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Shoulder Pain / frozen shoulder

Shoulder Pain / Frozen Shoulder

Overview
The shoulder joint is a ball-and-socket joint. The ball is the round shape at the top of the bone in the upper arm (humerus bone), which fits into the socket, the cup-shaped outer part of the scapula. The shoulder has a wide range of motion with three degrees of freedom. When something goes wrong in the shoulder, it affects your ability to move freely and can cause a great deal of pain and stiffness. The bones in the shoulder are cushioned by a layer of cartilage. There are two main joints. The acromioclavicular joint is between the highest part of the scapula and the clavicle. The glenohumeral joint is made up of the top, ball-shaped part of the humerus bone and the outer edge of the scapula. This joint is also known as the shoulder joint. The shoulder joint is the most mobile joint in the entire body. It moves the shoulder forward and backward. It also allows the arm to move in a circular motion and to move up and away from the body.

Causes of shoulder joint
There are many pathological conditions in the shoulder which can cause shoulder pain

Shoulder dislocation
When the top of the humerus moves out of its normal location in the shoulder joint that means the shoulder is dislocated. When it is only partially displaced and not totally out of its socket, it is called a subluxation.

What are the causes?

Causes will be related to injuries, these include;

• When an arm is pulled or twisted with extreme force in an outward, upward, or backward direction.

• Fall on an outstretched arm, a direct forceful blow to the shoulder can cause a shoulder dislocation.

• Seizures and shock can cause shoulder dislocations because they produce extreme, unbalanced muscle contractions that can cause the humerus out of the glenoid cavity.

Types of dislocation
There are 3 types of shoulder dislocation anterior, posterior, and inferior.


Anterior dislocation– when the humerus head displaced forward, toward the front of the body. This is the most common type of dislocation, in young people, most of the time the cause is typically sports-related. In older people, it usually caused by a fall on an outstretched arm.
Posterior dislocation– when the humerus is displaced toward the back of the body. Posterior dislocations account for 2% to 5% of all shoulder dislocations. It is related to seizures and shock and it also can happen because of a fall on an outstretched arm.
Inferior dislocation– when the humerus is displaced downward. This is a rare case and it can be caused by various types of trauma in which the arm is pushed downward.

Symptoms of shoulder dislocation

  • Limited range of motion of the shoulder
  • Severe pain in shoulder joint
  • Swelling over shoulder and pain gets worse with movement.
  • Not able to touch another shoulder.
  • Shoulder bruising or abrasions if dislocation caused by the injury.

Diagnosis of shoulder dislocation
Your doctor will ask you to move your shoulder and will ask if this ever happened before, what other symptoms you have experienced, how you injured your shoulder and how long your shoulder has been hurting to make a diagnosis. In most cases, you will be asked for an x-ray to see the exact position of your bones.

Treatment of shoulder dislocation
There is a combination of treatment which is necessary to treat shoulder dislocation, these are as follows;

Closed reduction– That means your doctor will adjust your bone with the help of sedative and muscle relaxant to reduce discomfort. X-ray is necessary to confirm whether it is adjusted in the right direction or not.

    • Immobilization- Once your bone has been reset, proper immobilization is done to prevent further relocation of bone. The time period will be depending on the severity of the injury it may vary from 1 week to 1 month.
    • Medication- It is prescribed in case of intolerable pain. Some pain relief medications are ibuprofen, acetaminophen. You can take an ice pack as well to reduce pain and swelling.
    • Surgery- Surgery is required in recurrent cases or if it’s difficult to reset humerus head into the glenoid cavity.
    • Physiotherapy- after surgery Physio rehab is very important for the speedy recovery and to reduce stiffness which you may have developed during immobilization. Mobilization exercises to reduce adhesions in the shoulder capsule. Stretching and strengthening exercises to correct the imbalance in your muscles. Range of motion exercises to gain full range.

    Physiotherapy is having an important role in preventing dislocations if your muscles are strong and flexible, you are less prone to have shoulder dislocation especially if it’s sports-related or injury-related because if your muscles are strengthened then they can bear most of the external forces.

 

Frozen shoulder

Frozen shoulder is characterized by pain and stiffness in the shoulder joint as a result of inflammation and fibrosis of the shoulder capsule. It is common after 40 years of age and women are at higher risk than men. It is also called adhesive capsulitis; some people think that its arthritis but both conditions are unrelated. In most of the cases, there is less synovial fluid in the joints, pain can be severe that person cannot even able to move the shoulder. There are three stages of frozen shoulder;

Freezing- this is the first stage of frozen shoulder, this stage starts with slight pain in shoulder and pain gets worse, up to the level of joint range restriction.  This stage typically lasts from 8 weeks to 9 months.

Frozen- In the second stage, pain becomes less but the stiffness remains the same or it increases more. Major daily life activities can be difficult because of so much restriction of joint range of motion. Frozen stage lasts from 4 to 6 months.

Thawing- In the last stage, symptoms start getting improve but for a full recovery, it can take 6 months to 2 years.

 

What are the causes of frozen shoulder?

There is no specific cause for frozen shoulder, but some factors can increase the risk of developing frozen shoulder for example;

  • Immobilization- if you are having any injury, fracture, or dislocation to shoulder joint, and you are prescribed to not move your arm or you have to immobilize your arm and shoulder for more than 1 month. Then you can develop a frozen shoulder because of no movement at the shoulder joint. Patients are prescribed to move shoulder and arm to reduce the risk of frozen shoulder.
  • Diabetes- it has been seen that diabetic patients are more prone to have a frozen shoulder, although the reason is unknown. Stiffness and pain continue for a longer time before the thawing stage.
  • Other diseases- some other medical conditions are also associated with a frozen shoulder for example; cardiac diseases, hypothyroidism, hyperthyroidism, and Parkinson’s disease.

Symptoms of frozen shoulder

  • Pain in the shoulder joint, it can go to arm also.
  • Limitation in joint range of motion.
  • Not able to perform overhead activities.
  • When it’s severe you might not able to perform daily activities like dressing and combing your hair.

Diagnosis of frozen shoulder

Diagnosis is depending on symptoms and physical examination. If you have pain and stiffness, you will go to your physiotherapist then your physiotherapist will assess your range of motion and specific movement. If you are not able to perform up to the normal range then it can be diagnosed as a frozen shoulder. There is one important thing for differential diagnosis that you cannot move your shoulder passively also because in some other conditions of the shoulder a person cannot move his shoulder but if someone else is moving his shoulder the range can go up to normal but he cannot move actively. So, if there is both active and passive range is restricted then it is confirmed for frozen shoulder.

Your doctor can ask for magnetic resonance imaging to rule out rotator cuff tear and x-ray for other bony abnormalities.

What is the treatment for frozen shoulder?

Frozen shoulder is a self-limited disease but symptoms can stay for 2 years if you left untreated. Combinations of treatment options can faster your recovery:

  • Physical therapy
  • Taking care at home
  • Medications
  • Surgery

Physical therapy

Physiotherapy is having an important and major role in treating frozen shoulder. Mobilization and stretching exercises for reducing stiffness and adhesions in the shoulder.  Strengthening exercises are also as important as stretching because it has been a long time that your shoulder is stiff and you are not moving your shoulder, result of that you are not using your muscles so your muscles strength must have reduced. Electrotherapy helps in reducing pain. Do all specific exercises under the supervision of a physiotherapist.

Taking care at home

Taking ice pack and just keep moving your shoulder can help you to reduce further deterioration in function and pain. You can do some basic exercises at home.

Medications

If your symptoms are so severe your doctor may prescribe an anti-inflammatory medication to reduce joint pain and inflammation.

Surgery

If in above-mentioned case options are not improving symptoms, it can be an option. But of the cases can improve with physiotherapy, very few cases required surgery. And after surgery also, physiotherapy is must require.

Impingement syndrome

In this condition, there is an impingement of rotator cuff muscles under the acromion process of the shoulder joint. It is also called swimmer’s shoulder since it is very common in swimmers. It is also common in some athletes who use their shoulders a lot for example; baseball or softball players. It is characterized by inflammation in rotator cuff muscles and pain in the shoulder joint. There are four rotator cuff muscles

(supraspinatus, infraspinatus, teres minor, and subscapularis) these muscles originate from scapular bone and insert into the humerus upper end. These are helping in overhead activities and rotation of the shoulder joint. These muscles are more prone to have injuries in comparison to other muscles of the shoulder joint.

Risk factors

There are some factors which can increase the risk of developing shoulder impingement such as swimming, baseball, and tennis. Occupations that require heavy lifting are also at higher risk. These include; constructor workers, painting, moving boxes, and other types of heavy lifters. Some people are having unusual acromion shapes from birth those are also at higher risk.

Symptoms of shoulder impingement syndromes

The symptoms of shoulder impingement are as follows;

  • Pain in the shoulder joint and it can go to the side of the arm also.
  • Pain aggravates in overhead activities.
  • Weakness in shoulder muscles.
  • Difficulty in daily life activities.
  • In case of severe pain, a person is not able to move the shoulder against gravity.
  • Pain can be minor but it’s constant and it can get worse at night.

Diagnosis of shoulder impingement

There are many physical tests that can help to diagnose it these are; neer’s impingement test, supraspinatus test, and drop arm test.

In some cases, you may need an x-ray to rule out arthritis and any bone anomaly in shoulder bones. MRI may be needed to see the severity of inflammation.

Treatment of shoulder impingement

Treatment is depending on the severity of the condition; these options are available to treat impingement syndrome:

  • Care at home
  • Physiotherapy
  • Medications
  • Surgery

Care at home

Take an ice pack for 10-15 mines to reduce inflammation and pain. Proper rest is also important for recovery. Avoid all type of activities which are putting a load on the shoulder.

Physiotherapy

  • Correction of muscle imbalances and biomechanical faults using strengthening and endurance exercises. Stretches of shoulder muscles are also important to improve performance.
  • Electrotherapy treatment to reduce inflammation, pain, and speedy recovery.
  • There are some specific exercises to treat impingement but those exercises you can do only under the supervision of a physiotherapist.

Medications  

Your doctor may recommend you some anti-inflammatory or pain relief medications in case of severe pain.

Surgery

Surgery is required in some cases for example; bony anomaly of the acromion and other bones of the shoulder. And if in the case above-mentioned treatment is not responding.

Subacromial bursitis

In this condition, there is intense pain in the shoulder and it gets worse when you move your shoulder. It often happens in the case of overuse and repetitive movement of the shoulder.

What is it?

In our body, there are small sacs all over and that is filled with a fluid called the bursa. These are thin cushions between your bones and the moving parts of your body like muscles and tendons. If a bursa gets swollen and fills up with more fluid than it should, then there will be inflammation in that specific bursa and this condition is called bursitis. This is most commonly happening in bursa near joints like shoulder, hips, elbows, and knees.

The subacromial (subdeltoid) bursa in each shoulder helps rotator cuff muscles to function. If it gets swollen because of overuse, you have subacromial bursitis.

Causes of subacromial bursitis

Causes are as follows;

  • Overuse of shoulder muscles.
  • Overhead lifting.
  • Forceful pulling of shoulder muscles.
  • The shape of your shoulder can also be a factor.
  • Being very active may also harm your bursa, especially if you do throw or pitching.
  • Inflamed joint.
  • Any trauma or injury to the shoulder joint.

Other factors are chronic irritation, shoulder muscle weakness, calcium deposits, and any type of shoulder arthritis.

 

Symptoms of subacromial bursitis

Symptoms would be as pain and stiffness in the shoulder, pain is typically on the lateral and anterior side of the shoulder and there might be swelling and redness over the shoulder. Tenderness (pain in touch) in front of the shoulder.

How to diagnose?

Your doctor will check your range of motion and physical examination to diagnose subacromial bursitis. Magnetic imaging resonance can show your bursa is filled with fluid. There is a difference between frozen shoulder and subacromial bursitis, in frozen shoulder restriction of active and passive movements, and in acromial bursitis, only active movements are restricted. Speed’s test is specific to diagnose subacromial bursitis

Treatment of subacromial bursitis

Ice pack for 10-15 mines for reducing swelling. You can apply once or twice a day.

Take proper rest and avoid repetitive activities, it will help in speedy recovery.

Physiotherapy is having an important and major role in treating subacromial bursitis. Mobilization and stretching exercises for reducing stiffness and in the shoulder.  Strengthening exercises are also as important as stretching because it has been a long time that your shoulder is stiff and you are not moving your shoulder, result of that you are not using your muscles so your muscles strength must have reduced. Electrotherapy helps in reducing pain. Do all specific exercises under the supervision of a physiotherapist.

Rotator cuff tendinitis

Tendons of the rotator cuff are susceptible to tendonitis, due to relatively poor blood supply near the insertion of muscles. The rotator cuff is a group of four tendons (supraspinatus, infraspinatus, teres minor, and subscapularis) that covers the humeral head and function of these muscles are arm rotation and elevation. These muscles and their tendons work together with the deltoid muscle to provide motion and strength to the shoulder for all overhead and waist level activities.

This condition is often caused by overuse of these muscles in repetitive overhead activities such as throwing, raking, washing cars or windows, and many other types of repetitive activities. It may also occur as a result of an injury. Rotator cuff injuries are the most common cause of shoulder pain and limitation of shoulder range of motion. Rotator cuff tendonitis is the mildest form of rotator cuff tear.

Symptoms of rotator cuff tendinitis

The classic symptoms include a ‘toothache’ like pain in the shoulder joint. Sometimes the pain is going to arm and front and lateral side of the shoulder. It may interfere with sleeping comfortably. Pain can be minor nut it is constant and it can get worse at night. Difficulty in daily life activities and in severe cases, a person is not able to move the shoulder against gravity.

The symptoms get aggravated by raising the arms overhead or in activities. Furthermore, reaching behind the back to fasten underclothing or to pass a belt can aggravate the arm and shoulder pain. Weakness in shoulder and arm muscles is also significant in this condition.

Diagnosis of rotator cuff tendinitis

Diagnostic tests utilized: MRI may be used, but sometimes not sensitive enough for an accurate assessment.

Clinical examination including the following special tests will be useful to make diagnose:

  • Supraspinatus test
  • Neer’s impingement test

Treatment of rotator cuff tendinitis

The following steps should be taken as a conservative treatment to treat rotator cuff tendonitis:

  • Avoid or decrease the activities which are
  • Apply ice to the affected area for 10-15 mines
  • Anti-inflammatory medications to reduce arm and shoulder pain.
  • Mobility exercise program to maintain flexibility.
  • Avoid carrying heavyweights with the affected arm or using shoulder-strap bags on the affected side.
  • If pain is severe, a cortisone injection is the option to treat intense pain.

Physiotherapy is very helpful in reducing pain and inflammation. Strengthening and stretching exercises to correct the imbalance in muscles. Ultrasound for treating localized pain. Range of motion exercises to increase range in shoulder joint

If the above-mentioned treatment is not responding, surgery to remove a spur on the acromion can increase the space for the inflamed tendon and can prevent further fraying or complete rupture. If MRI shows a complete tear of rotator cuff or muscle injury, surgical repair may be required.

Surgery for recurrent rotator cuff tendonitis (bursitis) is most of the time performed to:

  • Remove a prominence or spur on the undersurface of the acromion.
  • Remove chronically inflamed, thickened, and fibrotic bursal tissue.
  • Inspect the tendons and tidy up and sometimes repair a tear in the tendons.

These procedures are often done in combination. This can be done either through an open or an arthroscopic approach.

Physio rehab is crucial for faster recovery.

 

Frozen shoulder is basically, limitation in active and passive range of motion of shoulder joint. There are three stages of frozen shoulder: Freezing- Characterized by intense pain even at rest and limitation of motion by 2 to 3 weeks after onset. Frozen- Characterized by pain only with movement, significant adhesions and limited shoulder motions with substitute motions in the scapula. Thawing- Characterized by no pain no synovitis but significant capsular restrictions from adhesions.

Source: CAROLYN KISNER AND LYNN ALLEN COLBY)

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