Hi folks – thanks for coming back for more shoulder chat!
As most of you know already, May is the ‘Physifitt does shoulder series‘ after one of my clients asked me why shoulders were so crap and after my own shoulder injury flared up again. Here we will start to discuss common and rare shoulder injuries and our final section will look at treatment. Part one focussed on shoulder anatomy and if you haven’t already, check it out. It’ll give you a good foundation to help this segment make a little more sense.
It’s going to be a lengthy one today so go grab a coffee, get yourself comfy and buckle in for the ride.
Before we start unpicking shoulder injuries some background information might be helpful. Shoulder complaints are the third most common injuries that a Physio will see. That shows you how normal it is to experience an issue with your shoulder at some stage. No doubt when you’ve been down the pub, out with friends or in the gym and mentioned a niggle in your shoulder someone around you has said ‘I hurt my shoulder too!’. It’s common, it’s normal and Physios are well placed in helping you recover.
Remember back to the anatomy post where we spoke about how the shoulder isn’t just your arm? Well that means that injury can arise from any part of the shoulder complex making it an interesting area to treat – one person’s shoulder pain won’t be the same as another’s even if the symptoms are in a similar area.
Just how common is common though? Sorry ladies but if you’re a woman and aged between 45 and 64 you’re most likely to develop issues with your shoulder whereas men aged between 18 and 44 are the least likely group. Take a moment to think about why this might be. Why women? Why that age group and not older? Surely things get worse as we age right? I’d like to hear your thoughts on this so please do get in touch!
Over any one year 47% of the overall population may be dealing with shoulder pain. When we bring this down to any one month it’s 31% and if we look over a person’s lifetime we reach a 67% chance of shoulder symptoms. To keep it simple, what this means is that in a month, a year or over the duration of your lifespan it’s likely that you will develop an issue with your shoulder.
I can already hear you telling me you didn’t come here for stats and you want to know what these issues are. Let’s start unpicking these together. We will talk about 3 of the most common issues today in detail – frozen shoulder, rotator cuff problems and cartilage tears – before touching on some of the rarer conditions such as bony injuries, referred pain from the chest and nerve injuries.
Let’s start here. As with other shoulder issues this is extremely common. It has a couple of different names such as adhesive capsulitis or contracted shoulder and can last a couple of months or more commonly 1-2 years.
Remember when we looked at the anatomy we spoke about that loose fibrous structure called the capsule that helps to keep the joints lubricated? Well it’s this that’s predominantly the issue here. It can become sticky, thickened or scarred and doesn’t provide the joint with as much fluid meaning that it gets grumpy when being asked to move. Whilst we aren’t machines it can be likened to a bike chain that’s not got any oil on it. It might get rusty (thankfully we don’t!) but the bikes movement isn’t as smooth and sometimes doesn’t want to go at all which is a similar situation here.
Frozen shoulder can occur from primary reasons (the shoulder itself) or secondary reasons (something else has had an impact). We’re not really sure exactly why frozen shoulders develop (the researchers have found a like with persistent inflammation that causes scarring and thickening of the capsule but we don’t know where this inflammation really comes from) but we do know that if there’s been any period of immobilisation – so following a fracture when your arm has been in a sling or after a stroke or if we aren’t overly active in maintaining our full range of movement (think sedentary lifestyles and desk based jobs) – then we’re more at risk of developing frozen shoulder. Secondary reasons include things like diabetes, lung disease, infection and neck issues. If you’ve been diagnosed with any of those issues, then you may find yourself more susceptible to developing frozen shoulder.
The symptoms of frozen shoulder are usually described as a dull aching pain around the shoulder joint itself worsened when the arm is moved, at night and when in bed. Generally, people struggle to get the arm above head, round their back or rotating to the side meaning even tasks like driving and changing gear can cause significant pain.
Often frozen shoulder develops gradually over time. The first phase (‘freezing’ or ‘painful’) is when the capsule is starting to become thicker and reduce its lubricating properties. This is when the dull ache develops, and movement starts to become stiffer. It’s quite difficult to diagnose frozen shoulder at this point because it is only just developing and can last up to 9 months.
The second phase (‘frozen’ or ‘stiffness’) usually comes with a lot less pain (result) but movement is generally significantly affected, and it can become really difficult to move your arm away from your body. Your body naturally wants to protect it so keeps it close. This phase can last up to a year.
The third and final phase (‘thawing’ or ‘resolution’) is when you generally find that your symptoms start getting easier. You’re able to move your arm more than previously and your pain is vastly reduced although may still be present. It can last a long time though and may be another year before you reach this stage.
To sum this part up, frozen shoulders are common and generally you have a dull ache around your shoulder that’s worse with movement and at night. It has 3 phases and may last anywhere from a few months to a few years. Don’t worry though – it can be helped! Treatment and prevention will be discussed in the next segment.
Rotator Cuff Injuries
Moving on to rotator cuff injuries now. Remember the rotator cuff from our anatomy segment? It’s the small group of muscles and tendons that help keep the shoulder in its socket. Just like everything else with the shoulder, it’s really common to injure this area.
The rotator cuff can become irritated and inflamed for a host of different reasons. Repetitive overhead tasks tend to be the most common cause (think painting and decorating) but playing a lot of racket sports like tennis and badminton, being involved in throwing sports like javelin or cricket, occupations including carpentry or those where heavy lifting is required as well as age and genetic factors all work together to predispose you to rotator cuff issues.
You might have heard the term shoulder impingement being thrown around (get it?! I’m hilarious). This term is now quite outdated as it reflected inflammation of a single tendon whereas we have now found, through research, that generally the full cuff is involved in some way including altering movement mechanics around the shoulder blade to offset the pain experience. We tend to class these injuries now as rotator cuff pain syndrome (the medical world loves itself a syndrome) or simply a rotator cuff injury.
I touched on age a couple of paragraphs ago. We know that as we age our collagen production reduces. Collagen is a key player in muscle and tendon structure so, as collagen reduces, we can find that we develop injuries in muscles and tendons. The rotator cuff falls under this bracket. This is entirely normal the same way as your hair turns grey and you get wrinkles on your skin. Try and think of age-related changes to your tendons as tendon wrinkles rather than degeneration or wear and tear. It’s way more normal and a lot less scary! I can promise that you aren’t degenerating away to nothing nor are you tearing things with every movement you make. It’s normal to age!! We are so lucky if we get to experience the ageing process as so many people unfortunately don’t.
It’s really great to read about the risk factors but the symptoms are just as important. You will tend to find the following:
- Dull ache deep in the shoulder
- Disturbed sleep especially when lying on the sore side
- Painful arc – lifting your arm to the side is ok for a bit then gets sore and can then feel a little easier
- Weakness in the arm
Pretty similar to the frozen shoulder right! This is what makes it so difficult to diagnose.
Sometimes we can find that our rotator cuff becomes calcified – a wee bit of calcium grows within the tendon. This can cause a lot of clicking and inflammation so your symptoms can be intensified.
Occasionally, and especially common after a traumatic injury a fall or accident for example, the rotator cuff can tear completely. You would notice significant pain and reduction in movement as well as a hell of a lot of weakness in comparison to the other side.
That’s rotator cuff injuries in a nutshell. There’s a whole load more information I could add to this and I might even do a specific rotator cuff injury post so as not to bog you down in stuff at the minute!
Take a minute to remind yourself about the cartilage of the shoulder and what its purpose is.
The cartilage of the shoulder is also known as the labrum and can be injured in different ways. They’re classed as labral tears and can be quite tricky to differentiate between.
The first common tear is when the labrum is torn completely off the bone. This results in the humerus not sitting in the socket properly and so the shoulder becomes subluxed or even dislocated.
You can also fall victim to a Bankart lesion which is when the front of the labrum is torn and a small pocket develops in the cartilage itself. This can then cause the humerus to fall in to the area effectively dislocating.
Remember the biceps muscle and it’s two heads? The long head can sometimes pull away from its origin on the labrum taking a piece of the cartilage with it. We call this a SLAP tear which just refers to the location of the cartilage that is injured (superior labrum anterior posterior or more simply the upper front and back).
Sounds pretty nasty right? Bits of cartilage being torn and pulled around. But what does it feel like? You would commonly notice a deep dull ache in the shoulder which is accompanied by catching, clunking or popping sounds and feelings (not a click – it’s more than that). It often feels really deep within the shoulder rather than near the skin and you’ll normally struggle a lot with overhead movements. You will also notice a decline in the strength of your arm and might find it harder to participate in your hobbies and normal daily activities.
These things don’t just happen though. Generally, there needs to have been some sort of trauma so a fall on to an outstretched arm or landing directly on the shoulder, a sporting injury (think rugby and gymnastics when in the rings) or even a car accident could all cause a tear to the labrum. It’s quite unlikely that you would develop this gradually over time unless you are elderly where age related changes can impact the cartilage.
Well done on getting this far. It’s a lot of information and a thanks for keeping up! We’re moving on to slightly rarer structures to become injured but injured they can get!
Bursa, bone and nerves
Your bursa structure, bones and nerves can all also be injured. Bursas can become inflamed causing pinching like feelings and often sharp pains on movement and dull aches at rest. Your bones can fracture which I’m sure you’ll appreciate can be extremely painful and will normally cause the arm to look different as well. Nerves can become irritated where they begin to lack flexibility and so you can feel numbness, tingling, weakness and pain further down the arm and in to the hand as well.
Remember that pain in your shoulder doesn’t necessarily have to be coming from your shoulder or the structures of the shoulder girdle. If you are having a heart attack, struggling with angina or indigestion you can find that your shoulder will be painful as well. This generally travels to the face and jaw as well as further down your arm.
Remember folks, this is a medical emergency and so if you start to notice any of these symptoms don’t hang around – call 999.
The big C word. That’s right – sometimes shoulder pain can be because of cancer. This includes cancer of the bones themselves but also something a little rarer called a Pancoast Tumour. A Pancoast Tumour is when there’s a tumour in the top of the lung which sits at the clavicle. You will generally find that you have weakness and severe pain in the arm and scapula, breathlessness, have a persistent cough that won’t go away, weight loss, general fatigue, grey coloured skin and Horner’s Syndrome which means flushing on one side of the face, not being able to sweat on this same side, a smaller pupil and a drooping eye lid.
Pancoast tumours are extremely rare and are unlikely to develop in the general population. You’re more at risk if you’re a smoker or are surrounded by secondary smoke or have been exposed to asbestos, diesel, nickel or gold perhaps through your occupation.
If you do have any of these symptoms or are prone to the risk factors have a chat with your GP about things and see if there’s anything that can help. There are loads of things out there to help with stopping smoking for example and your GP has all this info ready for you.
And there we have it folks!!! Common and rarer reasons as to why your shoulder may be sore. This is by no means exhaustive there’s a hell of a lot of other reasons too -neck and mid back referral and don’t even start me on persistent pain problems! – but I think I’ve probably bored you with all this for long enough.
Remember any questions or anything you would like to know more about get in touch. If you’re suffering with shoulder pain give me a shout and I can help you understand it a little more.
*Please note that this is for information purposes only. Please consult a trained medical professional before reacting to any of the information included in this post*