resort intervention after all conservative measures have been exhausted.
What increases the chances of getting shoulder pain?
- Your age (unfortunately), due to wear and tear and overuse
- Trauma- falls, MVA, sporting injuries
- Activity levels/conditioning- throwing sports, overhead weights, lacking general strength and control
- Occupation- repetitive overhead tasks e.g. painting or
- Hormonal Changes- may contribute to inflammatory responses
- Connective Tissue Disorders- e.g. Marfans, Ehlos Danos- these conditions increase the laxity of the ligaments and capsule of the GHJ which increases the instability of the joint
How is shoulder pain diagnosed?
An accurate diagnosis of shoulder pain is essential to ensure the most appropriate management in undertaken.
Skilled clinicians, especially Physiotherapist’s, will be able to determine what are the likely structures and pathologies that are contributing to your pain based on a combination of assessment tools at their disposal.
A thorough assessment will incorporate a thorough subjective history assessment which will provide a wealth of information regarding how the pain started, how long it has been persisting, what aggravates and eases the pain and determine how much this pain is impacting your life.
This information can guide the clinician and assist them to prioritise their assessment.
Below is a summary of commonly encountered shoulder conditions and the characteristic patterns that they present with:
Muscular Strains, Overuse or Tightness
You might have gone out into the garden and pulled down a vine or gone to the gym and performed an exercise that you haven’t done before. The next day and the days afterwards, you feel a general ache in your shoulder and a sharper pain when you lift your arm or reach for a coffee cup.
There seems to have been a definite time that the pain started and it coincided with the unaccustomed activity or event.
Movement may be painful and restricted due to the muscular injury which may be detected with strength testing. If the weakness persists, there may be a muscular tear or strain which may take a little longer to recover.
Your myPhysioSA Physiotherapist is an expert in guiding you through the recovery of these injuries via ensuring you regain the strength and function of the shoulder with exercises specifically targeted towards the injured muscles.
There is not usually a need to image or scan the muscles in these cases unless a significant injury is suspected.
Shoulder impingement is a common source of shoulder pain and it occurs when the tendons or bursa of the shoulder are compressed or impinged.
Activities including overhead elevation of the shoulder, particularly with repetition may lead to impingement occurring.
Pain may develop following activities such as swimming, painting, serving in tennis or volleyball or other overhead activities.
Persistent shoulder impingement may lead to inflammation of the bursa (bursitis) and/or the tendons of the rotator cuff (tendinopathy) and this may in turn lead to deterioration and tearing of the tendons.
Let’s get to the bottom of what shoulder bursitis is, and what the treatment options are.
David, one of the Partner Physio’s at myPhysioSA summarises shoulder bursitis in his blog below:
If you’d like to jump straight to punchline, here it is. Bursitis is often caused by the way you move, and visiting a physiotherapist will help you to learn how to move in a way that doesn’t aggravate the bursitis.
Anti-inflammatories, including oral tablets and cortisone injections, can reduce the inflammation, but won’t stop the problem re-occurring.
Do you ever suffer from pain that makes it difficult for you to exercise, or even do daily activities?
It’s frustrating to be limited in this way, and sadly, it’s something that happens to a lot of people. What’s even worse, is that sometimes you might go to see a health professional about the pain, and end up with a misdiagnosis that leads to treatment recommendations that don’t help you get better, and sometimes can make it worse. All too often people are told to stop activity, which can lead them down a path to total inactivity and less and less mobility.
Sometimes rest is the best cure, and sometimes it isn’t. So let’s delve into one of the common problems that I come across, which is bursitis often of the shoulder.
Our friends at Move Through Life Dance Studios across Adelaide, interviewed me about shoulder bursitis and the below is excerpts from that interview.
I’ve got how many bursas?
Technically you have bursas all around your body. A bursa is like a friction pad that stops tendons rubbing onto bones, or bones putting pressure on tendons, so the tendons can glide and slide. If you use certain muscles and tendons a lot it can cause extra pressure on the bursa underneath it and the bursa can thicken and swell. This is what is called bursitis.
Bursas and pain
It’s quite common to have a bursa that’s enlarged or thickened. It’s like a sack with fluid in it and most are only a few mm thick. In the shoulder, there is not a lot of space for it, and there are bony bits all around. In bursitis, the bursa can thicken to 5-8mm, which can cause pinching. We call this shoulder impingement.
The pain associated with this kind of impingement as a ‘painful arc’ that would be called a shoulder impingement, but stresses that this isn’t necessarily caused by bursitis.
I’m talking about the arc of movement from when your arm is next to your leg until it is up over your head. This is a 180 degree arc. At 90 degrees, when your arm is at shoulder height, it’s most likely to be pinching the most, and then the pain with lessen as you lift it higher than shoulder height.
Diagnosis of bursitis
If someone had shoulder pain and presented to physio like this, we would label them as impingement, but wouldn’t know what is pinching. It could be a bursa, or it could tendonitis. Bursitis is normally diagnosed formally when someone goes and gets a scan.
The thing with getting a scan is that pretty much anyone with any sort of shoulder pain who gets a scan quite often gets bursitis diagnosed. But it doesn’t always mean that’s the cause of your pain.
Bursitis is reasonably common in both shoulders for anyone at any time. This is where it gets complicated – trusting scans. Often there are all sorts of things on the scan like bulged discs or arthritis. But quite often it’s none of those things giving them trouble. In the 45 plus age group, 80% will have a disc bulge at any one time. This is people with no pain. Just because something shows up on a scan doesn’t mean it is actually where the pain is coming from or that it is the problem.
Every scan I’ve had back in the last few years has shown some bursitis. But sometimes it doesn’t fit the clinical pattern of bursitis. I had a lady come in two days ago who could hardly move her shoulder. She’d had a scan and was told it was bursitis. She was given an injection and it didn’t help. I checked her shoulder and discovered she has frozen shoulder, which is a completely different shoulder problem where your shoulder capsule is damaged. Frozen shoulder can take up to 2 years to fully recover from, but it doesn’t show up on ultrasound scans.
The take home point on this is that a scan and injection is costly, and may not even be addressing the real cause of pain anyway.
Physios have done all these years of study in these areas, and can get most people better without needing scans and avoiding having to see specialists and scans. Ultrasound scans with an injections is often between $300-400. For that amount, you could get quite a few physio appointments, a natural treatment without needing injections, which is a longer term fix. An injection just settles down the inflammation around the bursa, but doesn’t solve what caused the inflammation in the first place.
The causes of bursitis
You can get bursitis because of something sudden, or it can creep up on you.
Bursitis can be caused by a trauma or car accident or it can be jarred or wrenched, for example if you have a heavy fall . But most times it’s a biomechanical imbalance. And the biggest thing is the shoulder blade not sitting in a good position or not moving properly. When you lift your arm up your shoulder blade abducts, which means it rotates and elevates. So there are two different things happening at the same time and they need to work in unison. If they don’t, something goes wrong.
It’s not surprising things can wrong with the shoulder joint, because it’s the most complicated join in the body.
You have the shoulder socket and the ball, and at any one time only 30% of the ball sits in the socket. As opposed to the hip, which has a really deep socket and sits inside snugly, so it’s a lot more stable. You can easily dislocate a shoulder because so little of the ball is in the socket. Shoulders need a lot of muscle control and coordination to control the ball in the socket. You just need one little thing to go wrong and the shoulder can start to give you pain.
Your shoulder is very vulnerable if you are doing repetitive overhead movements of putting a lot of your body weight through your shoulders, like in cartwheels or push-ups, especially if something is not in balance. To avoid this, you need to learn how to move the shoulder and your blade correctly. We do a lot of training to make sure people know where their shoulder blades sit and how they move. If you have a clicky shoulder but it’s not painful, a lot of the time it will eventually it may become painful and become a full impingement.
When do you need treatment for shoulder bursitis?
If you are an office worker or do something where you don’t need to lift or carry things about shoulder height too often, you have a low risk of having a shoulder problem. If you are someone that is an office worker but does gymnastics or repetitive heavy lifts, you have a good chance at some stage if your imbalances are likely. If you feel a pinch you should go to see your physio.
One thing that can be an early sign of shoulder bursitis is pain sleeping on your shoulder at night and causing an ache that makes it difficult to go to sleep and when you wake up with pain.
We should stress that waking up with pain on one day isn’t something to be alarmed about.
There was some worldwide research done recently that asked people if they got pain every week, and 97% of Australians said they did. We are the highest nation in the world with pain. This doesn’t mean you should run out and see the physio and the doctor. You might have an ache that comes up for no reason and goes, then you don’t need to see the physio. But if it doesn’t settle in a few days, see someone. If it is going on for more than a week or two then get it checked.
Treatment options for shoulder bursitis:
- One treatment option is medication, in other words, pain relief. You can take anti-inflammatories, which is better than taking just paracetamol, because anti-inflammatories act at the site. If it goes away, you are all good. If it doesn’t go away within a few weeks, then there is something more to it and there must be something biomechanical going on that needs to be addressed. This is where a physio can help.
- Cortisone Injection
- A cortisone injection does the same thing as anti-inflammatories. It reduces inflammation. But when you take an oral anti-inflammatory it goes all around your body and has a small effect everywhere. An injection is more localised. If someone truly has bursitis and all pain is coming from an inflamed bursa, there’s a good chance it will help. But if you haven’t addressed what caused it in the first place it could be only a matter of time before it happens again. Cortisone will address the symptoms, but usually only temporarily.
- A physio can find out how the shoulder pain is behaving and that gives us hints as to what imbalances could be causing it. We then do a whole lot of tests to see how the shoulder blade is moving, and also check your neck and mid back, because they could be part of your shoulder is giving you trouble. We also need to check for nerves, because sometimes it can be neck referring pain in the shoulder. Physios are good at chasing that stuff. If you just saw a massage therapist they’d probably just massage the area and not be very diagnostic.
- The last resort
- The last resort if things aren’t getting better is to go to a doctor and then get scans. If you have lots of night pain that started for no reason and some other flags, and it’s going on for more than six weeks, you’ll normally get a scan to rule out cancer or an inflammatory disorder. If you see a physio, the physio will work you and together you can quickly decide if you’re getting better quickly enough. The physio can then write to your doctor and offer a Plan B.
- Stay in touch with your physio
- It’s best if you keep in touch with your physio all the way through. At the end of the day, if the pain is caused by an inflamed bursa that doesn’t improve with physio treatment, and you do need a cortisone injection, you also need to make sure that you get any imbalances corrected. The physio can do this, and give you a proper rehab program so that your shoulder is even stronger than it was before.
Physio treatment for shoulder bursitis
All physios are a bit different, but we have lots of techniques we can use. Early on taping the shoulder can give a lot of relief. There will be a certain position you can put the shoulder and shoulder blade in which will relieve it a lot. Then we can do massage, trigger point therapy, acupuncture, and mobilisation. So quite a few hands on techniques that we can use to help someone move their shoulder with less pain. Then we often give exercises to do at home.
If the physio isn’t helping enough then we would recommend a scan and possible injections. I would always try some physio because around 80% of people we see here never need a scan or injections, so a pretty good success rate of settling a shoulder down and not needing to spend lots of money and time. Plus, it’s a natural solution.
An unexpected statistic!
Only about 10% of the population really know about physios and what we do and what we can help with. So one of the things we spend a lot of time on educational marketing. Our marketing is educational because we want to get the message out there that we are a solution to all these different problems. Lots of doctors don’t know much about physio and feel like it’s a risky thing to tell their patient to go to physio because they’re not sure if we can help them, so we spend a lot of time educating doctors on what we do and how to refer to us. If they say ‘you can try physio, it might help, if it doesn’t I can do a scan and injection’, then you probably won’t feel very confident about visiting a physio. But if you doctor says ‘the vast majority of people find a physio helps’ than I’m sure you’ll be more confident about visiting a physio.
Teaching people about physio
This idea that people don’t understand what physiotherapists do drives a lot of the marketing that myPhysioSA do.
Part of our marketing is based on knowing that people don’t make the decision to see a physio, because they don’t know enough about it or they think their problem is unique. We do our ‘can physio help me’ session which is a free 15 minute session for people who are not sure about whether physios can help. We sit them down, check them over, explain the diagnosis. We let them know, what the plan of attack would be, how many sessions it will be, and give them that info so they can make a better decision. This is to help people make better decisions, because most people just put up with pain instead of making a decision.
Advise on some exercises that can help with bursitis:
We have a three-video series, which goes from gentle starter ones that work on shoulder blade position and control, through to strengthening the rotator cuff muscles, which are the deep support muscles that control how your shoulder ball moves in the socket.”
It’s not a ‘one-size fits all’ solutions because the shoulder is a very complicated joint. Some people have pain when they reach behind, some in front, some only when they reach to the side. You do have to customise your exercise, ideally, depending on what is the cause of your problem. So go to your physio to get tailored exercises and learn how to move correctly.
Bursitis starts to pinch at about shoulder level, so avoid the painful arc. And then once, if you have it diagnosed and you are doing rehab at the physio, they’d give very specific things about what to avoid once they’ve tested your shoulder. Shoulders are one area of the body where you should no push through pain. If something hurts, avoid it or change the movement so that it doesn’t hurt. If you feel pain, stop what you are doing. If you don’t feel pain proceed with caution.
If you’re feeling any kind of muscular or join pain, I thoroughly recommend seeing a physiotherapist.
myPhysioSA has offices in Payneham and Mount Barker.
When you chat to your Physio, take notice of whether they explain what is happening in your body and give you exercises to do at home to help.
By David Wilson
myPhysioSA Partner Physiotherapist Mount Barker
Rotator Cuff Tears
As described above, the rotator cuff is a hood of muscles that wrap around the head of the humerus and assist with initiating movement of the shoulder and they also provide a degree of stability to the joint by keeping the head of the humerus in close proximity to the scapula.
Tears to the rotator cuff lead to painful movements of the shoulder, particularly with movements away from the body such as lifting a kettle or reaching for the alarm clock in bed.
The rotator cuff may be injured traumatically in a fall or a sudden loaded action e.g. lifting too heavier weight in the gym or pulling forcefully on a stuck object however there are longer term, gradual tears that may occur with repetitive actions like painting or manual work.
Rotator cuff tears are characterised by marked weakness on testing of rotary actions of the shoulder.
Your myPhysioSA Physiotherapist will be able to diagnose these injuries with a comprehensive physical examination.
Imaging may be indicated in the event of a traumatic onset of the tear and if function of the shoulder is significantly affected, an orthopaedic surgeon’s opinion may be warranted.
If the function of the shoulder is not improving over time, despite good conservative management via restoration of range of motion and strengthening, surgery may be required to restore the tensile integrity of the rotator cuff tendons.
The labrum of the shoulder is a circular rim of cartilage, often described as resembling a calamari ring, which lines the edge of the socket to which to humeral head attaches.
The labrum creates a suction effect and contributes to the passive stability of the shoulder joint.
This labrum may be injured when the shoulder is dislocated or via repetitive actions such as throwing. Another way the labrum is often injured is during bench press movements when the weight being lifted shifts throughout the pushing movement and increased pressure is placed on the edge of the joint under load.
Labral tears are often characterised by a clicking or clunking of the joint as the arm is lifted forwards and/or away from the body.
In throwing sports, a labral injury may present when the athlete reports a reduction in throwing power or distance e.g. being unable to throw the ball into the keeper from the outfield in cricket.
An MRI is the most sensitive imaging test for labral pathology and this may indicate following a dislocation episode. If the labral tear causes ongoing instability and/or lack of power, a surgical labral repair may be indicated following assessment by an orthopaedic surgeon.
Here is a blog written by myPhysioSA Partner Physiotherapist, David Wilson on: Shoulder pain with throwing- SLAP lesions
What causes shoulder pain (SLAP lesion) with throwing?
These injuries often occur gradually over time in repetitive throwing sports (i.e. baseball, water polo, cricket), gymnastics, or through a tennis or volleyball serving action.
It also can occur as a ‘one-off’ incident such as anterior shoulder dislocation, or fall on outstretched hand. A key component of the injury mechanism seems be a strong distraction force through the arm.
What are the common symptoms of a SLAP lesion?
Athletes with SLAP lesions report pain deep and/or behind the shoulder, ‘dead arm’ feeling (unable to generate speed), aggravated by overhead activities, and potentially catching/ locking/ popping/ grinding with movement.
Up to 35% of athletes with shoulder pain may have a SLAP lesion.
What types of SLAP lesions are there?
SLAP lesions can be classified into 4 types, with higher grades indicating more serious injuries. Type 1 lesions may naturally occur in elderly people without any feeling of pain.
How is a SLAP lesion diagnosed?
There are a multitude of tests for diagnosing SLAP lesions which physiotherapists conduct. If a SLAP lesion is suspected, initial management consists of some anti-inflammatory medication and rest from aggravating activities.
Treatment to restore the normal shoulder mechanics and muscle strength is important. Your throwing action may also need to be modified to reduce the likelihood of this injury occurring in the future.
If a 6-week period of physiotherapy does not reduce your shoulder pain to enable a return to sport, you may need a referral from your local doctor to get some scans of your shoulder (x-ray, MRI, or ultrasound) and/or an appointment with an orthopaedic surgeon.
Physiotherapists also assist patients with rehabilitation after surgery if that is decided as the best course of action.
So, if you are experiencing shoulder pain from overhead sport this winter, make an appointment to see one of the Physiotherapists at Payneham, Mile End or Mt Barker, so we can help you out!
A guide to Shoulder Dislocations
Dislocations of the shoulder generally occur as a result of trauma to the shoulder joint and are often seen occurring during contact sports.
The most common mechanism for a shoulder dislocation occurs when the arm is away from the body, often overhead and there is forceful contact placed on the arm, leading to leverage of the humerus and the head of the humerus forces forwards out of its socket.
Examples of this are an athlete tackling an opponent with the arm as the player runs past them. The arm is forced back and the humeral head drives forwards out of the socket.
Other mechanisms are a fall onto the bent elbow which drives the humerus upwards relative to the joint, a direct blow to the upper arm/shoulder from behind when the arm is away from the body or even a fall forward onto the outstretched arm, driving the humeral head back and out the back of its socket.
The direction that the humeral head moves corresponds to the type of dislocation described; anterior dislocation slides out the front, posterior dislocations slide out the back and inferior dislocations slide downwards out of the socket.
Traumatic dislocations are normally unidirectional meaning they only go out in one way.
However, there are some people who experience multi-directional instability where the joint is unstable in more than one direction. They may experience dislocations or partial dislocations (subluxations) in two or more of the anterior, posterior and/or inferior directions.
This may be due to multiple dislocation episodes or may be due to connective tissue abnormalities e.g. Marfans or Ehrlos Danos syndrome.
Dislocations can be distressing episodes for the person experiencing the event, however it may also be confronting for the people around the patient.
Our instinct is to help someone who is injured however, in the event of a shoulder dislocation, it is not a good idea to try and relocate the shoulder unless you are medically trained to do so.
Shoulder dislocations, if they don’t reduce or relocate spontaneously need to be relocated by a doctor in an emergency department.
While awaiting an ambulance to arrive, it is important to make the patient as comfortable as possible to encourage the muscles to relax.
This may in fact enable the joint to reduce of its own accord. Individuals who have had multiple dislocation episodes may be familiar with a manoeuvre that relocates the shoulder by themselves. The dislocated shoulder should never be forced into any position and relocation must be performed by a medically trained professional.
If you have had a dislocated shoulder, then watch this video to help decide what is the best course of action.
myPhysioSA interviews Dr James McLean on the topic of Shoulder Dislocation.
Dr McLean is an Orthopaedic Surgeon who specialises in the shoulder.
He covers the main types of shoulder dislocation, the common mechanisms and then symptoms that it will give.
Then there is discussion on when surgery is indicated, time frames for recovery and when conservative management should be considered as the first option.
Do you need a scan or investigations for your shoulder pain?
There are many different ways that a shoulder may be injured and numerous structures which may be at fault.
There may be times when radiological imaging is necessary in order to ascertain an accurate diagnosis.
Signs that you may require scans on your injured shoulder include:
- Constant, unrelenting, severe pain of unknown origin, particularly at night.
- Increasingly severe neurological signs including burning pain, weakness of the arm and hand muscles and/or loss of sensation.
- Following an acute trauma e.g. a fall, motor vehicle accident or sporting injury where there was a distinct onset of the pain.
- Following a dislocation with a period of locking out of the joint.
- Symptoms of weakness and pain that are not improving over time, despite a well-structured conservative management program.
Do you get shoulder pain at night? Then read this blog by Ryan, a myPhysioSA Sports Physiotherapist from our Mile End Adelaide clinic.
Is your shoulder causing you pain at night? Waking you from a deep sleep?
Stopping you from getting back to sleep in the middle of the night?
Shoulder pain at night in the shoulder and upper arm is common for many shoulder conditions.
Some of the shoulder conditions that may present with pain at night include tendon injuries (tendinopathy) and rotator cuff tears, impingement and bursitis or arthritis of the shoulder joint.
Pain in the shoulder at night can make sleeping difficult due to the discomfort that affects getting to sleep in the first place. Pain that may wake you when you are asleep. It may also keep you awake when you wake up in the middle of the night.
It is often hard to find a comfortable position to sleep when you are experiencing pain.
Thankfully, there are some simple thing you can do to improve your sleep which is vital to general health and injury recovery.
Why Does my Shoulder Hurt More at Night?
There appears to be an inflammatory component to many shoulder conditions which tends to peak at night time when we are at rest.
During the day, you are more active and you move your shoulder and arm much more, although you probably try to avoid the movements which cause you pain.
We find that a painful joint feels better when it is gently moved which may be one reason why you have less pain during the day compared to at night.
Lying on your painful shoulder can increase the pressure on the joint which can be aggravating for a shoulder that is already swollen, inflamed and painful.
Long periods of compression on the inflamed joint may result from lying on the painful shoulder whilst in a deep sleep and this may further increase the pain.
How Can I Help My Night Time Shoulder Pain?
There are a number of things that you can try to reduce and ease the night time pain you are experiencing in your shoulder and upper arm.
- Avoid Sleeping on your Painful Shoulder
- Prolonged pressure on the painful joint can be aggravating for the shoulder. It can sometimes be difficult to avoid sleeping on your painful shoulder if that is the side you normally sleep on. Propping a pillow behind your back may help to reduce the likelihood of rolling onto your painful joint while you are sleeping.
- Increase the General Joint Range
- Gentle range of motion exercises can improve the overall joint health and may reduce the pain associated with stiffness of the joint.
As with any exercise, don’t push your joint into positions which cause you more pain.
This may increase the inflammation in the joint rather than ease your pain.
Try these simple exercises to keep your shoulder moving:
- Stick Flexion
- Lying on your back, hold a stick with both hands with your arms fully extended
- Using your pain free shoulder to move them, raise your arms up and over your head
- Slowly return your arms towards your waist
- Repeat 10 times
- Shoulder Rolls
- Roll your shoulder blades up and back in little circles
- You should feel the muscles on the top of your shoulders working to lift your shoulder blades up and back
- Repeat 10 times
You can try these exercises just before you go to bed but don’t push them too hard to cause any increase in pain.
What If My Shoulder Night Pain Persists?
Having a clear understanding of what is causing the pain in your shoulder is a vital first step in managing your condition. An experienced Physiotherapist will be able to direct you to the most appropriate management strategies for your shoulder.
Medications including analgesics and anti-inflammatories may be useful to reduce the night pain however use of these should be recommended and monitored by a medical professional.
If you are experiencing shoulder pain at night time and it is affecting your sleep, the Physiotherapists at myPhysioSA are highly skilled clinicians with vast experience in managing shoulder injuries and are ready and waiting to help you.
Written by Ryan Florence-Rieniets, Sports Physiotherapist at myPhysioSA SPARC, Mile End in Adelaide. Ryan has a keen interest in helping people with shoulder problems. So if you are having trouble with shoulder pain at night, get Ryan to help you.
Do you need to consult an orthopaedic surgeon for your shoulder pain?
As mentioned above, there are numerous structures that may be injured and present as pain in and around the shoulder.
Some of these structures may impact on the structural integrity of the joint and therefore the opinion of an orthopaedic surgeon who specialises in the management of shoulder injuries.
There are some occasions where it is obvious that a surgical opinion is warranted.
These include following traumatic events where fractures or significant tendon or ligament injuries have occurred or are suspected.
Dislocation Surgery Advice
Orthopaedic review is also warranted following a dislocation event.
Your doctor or myPhysioSA Physiotherapist will be able to determine whether an orthopaedic opinion is required following a thorough assessment including ascertaining the history of the injury as well as a comprehensive physical examination.
Surgery to repair the injured structures may be required in the event of significant injury, especially in the event of fractures and recurrent dislocations.
Orthopaedic surgical intervention may involve the use of screws and plates to realign and reduce fractured bony fragments to ensure the shoulder is anatomically capable of moving through its optimal range of motion and performing the tasks that you require.
Soft tissue reconstruction of the ligaments, capsule, labrum and tendons may also be required in some injuries as outlined above.
Total Shoulder Replacement Advice
In the event of advance osteoarthritis involving erosion of the joint surfaces, a shoulder replacement may be indicated to relieve pain and improve function, similar to joint replacement that is common in knees and hips.
Orthopaedic surgery of the shoulder normally involves a hospital stay of 1-2 nights followed by a period of 2-6 weeks in a sling, depending on the surgical intervention required.
The use of the sling protects the repaired site and allows the joint to heal without excessive movement or activity.
Your Physiotherapist will be able to expertly guide you through the recovery and rehabilitation stage of your post-surgical journey.
Rotator Cuff Tear Surgery Advice
Learn all about shoulder rotator cuff tears and the best options for treating them.
David, a Partner Physiotherapist at myPhysioSA Mount Barker, interviews Orthopaedic Surgeon, Dr Jan Tomlinson from Adelaide Hills Orthopaedic Centre, on all things shoulder rotator cuff injuries.
Jan covers topics such as:
- What is your rotator cuff?
- How does it get injured?
- What are the tests to diagnose a rotator cuff tear?
- What are the best treatment options?
- How a rotator cuff surgery repair is done?
myPhysioSA: Payneham, Mount Barker & Mile End
Shoulder Bursitis Surgery Advice
In the video below, Dr Jan Tomlinson, an Orthopaedic surgeon discusses the assessment and management of bursitis of the shoulder.
Physiotherapist David, from myPhysioSA interviews Dr Jan Tomlinson, an Orthopaedic Shoulder Surgeon, on all things Shoulder Bursitis treatment.
Together they discuss:
- What is shoulder bursitis?
- What tests are done to diagnose bursitis?
- What the best treatment options are?
- What surgery can help treat shoulder bursitis?
What other treatment options are there for shoulder pain?
Physiotherapy and Exercise
Many shoulder injuries do not require surgical intervention and can be managed effectively with Physiotherapy.
Your myPhysioSA Physiotherapist may employ multiple strategies to optimise your recovery and return to function including specific exercises to rehabilitate the injured muscles and tendons.
Restoring range of motion and strength are important priorities when rehabilitating an injured shoulder and there is a myriad of exercises that may achieve these goals.
Some commonly used exercises are listed further below, however your myPhysioSA Physiotherapist will be able to tailor a specific exercise program for your shoulder.
Medications (analgesics, NSAID’s, neuropathic pain meds)
Medications may be useful to alleviate pain in your shoulder, as prescribed by your doctor.
Analgesics and NSAIDs (anti-inflammatories) may be useful in the early stages of the injury to allow your body to rest more effectively, especially at night.
If there is a nerve or neural component to your pain, there are specific medications that may alleviate neuropathic pain. As with any medications, you must consult your doctor before taking these medications for your shoulder pain.
Here is a blog explaining pain medications by Neal Fitton, one of our Mount Barker Physiotherapist’s:
Pain Medication Options
There are many types of pain medication. In general, all pain medications are referred to as ‘analgesics’. Some analgesics are better for a particular problem then another. With all these different types of pain medication it can be difficult to know what medication works the best for a particular condition.
Therefore, this blog will give some general advice about the most common analgesic and what they are used for. This blog is not giving medical recommendations, rather it is providing general information. Medication is only one way to manage pain and usually can be enhanced by using physical and/or cognitive therapy.
- Analgesic Pain Medications
- So one of the most common analgesic is Paracetamol (eg. Panadol, panama etc). This medication has been shown to be effective for mild to moderate pain. It is typically used for headache and generalised pain. It also has a fever reducing capability. Paracetamol works by reducing the nerve signals sent to the brain.
- Opiods are a stronger form of analgesic (eg. Vicodin, Oxcycodone, Codeine). These drugs are typically used for moderate to severe pain. Opioids work by binding to opioid receptors in the brain and spinal cord. Our bodies can also form its own natural opiods, called endorphins. Opiods reduce pain by reducing the nerve signals to brain. They also effect the regions of the brain that control emotion.
- The body can develop a dependence on opioids in just a few weeks. Opioids have significant side effects including sedation, and reduced breathing rate. Because of these factors opiods are a prescription medication that are given cautiously and need to be taken under medical advice.
- Anti-inflammatory Pain Medications
- NSAIDs (Non-steroidal anti-inflammatory) are commonly used to manage pain relating to inflammation. Therefore these medications work by changing the body’s response to swelling and pain at a local tissue level. These drugs are effective for muscle strains, and sprains, arthritis, and back or neck pain.
- There are many types of NSAIDs. Common NSAIDs include aspirin, voltaren, nurofen and ibuprofen, which are available over the counter at Pharmacies. Your GP can also supply prescription anti-inflammatories such as Mobic, celebrex, naproxen or stronger voltaren or brufen tablets.
- NSAIDs are generally safe in short periods. However, long term use may cause issues with your stomach and liver. Most importantly, NSAIDs should always be taken under the direction of your GP.
Injections and interventions
Corticosteroid injections are commonly used for shoulder pain and can be effective for short to medium term management of pain for conditions including impingement and inflammation of the capsule.
These injections are administered under ultrasound or X-Ray guidance to ensure the steroid is injected into the area which was intended.
A GP or specialist may refer you for a steroid injection, but what is it?
Below is blog by myPhysioSA Mount Barker Physiotherapist, David Wilson, explaining all things steroid injections:
A steroid, or cortisone/corticosteroid, injection contains a strong anti-inflammatory medication that may help to settle pain that is not changing with physiotherapy management or that is hindering you from completing an exercise program or functioning with daily life.
A cortisone injection may be administered for certain conditions to relieve pain, such as for bursitis, mild trigger finger or low back pain, but injections of cortisone and an anaesthetic such as lidocaine can sometimes be used to confirm a diagnosis.
For example, corticosteroid injections given in the shoulder may reduce localised soft-tissue inflammation or bursal inflammation. Epidural injections in the lumbar spine are cortisone injections inserted into a specific location in the spinal canal of the low back by a specialist under X-ray guidance.
These injections may help relieve back pain and sciatica.
Epidural injections can also be given in other areas of the spinal canal to relieve upper back and neck pain.
How are they administered?
Corticosteroid injections are commonly delivered by a specialist under a guided ultrasound to ensure the correct structure is targeted. Corticosteroid, as well as a local anaesthetic (such as lidocaine), may simultaneously be drawn into a syringe, which is then inserted into the tissue where the solution is injected. The needle is withdrawn and a sterile bandage is applied to the injection site. At times the relief from a cortisone injection begins almost immediately after the procedure, but it can take up to 14 days for someone to notice a change in symptoms.
Short-term complications are uncommon but include:
- Shrinkage (atrophy) of the subcutaneous fat/ tissues
- Lightening of the of the skin at the injection site
- Local infection
- Local bleeding
- Soreness at the injection site
- Aggravation of inflammation in the area injected because of reactions to the corticosteroid medication (post-injection flare)
- Tendons can be weakened by corticosteroid injections administered in or near tendons. Tendon ruptures as a result of steroid injection have been reported
Long-term complications of corticosteroid injections depend on the dose and frequency of the injections.
With higher doses and frequent administration, potential/rare side effects include:
- Thinning of the skin
- Thinning of the cartilage
- Ligament weakening
- Tendon rupture
- Arthritis due to crystallisation of the steroid
- Elevation of blood pressure
- Cataract formation
- Thinning of the bones (osteoporosis)
- Avascular necrosis or osteonecrosis (very rare)
How Long Does A Cortisone Injection Work For?
A steroid injection can be used to help reduce inflammation in the short term, but for longer term benefit physiotherapy and active management strategies are most important. With some conditions, the symptoms of the condition recur after a few weeks or months. In this situation, another cortisone injection can be given, but risks of side effects increase with more frequent or regular injections.
To find out whether we can help you with your pain or dysfunction, before or after a steroid injection, contact us now!
myPhysioSA Physiotherapist Mount Barker
Our best advice and tips for Shoulder Pain
Doing any exercise is better than doing nothing.
Even something as simple as walking may be enough to get some gentle movement into the shoulder which can help to make the joint experience a sensation other than pain.
Try going for short walks, often, rather than trying to go for one big long walk. Getting outside and getting some fresh air can be fantastic for your general wellbeing.
Bike riding, especially on a stationary bike where you don’t need to weight bear through the joint, is a good basic exercise to keep you moving.
The elliptical or cross trainer machine at the gym is also a nice exercise when you have a sore shoulder as you can rest your arms on the central handles without having too much swing or push through the arms.
Try this shoulder pain Physio exercise
If you have an aching shoulder especially at night or pinching pain when reaching , carrying or getting dressed, then you should try this Physio tip from David.
David is an experienced Partner Physiotherapist at myPhysioSA in Mount Barker Adelaide.
David teaches you a simple to do shoulder blade strength exercise that could really help to improve your shoulder pain.
Best gentle starter shoulder exercises you can do at home
If you have ongoing shoulder pain and are finding everyday tasks painful and difficult to do, then watch Stephens video with some gentle starter shoulder exercises.
Getting your shoulder moving and strengthening gently will help ease the pain and get you back to using your shoulder properly again.
There are many reasons why people can get shoulder pain, the shoulder is quite complicated and it relies on all the supporting muscles (rotator cuff muscles) to be strong and working well together.
These two basic exercises that Stephen will teach you are safe and effective to get started on today. After a few weeks, you will be ready to try more advanced exercises to further improve your shoulder.
Ellen, a Senior myPhysioSA Physiotherapist, shows a great shoulder blade strengthening exercises that you should be doing.
Getting the shoulder blade activating and moving in it’s proper pattern will help improve your shoulder movement and reduce shoulder pain.
If your shoulder feels tight and stiff, gentle stretching may help to improve your flexibility.
The golden rule with stretching is to avoid stretching into pain. Once you feel the tightness and a sense of stretching, hold that position for 30 seconds and then relax.
A great shoulder stretch is described below using a stick and raising your arms overhead whilst lying on your back.
The sore/stiff shoulder is able to be passive by just holding onto the stick and allowing the non-affected arm to do the work, lifting the arm up and overhead.
With regular repetitions, within your comfort levels, you should feel that your shoulder range of motion improves over time.
Get some great advice on how to start helping your pain and getting your shoulder moving better again.
Ryan, a myPhysioSA Sports Physiotherapist at the Sports & Arthritis Clinic at Mile End, specialises in helping athletes and everyday people with their shoulder problems, and he shares his advice with you.
Mobility of the trunk and in particular, the upper back is useful to increase the general range of motion for the shoulder.
Conversely, a stiff thoracic spine can lead to restriction of the freedom of movement of the shoulder complex.
Try the Bow and Arrow stretch described below:
- Sitting, reach your arm out in front of you and then reach your top arm past your bottom hand.
- You should feel a good rotation stretch across the top of your back, between your shoulder blades. Then proceed to rotate back so your top elbow reaches back behind you.
- This opens up across the front of your chest. Repeat this cycle back and forth and then swap to the other side.
Strength should be progressed from being isolated to muscle groups through to more global, functional tasks which replicate the demands placed on your shoulder.
For example, if you are a throwing athlete, you need to strengthen your shoulder complex such that it can sustain the demands of throwing a cricket ball or water polo ball.
An exercises such as the High to Low Woodchop with a Cable is a great functional exercise which incorporates shoulder strength and control with trunk rotation, lower limb strength and weight transfer.
The cable is set to the high point on the cable machine with a light to moderate eight. Start with your arms extended diagonally overhead and your feet shoulder width apart perpendicular to the line of the cable.
Clasp the handle of the cable with two hands, keeping your elbows locked out straight.
Keeping your elbows extended, pull down and across your body with the cable, pulling towards your opposite foot.
You will need to crouch down into a flexed position at the bottom of the movement as your trunk rotates. Slowly return to the starting position.
Try starting with 10 repetitions daily.
Image courtesy of Physiotec
Follow the steps of how to tape a shoulder for sport
Titled myPhysioSA Sports Physiotherapist and current Carlton Football Club Physiotherapist, Rohan Hattotuwa, demonstrates and gives tips/advice on the correct way to give support to a shoulder that has instability or is recovering from a dislocation or ligament damage or other shoulder injury.
Watch Rohan as he tapes a shoulder step by step, starting from where to put the anchors, what type of tape is best to use, and how to test that your taping is going to be effective.
Shoulder taping is one of the trickiest to do correctly and if done wrong it can be quite difficult for an athlete to tolerate. The shoulder needs to still be functional, and have enough movement to be able to play sport. So getting the tension correct and not inhibiting the movement they need can take practise.
I have seen a specialist or surgeon and they have recommended surgery, what should I do now?
Significant injuries may require the opinion and potentially the intervention of an orthopaedic surgeon who specialises in shoulder injuries. The surgeon will perform a physical examination and may request medical imaging such as an X Ray and /or an MRI. This is in order to determine the extent of the injury to specific structures that may be repaired surgically.
It is important that you feel comfortable with the recommendations of the specialist when it comes to the care of your shoulder.
If you are not convinced that the advice provided to you is appropriate, you are well within your rights to gain a second opinion to ensure you are comfortable.
Knowledge is a powerful asset and make sure you ask as many questions as you need to fully understand the process that you will encounter.
Understanding the procedure that the surgeon will perform will allow you to better prepare for your surgical date and there are potentially less surprises associated with the whole process.
Preparing for any surgery that may be indicated is an important part of the whole process. Your Physiotherapist can guide you through a pre-surgical strengthening program which will maximise the condition of the shoulder before the surgery takes place. This period is a good opportunity to discuss the post-operative rehabilitation including what to expect in the days immediately after your surgery.
Your Physiotherapist can also guide you on the immediate post-operative exercises which will help with your recovery.