Shoulder Pain, Rotator Cuff and Impingements

The complexity of the shoulder joint allows it to perform many different movements and activities. Anatomically, the shoulder involves three different bones - the scapula, the clavicle, and the humerus - many connecting ligaments, and approximately 20 different muscles. The shoulder allows the greatest range of motion of any joint in the body. This is due to the four tendons which stabilise the upper arm bone in the shoulder socket. This great range of motion, however, tends to make us susceptible to shoulder pain (1,2).

As with other joints, shoulder problems can be caused by:
  • Trauma such as a fall
  • Sports injuries and overuse in sports such as swimming, tennis and golf
  • Mechanical dysfunction due to imbalances in the muscles
  • Wear and tear of the tissues surrounding the joint.
  • Poor posture, people who sit a lot in a slouched position or with the shoulders held forward are at risk of developing shoulder problems

Arthritic changes can occur in the shoulder joint though not as commonly as the weight bearing joints of the spine, hips and knees (1).

Problems in the shoulder may sometimes originate in the cervical spine as the nerves from this region innervate all of the muscles and other tissues of the shoulder, arm and hand. If these nerves are irritated, the shoulder muscles can become tight or weak causing dysfunction in the normal mechanics of the joint, especially in the rotator cuff.



Shoulder sprains, strains and dislocations are very common.  Symptoms of shoulder pain include aching on the side and upper arm, or aching in the top and front of the shoulder. Two of the most common shoulder injuries are Rotator Cuff Syndrome and  “Frozen shoulder”.

Rotator Cuff Syndrome

The rotator cuff is a confluence of tendons in the shoulder that insert into the outer aspect of the upper arm. They allow the muscles to raise and lower the arm, and rotate in and out. Regardless of the reasons for pain (see above), if the imbalances and irritation to the shoulder are not corrected, pain and limitation of normal motion may develop (4). The severity can vary from a slight catching or pain to an almost complete inability to use the shoulder(4). This painful condition is often called Shoulder Impingement or Rotator Cuff Syndrome and can afflict individuals of all ages. Pain can be aggravated by overhead use, and daily activities such as twisting a screwdriver, opening a bottle top or pulling a cork. If the rotator cuff is torn, the problem is more serious, however the symptoms are similar for the impingement syndrome. While serious cases may require surgery or cortisone, most cases can be managed by an approriate health practitioner.

Frozen Shoulder (Adhesive Capsulitis)

“Frozen Shoulder” is often a debilitating condition which occurs when the ligaments and tendons of the glenohumeral joint get so irritated that adhesions develop making the joint almost stuck together. This results in an extreme limitation of shoulder motion and pain that makes it difficult for some individuals to even get dressed (5).

There are many other disorders of the shoulder including bursitis and tendinopathy which can also be causes of pain.

The treatment of most conditions of the shoulder is often similar. The aim is to try and improve muscle imbalances with soft tissue massage, soft tissue release, joint mobilisation, ice and heat, and strengthening exercises, optimise mobility to the shoulder joints and address any mechanical blockages (7). Rehabilitation exercises advised by your health practitioner may also be important for recovery (2,3,5,8).

References:
(1) Magee DJ (2008). Orthopedic Physical Assesment Ed 5. pg 972-1012. Saunders Elsevier. ISBN-13:978-0-7216-0571-5
(2) Page P, Frank C, Lardner R, (2010) Assessment and treatment of Muscle Imbalance. The Janda Approach. Human Kinetics. ISBN10:0-7360-7400-7
(3) Christensen BH, Andersen KS, Rasmussen S et al (2016) Enhanced function and quality of life following 5 months of exercise therapy for patients with irreparable rotator cuff tears - an intervention study. BMC Musculoskelet Disord. 2016 Jun 8;17:252. doi: 10.1186/s12891-016-1116-6.

(4). Seitz, AL, McClure PW, Finucane S et al. Mechanisms of rotator cuff tendinopathy: Intrinsic, extrinsic, or both? Clinical Biomechanics. January 2011Volume 26, Issue 1, Pages 1–12

(5) Murphy F, Hall M, D’Amico L, Jensen A (2012). Chiropractic management of frozen shoulder syndrome using a novel technique. A retrospective case series of 50 patients. J Chiropr Med. 2012 Dec; 11(4): 267–272.

(6) Lee SY, Lee KJ, Kim W, Chung SG (2015) Relationships Between Capsular Stiffness and Clinical Features in Adhesive Capsulitis of the Shoulder. 2015 Dec;7(12):1226-34. doi: 10.1016/j.pmrj.2015.05.012. Epub 2015 May 21.
(7) Noten S, Meeus M, Stassijns G, et al. Efficacy of different types of mobilsation techniques in patients with primary adhesive capsulitis of the shoulder: A systematic Review. Arch Phys Med Rehabil. 2016 May;97(5):815-25. doi: 10.1016/j.apmr.2015.07.025. Epub 2015 Aug 15.

(8) Hanratty CE, McVeigh JG, Kerr DP etal The effectiveness of physiotherapy exercises in subacromial impingement syndrome: a systematic review and meta-analysis. Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. Review published: 2012.