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Shoulder disorders: physiotherapy can help
Shoulder disorders are commonly seen by physiotherapists. The shoulder complex is a complicated area. It consists of the:
• glenohumeraljoint• acromio-clavicularjoint• sterno-clavicularjoint• scapulothoracicarticulation.
Thereisminimalbonysupportwhichenablesalargerangeofmovementtooccurthroughtheupperlimb.Thisleadstoproblems as in essence, the shoulder complex is controlled by soft tissue.
Thegleno-humeraljointhasoftenbeendescribedas a watermelon on a saucer. This is not far from the truth. Therotatorcuffmusclesneedtoworkingoodsynchronisation, withsupportiveligamentsforeffectiveshoulderfunction.
Afullsubjectiveandobjectiveassessmentoftheshoulderandsurroundingareascanbealengthyprocessbutis essentialforgoodclinicaloutcomes. Therearethreemainsubdivisionsintowhichshoulder disorders nearly always fall:
1.impingement/rotatorcuffinjuries2. instability3.adhesivecapsulitis/capsularrestrictions.
Itisalsoimportanttoconsiderotherfactorswhenassessinga shoulder disorder. This includes:
• referredpain(fromthecervicalorthoracicspine)• sportingtechniqueincludingequipmentchanges/ modifications,eg.tennisracquetchange• biomechanicalandposturalissues.
Ifthesefactorsarenotaddressedtheywillaffectthehealingprocess and the patient’s outcome.
Athoroughsubjectiveandobjectiveassessmentisimportant. Experienceinorthopaedicshouldertestsisvital.Shoulderrange ofmovement,scapulathoracicrhythm,strength,impingementand stability tests should be an essential part of your assessmenttoassistdiagnosis.Ifnecessary,imagingwillalsoassistdiagnosis.Researchshowsthemajority ofshoulderproblemswillsettlewithexercise,modifiedrestandre-education.Althoughosteoarthritisisuncommoninthegleno-humeraljoint,subtlechangesinthebonemaybepresentthatcanpredisposetospecificconditionsdeveloping. Acromial spurs are an example of this.
Earlydiagnosisandphysiotherapytreatmentwillproducequickerimprovementsandbetteroutcomesinthemajorityofclients.Diagnosisandtreatmentmustbetailoredtotheindividualclient.
Physio In Practice
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Medical management• Non-steroidalanti-inflammatorydrugsareoften beneficialintheacutestageandshortperiodsofrest canhavesomevalue• Cortico-steroidinjectionsintotheshoulderjointor surroundingareascanbeverybeneficialtoreducepain, inflammationandallowrehabilitationtoprogress• Surgerymaybeindicatedforfullthicknessrotatorcuff tears,impingementduetobonyspursandlabralrepairs in instability problems.
PhysiotherapyPhysiotherapyplaysalargeroleinshoulderdysfunction.Delaysinreferralcanmeanfurtherdamagetothejointsleadingtoincreasedriskofsurgeryandmoreinvasive treatments.Accurateandthoroughdiagnosisalongwithgoodexerciseprescriptionwillsettlethemajorityoftheseshoulder disorders, especially if seen early.
Therotatorcuffisanimportantgroupofmusclesforthe stability of the shoulder complex. They act to stabilise theheadofhumerousintheglenoidfossa.Forthisreasontheywilloftenformpartoftherehabilitationprogram. The physio will also look closely at scupulohumeral control whichisthequalityofthescapulamovementasthearm ismoved.Specificexerciseswillbeprovidedtooptimisethis control if necessary.
Maintaininggoodfunctionofthesurroundingjoints oftheshoulderwillassistrecovery.Mobilisationofthe lowercervicalandthoracicspinecaninsomecases, produceinstantimprovementsinshoulderrangeandpain.
Thisisbecausegoodfunctionandposturechanges inthespinewill‘de-load’theshoulderjointandtissues.
Gradual hydrotherapy and exercise rehabilitation can beusefultoimproverangeofmovementandstrength especiallyifaclientisfindinglandtreatmenttoopainful.
Physio In Practice
Theglenohumeraljoint—wheretheheadofthehumerus(upperarm bone)attachestotheshoulderblade—isclassifiedasaball-and-socketjoint.Howeveritismoreakintoagolfballsittingonateeasthesocketisquiteshallowanddoesnotactuallyencapsulatemuchoftheball.Thesternoclavicularjoint—wherethecollarboneattachestothesternum—istheonlyjointthatconnectstheentireupperlimbtothemainskeleton.Thisdesignallowstheshouldertobethemostmobilejointinthebody,butmakesitpronetoinjurydue to the lack of inherent stability and the reliance on muscles andligamentsforsupport.
SymptomsTraumaticshoulderdisordersresultingfromfallsorimpactrangeinseverityfrombruisesandminormuscleandtendonstrainstofracturesanddislocations.Theseverityandfrequencyofpainoftenrelatestotheseverityoftheinjury,soifthepainisconstantandsevere,itislikelyyourshoulderinjurywilltakelongertoheal.However,ifyourpainismildanddoesnotsignificantlyrestrictyourmovement,itislikelythatwithpropermanagement,yourshoulderwillreturntonormalquitequickly.
Non-traumaticandoveruseinjuriesoftheshoulderareverycommon. Heavyorrepetitivemovements,particularlyinawkwardpositions,greatlyincreasetheriskofshoulderinjury.Disuse,poorpostureandpreviousinjurycancausetightorweakmusclesaroundtheshoulderwhichcanleadtoinjury.
Intheearlystages,painmaybelimitedtospecificmovementsoronlyevidentafteradayofheavyorrepetitivework.Iftheconditionisallowedtoprogress,theinflamedstructuresintheshouldercancauseimpingementduringmovement,resultingingreaterpain anddecreasedrangeofmotion.Thelongerthisprocesscontinues,themoretheaffectedtendonscan‘wearout’andinlongstanding,untreated cases, this can potentially cause the tendon to rupture. Inmoreadvancednon-traumaticoroveruseshoulderconditions,symptomswillincludepainatrest,difficultywithmovementslikereachingaboveyourheadorbehindyourbackanddisturbedsleep.
Physio 4 You
Shoulderdisorders
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Physio 4 You
What can you do?Thebestinitialtreatmentis‘relativerest’fromactivitiesthatworsenthesymptoms.Thisdoesnotmeanrestingcompletely,rathermodifyingorlimitingaggravatingactivities.Somerelativerest examples include:
• placingyourcomputermouseasclosetoyourselfaspossible tolimitreaching• carryingitemsclosetoyourbodyanduseabackpack where possible• avoidingliftinganythingaboveyourhead• takingregularbreaksorfrequentlychangeyouractivity, ifyouareunabletomodifyaggravatingactivities• applyinganicepackaftertraumaticinjuriesorifyourshoulder painhasflaredup• applyingaheatpackwhenexperiencingshoulderstiffness.
What can physiotherapy do?A physiotherapist can determine whether the shoulder disorder isbeingcausedbymusculoskeletalfactorsorifthereareotherreasons for the pain. Your physiotherapist will then undertake athoroughassessmentincluding:
• postureanalysistoassesswhetheryournormalsitting orstandingpositionisstressingyourshoulder• examinationofyourshoulderrangeofmovementandbiomechanics• jointandmuscletestingtomeasurepain,restriction, weaknessandtightness• assessmentofotherareasofthebodytodetermineother factorsthatmaybecausingpain• organisingimagingsuchasx-ray,ultrasoundorMRIscans.
Atailoredtreatmentplanwillthenbedesignedtosuityourwork and recreational lifestyle. This will typically include a combination of:
• massagetostretchtightmuscles• jointmobilisationstoregainlostrangeofmotion• strengthwork• stretches• posturalcorrection• taping.
Shoulderdisorders