We often see patients who visit us with shoulder pain as it impacts their ability to sleep on their affected side and other daily tasks such as driving and dressing. The most common cause of shoulder pain we see in the clinic is rotator cuff related pain. To learn more about rotator cuff pain and what you can expect in your shoulder rehabilitation see our article below.
The shoulder complex is made up of 3 different joints, the scapulohumeral joint (shoulder joint), Acromioclavicular joint (collar bone joint) and the scapulothoracic joint (shoulder blade joint). It’s important that all 3 of these joints can move throughout their entire range for the rotator cuff to work well.
The rotator cuff is made up 4 different muscles, infraspinatus, supraspinatus, subscapularis and teres minor, the long head of the bicep tendon is also closely related to the rotator cuff. The supraspinatus is the most affected muscle in the rotator cuff involving up 70% of all shoulder related pain. To help all these muscles and joints move frictionlessly our shoulders contains a bursa. A bursa is a fluid filled sac that lubricates the shoulder. The subacromial bursa can be aggravated with rotator cuff related pain. If a bursa becomes inflamed then this is known as a bursitis.
Rotator cuff related pain is often described as a dull, achey, or bruise like sensation in the shoulder or upper arm and can also be sharp on certain movements. Rotator cuff pain is always mechanical, meaning “my shoulder is sore when I do this”. Typically, people will struggle with long lever movements, such as lifting a handbag from the back seat of their car, placing a baby in a cot, or lifting luggage from the back of a car boot. People are sometimes confused as they can perform some movements without pain like lifting a heavy kettle but are unable to pour the tea. This is because short lever movements (lifting the kettle) are often pain free but as the arm extends away from the body the load of the rotator cuff increases (pouring the tea). Another common cause is putting on t-shirt or undoing a bra strap, these aren’t typically due to a lack of strength but are often painful due to the lack of range of motion in the shoulder joint. Muscle spasm can create stiffness in the shoulder making these daily activities more difficult.
Rotator cuff related pain can be caused by various different pathologies but the most common are;
Other shoulder conditions can include;
Diagnosing a rotator cuff related tear or tendinopathy often doesn’t require imaging however your physiotherapist may order an x-ray and ultrasound if they have concerns about a larger tear that may require a surgical opinion or they may want to rule out less common causes for your shoulder pain. Not all abnormalities identified on diagnostic imaging are relevant to your particular shoulder condition. Your physiotherapist will weigh up correlations between your symptoms, clinical findings and imaging findings to identify the main drivers for your shoulder pain. We treat the person, not the image.
Most shoulder rehabilitation plans will take between 8 – 12 weeks but this can vary significantly. This is because patients may have other co-existing health conditions, the level of desired function, the patient’s lifestyle, and the severity of the injury. Rehabilitation plans will likely include the following components.
This can include acupuncture, dry needling, massage and joint mobilization. These techniques are used to reduce your pain and facilitate an increase in range of motion. This can help accelerate the beginning phases of your rehabilitation and lead to a quicker discharge date.
Sometimes patients shoulders are too sore to tolerate any loading. In this case taping or the use of a brace is used to offload the damaged tissues allowing the pain settle before a graded exercise program begins.
A graded exercise program is essential in rotator cuff rehabilitation. A well structured graded exercise program focuses on addressing any deficits from the damaged tissues and ensuring your shoulder has good strength throughout its entire range of motion. As a rule of thumb, therapeutic exercise prescription aims to achieve a low level of irritability. Meaning that the pain should be very manageable and gone within the first hour after completing the exercise. A highly irritable shoulder injury or exercise will continue to be painful hours after the exercise has been completed. Highly irritable exercises are not advised.
It’s important to know what outcome measures you and your physiotherapist will use to decide when you and your physiotherapist are happy to part ways. Nobody wants to continue doing physio exercises forever!
The LSI calculates the amount of force your injured rotator cuff can exert using a dynamometer and then divides the score against your non-affected shoulder. For example, if your non injured shoulder can exert 20kg of force then it would be advised to continue your rehabilitation until your injured shoulder can produce a force greater 16kg, giving you a limb symmetry index of 80%. The closer the score is to 100% the better.
This test involves balancing a 2kg medicine ball on the palm of your hand as your shoulder moves through a series of movements out to the side and above your head.
Lastly, the most important outcome measure is whether or not you are happy with your shoulder and if you have been able to go back to your desired activities. This is scored simply by using a 1 to 10 scale from the PSFSQ.
After the rehabilitation has been completed your discharge outcome will be recorded. After this it is common for our patients to ask what their risk of re-injury is. While this can vary greatly depending on the nature of your shoulder injury and your lifestyle. Some sports and occupations put people more at risk of shoulder injuries than others. In general, if you have a well moving and strong shoulder that is conditioned to your sport and occupation then your risk of re-injury should remain low.
We have experienced senior clinicians with one of the best equipped facilities on Auckland’s North Shore. We are part of several ACC programs, and you may be eligible to receive fully subsidised healthcare for your injury. To find out more don’t hesitate to book online or contact us on 09 5536565.