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Shoulder Problems

There are many aetiologies of shoulder pain. The most common shoulder complaint is what is commonly referred to an an 'impingement syndrome' where immune-metabolic changes within the substance of the tendon of the supraspinatus (rotator cuff) muscle and subacromial bursa create a 'painful arc' when lifting the arm above shoulder height (this usually occurs in the ranges of 70 - 120 degrees). Other pathology includes subscapularis tears from anterior dislocation of the shoulder, biceps tendon issues and posterior shoulder capsule tightness with weakness of the rotator cuff. Additional problems may arise with the acromioclavicular and sternoclavicular joints as these are the joints connecting the shoulder blade, via the bony strut (collar bone) to the skeleton. These shoulder pathologies may need differential diagnosis with referred pain and weakness from neck and thorax pathology.

Posterior shoulder dislocation

posterior-shoulder-dislocation

posterior-shoulder-dislocation1

Biceps tendon pathology

- according to Dr Stephen J O'Brien MD, MBA (2011), the O'Brien's test is 88% positive for an incarcerated long head of biceps tendon and only 54% have a labral tear, whereas the Subscapularis is usually normal in 300 cases.

- 63.6% of people under 40 will complain of fatigue discomfort, whereas 42.1% between the ages of 40 and 60 will complain of this when dealing with an 'incarcerated biceps'.

- "3 Pack" examination

"extra-articular"

- direct palpation of bicipital groove

- throwing test

"Intra-articular"

- active compression test

- 90 abd ER isometric test -> palpate biceps tendon in bicipital groove if pain anterior it's a tendon problem, if the pain is posterior then it is likely to be internal impingement

Shoulder-cuff

- tightness of the posterior capsule will cause the head of the humerus to migrate superiorly during abduction and external rotation resulting in subacromial impingement. Subacromial impingement is where the bursa and rotator cuff impinge between the humeral head and acromion. Frequently people have pain at night. Hawkins test can be preformed with isometric internal and external rotation to  confirm a 'working hypothesis' of subacromial issues. MRI  can further add diagnostic weight if not all of the three clinical signs are present

rotator-cuff-muscles

- rotator cuff tears (R.C.T) increase in frequency with aging (20% in 30-39 year olds, 60% in 60-69 year olds and 80% in 70-79 year olds) (Julie R Walton PhD 2011). Young tendon fibroblasts have a progressive collagen cross-linked matrix. There is very little renewal of collagen after 30 years of age. Tendon trauma causes the induction of protein kinases resulting in cell apoptosis (programmed death). This can be seen around small blood vessel proliferation. Hypoxia induces type III collagen production which appears to be driven by immune inflammatory cytokinase markers such as IL I, IL6, IL8, MCP-1. This process has been referred to as a "Collagen Switch" (George Murrell 2011). Additionally, there seem to be some markers associated with lipid metabolism which drive degenerative tendonopathy, suggesting people who are over-weight or who have metabolic syndrom (hyperlipidemia, diabetes) may be more susceptible to tendonopathy

- the supraspinatus muscle architecture means that the tendon is more likely to degenerate on the subsurface i.e. adjacent to the head of humerus. Mid substance and superior degeneration can also occur but less frequently.

- three predictive tests for R.C.T's are supraspinatus weakness, weakness in external rotation, impingement pain in external rotation and/or internal rotation. Full thickness tears of <2cm2 are considered small, 2-4cm2 large and >4cm2 are 'massive and irreparable' (Prof George Murrell 2011). 

- shoulder instability can occur when the intra articular pressure of -40cmH2O (ie the vacuum) is disturbed. Clinically, they present with increased strength of the external rotators over the internal rotators (normally ER strength is 60% of IR, whereas with anterior instability the ER strength is 85% of IR strength) (Eiji Itoi, MD, PhD Sendei, Japan 2011). In 0 degrees the Superior Glenohumeral ligament acts as a stabiliser, at 45 degrees abduction it is the Mid GHL and at 90 degrees the inferior IGHL. The latter acts as a hammock for the humerus. For this reason proprioceptive isometric stabilisation exercises of the subscapularis and infraspinatus with the arm resting on table at 90 degrees abduction is considered important in the rehabilitation of the throwing arm.  Remember the rotator cuff muscles blend with the ligaments except at the foramen of Weitbrecht. Even at 45 degrees abduction O'Brien considers the Ant IGHL as the primary restrainer.

- Frozen shoulders also known as adhesive capsulitis are frequently of unknown aetiology. However, people with diabetes or hyperlipidemia have an increased tendency towards frozen shoulders due to the effect on the blood vessels of the suprascapula nerve as well as the direct effect on tendon metabolism. Immune compromise in for example people with severe neutropenia are also more susceptible to frozen shoulder. Post traumatic inflammation is also a potential contender to set the scene for a frozen shoulder. Moreover, there frequently appears to be a familial tendency in it's aetiology. People with Dyputrens contractures tend to have more severe problems. The severe acute painful stage can last from 6 weeks to 6 months. The 'cold' frozen stage can last up to 18 months. Cortisone can in some cases help with pain in the acute phase. Hydrodilation is sometimes used in the 'cold' frozen stage. People frequently find a lot of comfort using a hot pack in the arm pit. High doses of fish oil using 3000mg of EPA/DHA have been advocated. Physiotherapy includes a multimodal approach such as dry needling, laser therapy, soft tissue massage, joint mobilisations of the shoulder, ribcage, spine and a series of exercises.

Altered biomechnical conditions are a result of misuse, disuse, abuse whose damage causes a reciprocating viscious cycle of muscle-tendon atrophy, degenerative changes, and immune-metabolic dysfunction. At Back in Business Physiotherapy we use a combination of 'hands-on' therapy, exercise and nutritional supplementation to optimise the rehabilitative process.

Immunological factors as a result of disuse

A biphasic stress response has been described in muscles during 'reloading' after a period of 'unloading'. Mechanical unloading as a result of disuse results in substantial muscle atrophy. This atrophy is a result of both increased protein degradation and reduced protein synthesis. Signaling pathways leading to this, include oxidative stress, proinflammatory signaling, reduced stress response, including heat shock proteins (HSP) and insulin-like growth factor (IGF-1). Insufficient HSP and antioxidant enzymes elicits oxidative damage of proteins and lipids (Lawler et al 2003, Free Radic Biol Med, 35, 9-16). Hence, unloading elevates oxidative stress. Paradoxically, loading also elevates oxidative stress. Nuclear Factor kB (NF-kB) has been implicated in both processes. During unloading it is thought to induce numerous pro-inflammatory genes including nitirc oxide synthase, cytokines, ubiquitin pathway ligases as a result of withdrawal of the stress - response including HSP25, HSP70, IGF1/Akt pathway (Lawler et al 2006, Muscle Nerve, 33, 200-207). The early portion of reloading, after a period of immobilisation is characterised by muscle damage and inflammation which requires a cognitive approach using a realistic time-frame for recovery to take place. although, muscle recovery after 7-10 days of unlaoding is rapid (7 - 9 days), prolonged immobilisation greater than 17 days exhibits impaired recovery of muscle mass (Kasper 1995, J Appl Physiol, 79, 607-614). Reloading of muscles have been shown to result in a large up-regulation of NF-kB DNA-binding activity (Lawler et al 2012, Med Sci Sp Ex, 44, 4, 600-609). HSP25 phosphorylation decreased during prolonged unloading but returned to normal after 28 days of reloading. HSP70 and IGF-1 remained depressed during short term reloading but returned to normal levels as muscle mass improved, whereas in contrast Akt phosphorylation was greater in short term reloading but returned to normal by day 28 (Lawler et al 2012).

Joint stability in the shoulder

- biomechanics and gamma reflexes

 

Joint stability is determined by the muscular stiffness in 'soft' joints such as the neck knee and shoulder.

Muscular tension generates stability at the glenohumeral jnt the outward curves represent the stabilising influence when the prime mover muscles act on the shoulder

 

 

To enable stability at the glenohumeral joint during arm elevation  the scapula muscles position the glenoid to provide  optimal orientation  for the rotator cuff stabilising function

 

 

If the rotator cuff and scapular muscles do not operate synergistically then the potential for glenohumeral subluxation & subacromial impingement is generated

Thorax

Patients frequently seek treatment for pain in various parts of the body, but infrequently present for treatment of thoracic pain. Yet, simple, quick assessment and correction of the thoracic rings frequently demonstrates a link to the pain and musculoskeletal dysfunction in areas some distance away. Wainner et al (J orthop Sports Phys Ther, 2007; 37, 658-660) describe regional interdependence as “the concept that seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, the patient’s primary complaint.” This perception suggests that interventions targeting adjacent anatomical areas may directly affect the outcomes of the involved joint. Boyles et al (Manual Therapy, 2009 Aug;14(4):375-80) and Strunce et al (J Man Manip Ther, 2009, 17(4): 230-236) have demonstrated the immediate effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. The latter describing  a 51% reduction in shoulder pain, 30-38 degree increase in range of motion (ROM), and a mean patient perceived global rating change of 4.2 in 21 subjects. McCormack (J Man Manip Ther., 2012 Feb;20(1):28-34) showed a 25 degree improvement in shoulder ROM when using thoracic spine manipulation in the treatment of adhesive capsulitis. Brian Mulligan described 'mobilisation with movement' (MWM) techniques on the first rib which have dramatic effects on the cervical ROM for contralateral lateral flexion and ipsilateral rotation. Canadian physiotherapist Linda Joy Lee has advocated ring shift corrections for low back pain, pelvic girdle pain and hip problems, as well as shoulder and neck issues.

Interested readers should look at the thorax apsect of this website.

Summary

  • the rotator cuff muscles provide glenohumeral stability
  • the scapular muscles provide the positioning for inferior stability of the glenoid labrum for a snug fitting humeral head
  • with the deep joint stabilizing muscles providing the stability, the prime movers may provide the 'action'
  • generally speaking the stabilizing muscles of most joints are one joint muscles with an endurance function; whereas the prime movers are the muscles which lend power to the movement e.g. Pectoralis Major.  Therefore when designing an exercise regime the client must begin with good muscular stability before commencement of training of the prime movers.
  • Frequently, clients compensate for lack of stability by increasing the speed at which they do the task.  This then leads to further in-coordination, poor timing between muscles, loss of synergy, and more dysfunction.
  • Closed kinetic chain training to gain scapula and rotator cuff stability may encourage gamma afferent feedback from the annulospiral endings, as well as activate the nuclear bag and nuclear chain fibres
  • Plyometric type exercises using theraband are designed to encourage eccentric-concentric control of the prime movers.

Plyometrics

 

 

EMG biofeedback

Altered immune responses and altered lipid metabolism have been implicated as a causative factor in shoulder tendonopathies. Interested readers should look at Exercise and the Immune System as well as Exercise and Weight Loss elsewhere on this website for further explanations.

Interesting articles

these articles are particularly interesting in respect to synergistic 'timing' of muscle action in the upper and lower limbs

Commerford & Mottram (2001). Functional stability re-training: principles and strategies for managing mechanical dyfunction.  Manual Therapy, 6,1, 3-14

Commerford & Mottram (2001). Movement and stability dysfunction - contemporary developments.  Manual Therapy, 6,1, 15-26

Animated muscular synergistic interaction for shoulder abduction - refer to Climbing section

Shoulder Problems(English)

Schulter Probleme (Deutsch)

Last update : 8 January 2014


 

Trending @ Back in B Physio

  • Thu 22 Dec 2016

    Ehlers Danlos Syndrome

    Is your child suffering Ehlers Danlos Syndrome? Hypermobile joints, frequent bruising, recurrent sprains and pains? Although a difficult manifestation to treat, physiotherapy can help. Joint Hypermobility Syndrome (JHS) When joint hypermobility coexists with arthralgias in >4 joints or other signs of connective tissue disorder (CTD), it is termed Joint Hypermobility Syndrome (JHS). This includes conditions such as Marfan's Syndrome and Ehlers-Danlos Syndrome and Osteogenesis imperfecta. These people are thought to have a higher proportion of type III to type I collagen, where type I collagen exhibits highly organised fibres resulting in high tensile strength, whereas type III collagen fibres are much more extensible, disorganised and occurring primarily in organs such as the gut, skin and blood vessels. The predominant presenting complaint is widespread pain lasting from a day to decades. Additional symptoms associated with joints, such as stiffness, 'feeling like a 90 year old', clicking, clunking, popping, subluxations, dislocations, instability, feeling that the joints are vulnerable, as well as symptoms affecting other tissue such as paraesthesia, tiredness, faintness, feeling unwell and suffering flu-like symptoms. Autonomic nervous system dysfunction in the form of 'dysautonomia' frequently occur. Broad paper like scars appear in the skin where wounds have healed. Other extra-articular manifestations include ocular ptosis, varicose veins, Raynauds phenomenon, neuropathies, tarsal and carpal tunnel syndrome, alterations in neuromuscular reflex action, development motor co-ordination delay (DCD), fibromyalgia, low bone density, anxiety and panic states and depression. Age, sex and gender play a role in presentaton as it appears more common in African and Asian females with a prevalence rate of between 5% and 25% . Despite this relatively high prevalence, JHS continues to be under-recognised, poorly understood and inadequately managed (Simmonds & Kerr, Manual Therapy, 2007, 12, 298-309). In my clinical experience, these people tend to move fast, rely on inertia for stability, have long muscles creating large degrees of freedom and potential kinetic energy, resembling ballistic 'floppies', and are either highly co-ordinated or clumsy. Stabilisation strategies consist of fast movements using large muscle groups. They tend to activities such as swimming, yoga, gymnastics, sprinting, strikers at soccer. Treatment has consisted of soft tissue techniques similar to those used in fibromyalgia, including but not limited to, dry needling, myofascial release and trigger point massage, kinesiotape, strapping for stability in sporting endeavours, pressure garment use such as SKINS, BSc, 2XU, venous stockings. Effectiveness of massage has been shown to be usefull in people suffering from chronic fatigue syndrome (Njjs et al 2006, Man Ther, 11, 187-91), a condition displaying several clinical similarities to people suffering from EDS-HT. Specific exercise regimes more attuned to co-ordination and stability (proprioception) than to excessive non-stabilising stretching. A multi-modal approach including muscle energy techniques, dry needling, mobilisations with movement (Mulligans), thoracic ring relocations (especially good with autonomic symptoms), hydrotherapy, herbal supplementaion such as Devils Claw, Cats Claw, Curcumin and Green Tee can all be useful in the management of this condition. Additionally, Arnica cream can also be used for bruising. Encouragment of non-weight bearing endurance activities such as swimming, and cycling to stimulate the endurance red muscle fibres over the ballistic white muscles fibres, since the latter are preferably used in this movement population. End of range movements are either avoided or done with care where stability is emphasized over mobility. People frequently complain of subluxation and dislocating knee caps and shoulders whilst undertaking a spectrum of activities from sleeping to sporting endeavours. A good friend of mine, Brazilian Physiotherapist and Researcher, Dr Abrahao Baptista, has used muscle electrical stimulation on knees and shoulders to retrain the brain to enhance muscular cortical representation which reduce the incidence of subluxations and dislocations. Abrahao wrote : "my daughter has a mild EDS III and used to dislocate her shoulder many times during sleeping.  I tried many alternatives with her, including strenghtening exercises and education to prevent bad postures before sleeping (e.g. positioning her arm over her head).  What we found to really help her was electrostimulation of the supraspinatus and posterior deltoid.  I followed the ideas of some works from Michael Ridding and others (Clinical Neurophysiology, 112, 1461-1469, 2001; Exp Brain Research, 143, 342-349 ,2002), which show that 30Hz electrostim, provoking mild muscle contractions for 45' leads to increased excitability of the muscle representation in the brain (at the primary motor cortex).  Stimulation of the supraspinatus and deltoid is an old technique to hemiplegic painful shoulder, but used with a little different parameters.  Previous studies showed that this type of stimulation increases brain excitability for 3 days, and so we used two times a week, for two weeks.  After that, her discolcations improved a lot.  It is important to note that, during stimulation, you have to clearly see the humerus head going up to the glenoid fossa" Surgery : The effect of surgical intervention has been shown to be favourable in only a limited percentage of patients (33.9% Rombaut et al 2011, Arch Phys Med Rehab, 92, 1106-1112). Three basic problems arise. First, tissues are less robust; Second, blood vessel fragility can cause technical problems in wound closure; Third, healing is often delayed and may remain incomplete.  Voluntary Posterior Shoulder Subluxation : Clinical Presentation A 27 year old male presented with a history of posterior shoulder weakness, characterised by severe fatigue and heaviness when 'working out' at the gym. His usual routine was one which involved sets of 15 repetitions, hence endurance oriented rather than power oriented. He described major problems when trying to execute bench presses and Japanese style push ups.  https://youtu.be/4rj-4TWogFU In a comprehensive review of 300 articles on shoulder instability, Heller et al. (Heller, K. D., J. Forst, R. Forst, and B. Cohen. Posterior dislocation of the shoulder: recommendations for a classification. Arch. Orthop. Trauma Surg. 113:228-231, 1994) concluded that posterior dislocation constitutes only 2.1% of all shoulder dislocations. The differential diagnosis in patients with posterior instability of the shoulder includes traumatic posterior instability, atraumatic posterior instability, voluntary posterior instability, and posterior instability associated with multidirectional instability. Laxity testing was performed with a posterior draw sign. The laxity was graded with a modified Hawkins scale : grade I, humeral head displacement that locks out beyond the glenoid rim; grade II, humeral displacement that is over the glenoid rim but is easily reducable; and grade III, humeral head displacement that locks out beyond the glenoid rim. This client had grade III laxity in both shoulders. A sulcus sign test was performed on both shoulders and graded to commonly accepted grading scales: grade I, a depression <1cm: grade 2, between 1.5 and 2cm; and grade 3, a depression > 2cm. The client had a grade 3 sulcus sign bilaterally regardless if the arm was in neutral or external rotation. The client met the criteria of Carter and Wilkinson for generalized liagmentous laxity by exhibiting hyperextension of both elbows > 10o, genu recurvatum of both knees > 19o, and the ability to touch his thumbto his forearm Headaches Jacome (1999, Cephalagia, 19, 791-796) reported that migraine headaches occured in 11/18 patients with EDS. Hakim et al (2004, Rheumatology, 43, 1194-1195) found 40% of 170 patients with EDS-HT/JHS had previously been diagnosed with migraine compared with 20% of the control population. in addition, the frequency of migraine attacks was 1.7 times increased and the headache related disability was 3.0 times greater in migraineurs with EDS-HT/JHS as compared to controls with migraine (Bendick et al 2011, Cephalgia, 31, 603-613). People suffering from soft tissue hypermobility, connective tissue disorder, Marfans Syndrome, and Ehler Danlos syndrome may be predisposed to upper cervical spine instability. Dural laxity, vascular irregularities and ligamentous laxity with or without Arnold Chiari Malformations may be accompanied by symptoms of intracranial hypotension, POTS (postural orthostatic tachycardia syndrome), dysautonomia, suboccipital "Coat Hanger" headaches (Martin & Neilson 2014 Headaches, September, 1403-1411). Scoliosis and spondylolisthesis occurs in 63% and 6-15% of patients with Marfans syndrome repsectively (Sponseller et al 1995, JBJS Am, 77, 867-876). These manifestations need to be borne in mind as not all upper cervical spine instabilities are the result of trauma. Clinically, serious neurological complications can arise in the presence of upper cervical spine instability, including a stroke or even death. Additionally, vertebral artery and even carotid artery dissections have been reported during and after chiropractic manipulation. Added caution may be needed after Whiplash type injuries. The clinician needs to be aware of this possibility in the presence of these symptoms, assess upper cervical joint hypermobility with manual therapy techniques and treat appropriately, including exercises to improve the control of musculature around the cervical and thoracic spine. Atlantoaxial instability can be diagnosed by flexion/extension X-rays or MRI's, but is best evaluated by using rotational 3D CT scanning. Surgical intervention is sometimes necessary. Temperomandibular Joint (TMJ) Disorders The prevelence of TMJ disorders have been reported to be as high as 80% in people with JHD (Kavucu et al 2006, Rheum Int., 26, 257-260). Joint clicking of the TMJ was 1.7 times more likely in JHD than in controls (Hirsch et al 2008, Eur J Oral Sci, 116, 525-539). Headaches associated with TMJ disorders tend to be in the temporal/masseter (side of head) region. TMJ issues increase in prevelence in the presence of both migraine and chronic daily headache (Goncalves et al 2011, Clin J Pain, 27, 611-615). I've treated a colleague who spontaneously dislocated her jaw whilst yawning at work one morning. stressful for me and her! Generally, people with JHD have increased jaw opening (>40mm from upper to lower incisors). Updated 18 May 2017  Read More
  • Fri 09 Dec 2016

    Physiotherapy with Sharna Hinchliff

    Physiotherapy with Sharna Hinchliff    Martin is pleased to welcome the very experienced physiotherapist Sharna Hinchliff to Back in Business Physiotherapy for one on one physiotherapy sessions with clients in 2017.  Sharna is a passionate triathelete and mother and has had several years experience working locally and internationally (New York and London) in the field of physiotherapy. Originally from Western Australia, Sharna graduated from the world renowned Masters of Manipulative Physiotherapy at Curtin University. read more Read More
  • Mon 07 Nov 2016

    Pilates – with Brunna Cardoso

    Pilates – with Brunna Cardoso Martin is pleased to welcome the bubbly Brunna Cardoso to Back in Business Physiotherapy for Pilates Classes in February 2017.  Brunno is an experienced pilates instructor and has had several years experience training with pilates instructors in Brazil. Read more Read More

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Updated : 10 May 2014

No responsibility is assumed by Back in Business Physiotherapy for any injury and/or damage to persons or property as a matter of product liability, negligence, or from any use of any methods, products, instruction, or ideas contained in the material in this and it's related websites. Because of rapid advances in the medical sciences, the author recommends that there should be independent verification of diagnoses and exercise prescription. The information provided on Back in Business Physiotherapy is designed to support, not replace, the relationship that exists between a patient/site visitor and their treating health professional.

Copyright Martin Krause 1999 - material is presented as a free educational resource however all intellectual property rights should be acknowledged and respected