SHOULDER PAIN
The shoulder joint is the most versatile and mobile joint in the body giving us great ability to do lifting and reaching tasks; and thus it depends on a group of strong, and efficient muscles coordinating to control it. Uniquely our shoulder muscles attach onto the neck, shoulder blade, ribcage, and arm. As a result, shoulder pain can also affect and extend into the neck, trunk and arm. Shoulder pain is a term that relates to pain in and around the front, back and sides of shoulder.
Medical diagnostic labels common for shoulder pain include:
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Rotator cuff tear (partial thickness, full thickness, interstitial, rupture),
Rotator cuff related shoulder pain (RCRPS) -
Rotator cuff / Long head of bicep tendi-nosis/nitis/nopathy,
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SLAP labral tear, Shoulder instability
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Subacromial bursitis, Subacromial impingement syndrome,
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Shoulder arthritis, fractures (proximal humerus – head, shaft)
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Frozen shoulder (adhesive capsulitis) and acromio-clavicular joint pain
Physiotherapists are key healthcare providers for conservative shoulder care, being tasked to prevent persistent pain and disability, and facilitating a pathway to wellness and functional restoration.
There is strong evidence that physiotherapy should be the first line of shoulder pain treatment once serious injury has been ruled out (e.g. fracture or traumatic tendon rupture). Shoulders recover best when we move and get it stronger progressively. This may involve a range of helpful recovery strategies such as pain reduction, shoulder gentle movements and strengthening exercises (level 1 evidence).
SHOULDER PAIN GALLERY
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rotator cuff partial thickness tears (<75%) exercise is as effective as surgery at a fraction of the cost of surgery
Kukkonen, J., Joukainen, A., Lehtinen, J., Mattila, K. T., Tuominen, E. K. J., Kauko, T., & Äärimaa, V. (2014). Treatment of non-traumatic rotator cuff tears: A randomised controlled trial with one-year clinical results. The bone & joint journal, 96(1), 75-81.
(atraumatic) full thickness rotator cuff tears exercise significantly reduces the need for surgery up (75%) (@ 2years)
Dunn, W. R., Kuhn, J. E., Sanders, R., An, Q., Baumgarten, K. M., Bishop, J. Y., ... & Wright, R. W. (2016). 2013 Neer Award: predictors of failure of nonoperative treatment of chronic, symptomatic, full-thickness rotator cuff tears. Journal of shoulder and elbow surgery, 25(8), 1303-1311.
subacromial impingement syndrome exercise significantly reduces the need for surgery up to 80%
Holmgren, T., Hallgren, H. B., Öberg, B., Adolfsson, L., & Johansson, K. (2012). Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study. Bmj, 344.
A specific exercise strategy, focusing on strengthening eccentric exercises for the rotator cuff and concentric/eccentric exercises for the scapula stabilisers, is effective in reducing pain and improving shoulder function in patients with persistent subacromial impingement syndrome. By extension, this exercise strategy reduces the need for arthroscopic subacromial decompression within the three month timeframe used in the study.
Ketola, S., Lehtinen, J., Arnala, I., Nissinen, M., Westenius, H., Sintonen, H., ... & Rousi, T. (2009). Does arthroscopic acromioplasty provide any additional value in the treatment of shoulder impingement syndrome? A two-year randomised controlled trial. The Journal of bone and joint surgery. British volume, 91(10), 1326-1334.
Arthroscopic acromioplasty provides no clinically important effects over a structured and supervised exercise programme alone in terms of subjective outcome or cost-effectiveness when measured at 24 months. Structured exercise treatment should be the basis for treatment of shoulder impingement syndrome, with operative treatment offered judiciously until its true merit is proven.
Haahr, J. P., & Andersen, J. H. (2006). Exercises may be as efficient as subacromial decompression in patients with subacromial stage II impingement: 4–8‐years' follow‐up in a prospective, randomized study. Scandinavian journal of rheumatology, 35(3), 224-228.
Objectives: To compare the prognosis of subacromial impingement (SAI) stage II treated conservatively or with subacromial decompression.
Methods: A follow‐up study after 4–8 years in a randomized controlled trial (RCT) with 90 adult cases with SAI treated in a Danish hospital from 1996 to 2000 with graded physiotherapy and exercises or arthroscopic subacromial decompression. Outcomes were proportion of time per year with income transfers (indexed 0–1), including total transfers (marginalization), sick leave and disability pension obtained from the registry at the Ministry of Work. Self‐reported function, working capability, employment status and global improvement were obtained by questionnaire in September 2004. The main outcomes are given as differences in development from baseline.
Results: Seventy‐nine (88%) responded to the questionnaire and registry data were obtained from 81. After 1 year the marginalization index increased by 0.45 [95% confidence interval (CI) 0.35–0.56] for surgery and 0.25 (0.16–0.34) for physiotherapy. Cases undergoing surgery also tended to have more sick payments during the first year, but the difference was not significant. Four years after inclusion, changes in indices did not differ between treatment groups. Self‐reported outcomes after 4–8 years did not differ between treatment groups.
Conclusion: The results of surgical decompression were equal to those of conservative treatment, and the surgery group had more income transferrals during the first year of follow‐up.
Haahr, J. P., Østergaard, S., Dalsgaard, J., Norup, K., Frost, P., Lausen, S., ... & Andersen, J. H. (2005). Exercises versus arthroscopic decompression in patients with subacromial impingement: a randomised, controlled study in 90 cases with a one year follow up. Annals of the rheumatic diseases, 64(5), 760-764.
Abstract
Objectives: To compare the effect of graded physiotherapeutic training of the rotator cuff versus arthroscopic subacromial decompression in patients with subacromial impingement.
Methods: Randomised controlled trial with 12 months’ follow up in a hospital setting. Ninety consecutive patients aged 18 to 55 years were enrolled. Symptom duration was between six months and three years. All fulfilled a set of diagnostic criteria for rotator cuff disease, including a positive impingement sign. Patients were randomised either to arthroscopic subacromial decompression, or to physiotherapy with exercises aiming at strengthening the stabilisers and decompressors of the shoulder. Outcome was shoulder function as measured by the Constant score and a pain and dysfunction score. “Intention to treat” analysis was used, with comparison of means and control of confounding variables by general equation estimation analysis.
Results: Of 90 patients enrolled, 84 completed follow up (41 in the surgery group, 43 in the training group). The mean Constant score at baseline was 34.8 in the training group and 33.7 in the surgery group. After 12 months the mean scores improved to 57.0 and 52.7, respectively, the difference being non-significant. No group differences in mean pain and dysfunction score improvement were found.
Conclusions: Surgical treatment of rotator cuff syndrome with subacromial impingement was not superior to physiotherapy with training. Further studies are needed to qualify treatment choice decisions, and it is recommended that samples are stratified according to disability level.](https://static.wixstatic.com/media/93313e_499056c80248406b8a4be59d22cbbb1a~mv2.jpeg/v1/fit/w_1190,h_740,q_75/93313e_499056c80248406b8a4be59d22cbbb1a~mv2.webp)
![12) frozen shoulder aetiology diagnosis & management
Lewis, J. (2015). Frozen shoulder contracture syndrome–Aetiology, diagnosis and management. Musculoskeletal science and practice, 20(1), 2-9.
Frozen shoulder is a poorly understood condition that typically involves substantial pain, movement restriction, and considerable morbidity. Although function improves overtime, full and pain free range, may not be restored in everyone. Frozen shoulder is also known as adhesive capsulitis, however the evidence for capsular adhesions is refuted and arguably, this term should be abandoned. The aim of this Masterclass is to synthesise evidence to provide a framework for assessment and management for Frozen Shoulder. Although used in the treatment of this condition, manipulation under anaesthetic has been associated with joint damage and may be no more effective than physiotherapy. Capsular release is another surgical procedure that is supported by expert opinion and published case series, but currently high quality research is not available. Recommendations that supervised neglect is preferable to physiotherapy have been based on a quasi-experimental study associated with a high risk of bias. Physiotherapists in the United Kingdom have developed dedicated care pathways that provide; assessment, referral for imaging, education, health screening, ultrasound guided corticosteroid and hydro-distension injections, embedded within physiotherapy rehabilitation. The entire pathway is provided by physiotherapists and evidence exists to support each stage of the pathway. Substantial on-going research is required to better understand; epidemiology, patho-aetiology, assessment, best management, health economics, patient satisfaction and if possible prevention.
stages:
1) pain more than stiffness
2) stiffness more than pain
Keywords
Frozen shoulder Assessment Management
frozen shoulder: stiffness more than pain
findings from RCTs of low risk of bias
joint mobilisation and upper limb ergometer (non diabetic population) - 2-3 sessions per week (10 total)
ergometer and mobilisation:
15 mins upper extremity cycle ergometer + mobilisation supine with shoulder in 30-40 degrees abduction and external rotation (at the end of available motion); glenohumeral axial 'distraction' kaltenborn type III followed by posterior glide without oscillations for 1 minute rest, repeated 15 times. Results: significant improvement in function (constant) & increased ROM (passive)
Espinoza, H. G., Pavez, F., Guajardo, C., & Acosta, M. (2015). Glenohumeral posterior mobilization versus conventional physiotherapy for primary adhesive capsulitis: a randomized clinical trial. Medwave, 15(8), e6267.
Çelik, D., & Kaya Mutlu, E. (2016). Does adding mobilization to stretching improve outcomes for people with frozen shoulder? A randomized controlled clinical trial. Clinical rehabilitation, 30(8), 786-794.
Objective:
To assess the effectiveness of joint mobilization combined with stretching exercises in patients with frozen shoulder.
Design:
A randomized controlled clinical pilot trial.
Setting:
Department of Orthopedics and Traumatology.
Subjects:
Thirty patients with frozen shoulder.
Intervention:
All participants were randomly assigned to one of two treatment groups: joint mobilization and stretching versus stretching exercises alone. Both groups performed a home exercise program and were treated for six weeks (18 sessions).
Main measures:
The primary outcome measures for functional assessment were the Disabilities of the Arm, Shoulder and Hand score and the Constant score. The secondary outcome measures were pain level, as evaluated with a visual analog scale, and range of motion, as measured using a conventional goniometer. Patients were assessed before treatment, at the end of the treatment, and after one year as follow-up.
Results:
Two-by-two repeated-measures ANOVA with Bonferroni corrections revealed significant increases in abduction (91.9° [CI: 86.1-96.7] to 172.8° [CI: 169.7-175.5]), external rotation (28.1° [CI: 22.2-34.2] to 77.7° [CI: 70.3-83.0]) and Constant score (39.1 [CI: 35.3-42.6] to 80.5 [75.3-86.6]) at the one-year follow-up in the joint mobilization combined with stretching exercise group, whereas the group performing stretching exercise alone did not show such changes.
Conclusion:
In the treatment of patients with frozen shoulder, joint mobilization combined with stretching exercises is better than stretching exercise alone in terms of external rotation, abduction range of motion and function score.
Keywords
Adhesive capsulitis, manual therapy, exercise, shoulder pain, shoulder function
Ibrahim, M., Donatelli, R., Hellman, M., & Echternach, J. (2014). Efficacy of a static progressive stretch device as an adjunct to physical therapy in treating adhesive capsulitis of the shoulder: a prospective, randomised study. Physiotherapy, 100(3), 228-234.
Abstract
Background
Stress relaxation and static progressive stretch are techniques used for non-surgical restoration of shoulder range of motion for patients with adhesive capsulitis.
Objectives
To compare a static progressive stretch device plus traditional therapy with traditional therapy alone for the treatment of adhesive capsulitis of the shoulder.
Design
Prospective, randomised controlled trial.
Participants
Sixty patients with adhesive capsulitis of the shoulder were assigned at random to an experimental group or a control group.
Interventions
Both groups received three traditional therapy sessions per week for 4 weeks. In addition, the experimental group used a static progressive stretch device for 4 weeks.
Main outcome measures
The primary outcome measure was shoulder range of motion (active and passive shoulder abduction, and passive shoulder external rotation). The secondary outcome measures were function [measured by the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire] and pain [measured using a visual analogue scale (VAS)].
Results
At baseline, there were no differences between the two groups. However, after the intervention, there were significant (P < 0.05) differences between the groups for all outcome parameters: 0.3 for mean VAS scores [95% confidence interval (CI) −0.6 to 1.1], −10.1 for DASH scores (95% CI −21.0 to 0.9), 21.2° for shoulder passive external rotation (95% CI 16.8 to 25.7), 26.4° for shoulder passive abduction (95% CI 17.4 to 35.3), and 27.7° for shoulder active abduction (95% CI 20.3 to 35.0). At 12-month follow-up, the differences between the groups were maintained and even increased for mean shoulder range of motion, VAS scores and DASH scores, with significant differences (P < 0.001) between the groups: −2.0 for VAS scores (95% CI −2.9 to −1.2), −53.8 for DASH scores (95% CI −64.7 to −42.9), 47.9° for shoulder passive external rotation (95% CI 43.5 to 52.3), 44.9° for shoulder passive abduction (95% CI 36.0 to 53.8), and 94.3° for shoulder active abduction (95% CI 87.0 to 101.7).
Conclusion
Use of a static progressive stretch device in combination with traditional therapy appears to have beneficial long-term effects on shoulder range of motion, pain and functional outcomes in patients with adhesive capsulitis of the shoulder. At 12-month follow-up, the experimental group had continued to improve, while the control group had relapsed.](https://static.wixstatic.com/media/93313e_effc8a80d86940bba2ec1b033eb63f8f~mv2.jpeg/v1/fit/w_1329,h_771,q_75/93313e_effc8a80d86940bba2ec1b033eb63f8f~mv2.webp)
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