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Help I Have Shoulder Pain! Now what?

Second only to low back pain, shoulder pain is the most common ailment we see in an outpatient physical therapy practice. If you have this, you are not alone! It is common among all age groups and backgrounds, from sedentary folks through elite athletes. There are many different reasons for shoulder pain. Read on to find out more about the more common things we see in the clinic.

Rotator cuff disorders: Many terms have been used over the years for this including rotator cuff tendinopathy, subacromial pain syndrome, rotator cuff related shoulder pain, subacromial impingement syndrome, subacromial bursopathy / bursitis, long head biceps tendinopathy / tendinitis, and partial-thickness rotator cuff tear. Management often includes NSAIDS to reduce pain early on. Corticosteroid injections are not typically recommended immediately but may be considered in severe or chronic cases, recognizing that evidence shows they are only effective short term and they are not recommended if two injections have not been successful in reducing pain or improving function. Joint mobility exercises, strengthening, endurance training, and motor control exercises have all been shown to be helpful in addition to manual therapy by a physical therapist. Modalities including taping, TENS units, IFC, and iontophoresis may be helpful for some. Subacromial decompression surgery has not been shown to reduce pain or improve function any better than a placebo surgery, therefore physical therapy is the way to go!

Rotator cuff tears: When a rotator cuff tear covers the entire thickness of at least 1 of the 4 rotator cuff tendons, it is considered a full-thickness rotator cuff tear. It will be further classified by the extent of the tear (small, medium, large, or massive), how many of the 4 tendons are involved (supraspinatus, infraspinatus, teres minor, and subscapularis), whether it occurred traumatically or degenerative over time, whether there is fatty infiltration, and whether the tendon(s) has retracted. Surgery is more common in this case. When non-operative management is elected, we address range of motion and strength as much as possible in addition to coaching on activity modification. 

Osteoarthritis: 23% of older adults are diagnosed with osteoarthritis and it is one of the leading causes of pain, disability and use of health care resources in the US. Specifically in the shoulder, 17-20% of adults over age 65 have degenerative changes in their glenohumeral (shoulder) joint. It is more frequent in women, those who have had previous shoulder injuries, those in occupations requiring heavy lifting, and those active in sports requiring overhead use of the arm. There is cartilage loss and bony changes which impacts function of the shoulder. Common complaints are difficulty with overhead activities, difficulty with activities requiring external rotation of the arm, and sleep difficulties. Nonoperative management typically includes NSAIDS, injections, and physical therapy. We work on range of motion and strengthening and help reduce the need and potential harm of ongoing use of NSAIDS and repeated injections.

Total shoulder replacement: Shoulder joint replacements are the third most commonly performed surgeries to address pain and disability, behind hip and knee replacement surgery. After surgery, there is initial use of a sling with instructions to avoid use of the shoulder. Typically physical therapy begins around 4 weeks post-operatively for range of motion exercises which help reduce pain and swelling, gradually returning the patient to activity over time.

Frozen shoulder: Also known as adhesive capsulitis, frozen shoulder is characterized by significant loss of passive motion in multiple planes. It can occur out of nowhere or following a previous injury to the shoulder. People with thyroid disease and/or diabetes mellitus (type I or II) are more susceptible and prevalence is greater in females and individuals who are between the ages of 40-65. There is typically a progression over a continuum of 4 stages described. Stage 1 is characterized by sharp pain at the end ranges of motion, achy pain at rest, and sleep disturbance but there are not yet significant range of motion restrictions. The “freezing” stage 2 has a gradual loss of motion in all directions due to pain. The “frozen” stage 3 has pain and loss of motion. Finally, in the “thawing” stage 4, the pain resolves but significant stiffness can persist. The whole process can take 2 years, however physical therapy can be very helpful in expediting this timeframe. In the initial stages with higher pain levels, we use modalities for pain management and low intensity / gentle range of motion exercises and stretches. Corticosteroid injections are very effective in the short term as well. As time goes along and pain improves, the stretches we use intensify and begin to incorporate strengthening into the gained movement within sessions. 

Labral tears: The labrum is the layer of cartilage which lines the glenoid (socket) of the shoulder joint. Injuries to this tissue are commonly referred to as SLAP (superior labral anterior posterior) lesions and may or may not involve the biceps tendon. They occur when falling on an outstretched arm, an episode of sudden traction to the arm, a blow to the shoulder, or due to repetitive overuse such as in an overhead athlete. Initial non-operative treatment includes NSAIDS, rest, ice, activity modification, and physical therapy. We perform range of motion and stretching to help restore normal motion and strengthening to stabilize the joint. Some patients are able to continue with non-operative treatment successfully, but if it fails, surgery is considered. Physical therapy is part of the post-operative protocol initially to restore motion and progressing to strengthening to return to prior activity levels.

Shoulder dislocation and/or instability: Over time, instability causes loosening of the joint. This can be caused by a traumatic injury (dislocation), overuse, or a hypermobile type of anatomy such as that seen in Ehler’s Danlos Syndrome. It may feel like the shoulder is not staying in position or like it could “pop out” at any point. The shoulder joint is more likely to dislocate again if it has sustained a true dislocation in the past due to the damage to the ligaments at the time of the initial injury. A significant amount of strengthening and endurance training is required in this case. We gradually progress the difficulty of the exercises over time, with an emphasis on teaching your muscles to work together as a unit to stabilize your joint. In severe cases with recurrent subluxations or dislocations, surgery is considered.

As you can see, physical therapy is a very important part of managing all shoulder pain. Most cases can and should be treated conservatively, meaning without surgery, and we are critical in this approach. If surgery is appropriate, we are an integral part of the post-operative phase in getting patients back to their prior activity levels. Come check us out and see what we can do for you!

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