A healthy shoulder is an integral part of normal daily activities and overall independence. A functional shoulder allows you to wash your hair, put on a shirt, swing a golf club, lift groceries into your boot to name a few. Maintaining a healthy shoulder is an important part of having optimal quality of life.
The shoulder is a very mobile joint that allows movement of the arm in several directions. Because the shoulder joint is very shallow, it is supported by several important tendons known as the rotator cuff. There are also other several important joints that work with your shoulder such as acromioclavicular joint which is the articulation of the shoulder blade (scapula) and the collarbone (clavicle). The aging shoulder should be viewed like the normal process of getting grey hair. The collagen being laid down during healing is reduced. We may experience muscle and joint problems such as an increasing sensation of shoulder stiffness. We lose elasticity, and the quality of mechanical movement reduces.
It is important to stay active to help slow down the normal ageing shoulder joint. It also allows us to continue to participate in social and leisure activities we enjoy. When you notice shoulder pain, or restriction, it is important to see your Physiotherapist for a proper evaluation of its range of movement and strength. They will then determine what strength and stretching exercises in conjunction with adjunct therapies are needed to maintain optimal shoulder function. This may not be the same as before the onset of symptoms, but with proper management, it is more likely a person will improve from their current limitations.
Common Clinical Shoulder Problems:
Rotator cuff tears:
Rotator cuff tears unfortunately become more common with age. Degenerative changes (thinning, disorientation, and weakness) accumulate in collagen fibres of the rotator cuff over time, increasing the likelihood of a tear. These injuries can occur during a traumatic event, such as a fall, or insidiously without any specific mechanism.
Rotator cuff tears can be stubborn and slow to heal due to limited blood supply. Individuals may experience reduced arm strength and increased neck strain (muscles overworking). For some, it may come from a stiff thoracic or decreased range of movement in the shoulder. For others, injuries to the rotator cuff may come from throwing, or overdoing a certain overhead activity such as painting a house. However, many tears do very well with conservative (i.e., non-surgical) management.
The first line of treatment for rotator cuff injuries is to reduce overall load (i.e., limited aggravating activities) to calm the irritated tissues and promote healing. That said, tendons need to be loaded and therefore it is important to maintain some shoulder movement during the recovery stage to ensure the tendons stay healthy. Progressive strengthening exercise not only help to handle everyday loading activities, it also builds confidence in regaining functional movements.
Imaging may be useful if the tear is significant. Shoulder imaging is not something that needs to occur immediately. Clients should collaborate with a physiotherapist or general practitioner to establish if/when scans are required. Conservative management should be given a fair trial for three to six months before considering whether more invasive treatment alternatives are appropriate.
Rotator cuff tendinopathy:
Rotator cuff tendinopathy is an overuse injury of the tendon that results in degeneration of the tendon’s collagen (main structure). It occurs when too much stress is put on the tendon and does not have enough time to recover before it is loaded again. The pain is usually felt following specific activity, or after little movement such when getting out of bed in the morning. These tend to improve after warming up with gentle movements.
An important fact about tendinopathies is that complete rest does not help and neither is pushing through pain. Once diagnosed, it is recommended to reduce loading the tendon and follow a personalised exercise program from your physiotherapist to bring your shoulder back to health. it’s safe to do activity with a bit of pain as long as it’s within a tolerable level and comes back down shortly after the activity is done.
Biceps tendinopathy:
The biceps muscle is located at the front of your upper arm. It allows to flex your elbow and rotate the wrist out (supination). Biceps tendonitis is also known as tenosynovitis, most commonly affecting the tendinous portion of the long head of biceps (LHB). Less than 5% of people experience biceps tendinopathy alone, it is mostly common while having rotator cuff tendinopathy as the tendon inserts in the shoulder joint and becomes a continuation of the glenohumeral joint. The tendon is affected due to taking on more load to compensate for other rotator cuff muscle deficits or stiffness. A sore biceps will present with difficult lifting your arm above your head. The pain is often experienced on the side of the arm around the deltoid region. Treating a biceps tendinopathy involves treating the rotator cuff as well to make sure every muscle is moving and working properly.
Is it stiff or frozen?
Increased shoulder stiffness may not mean “frozen shoulder”. A shoulder is diagnosed as “frozen” when it has a significant loss of both active and passive movement in most directions but looks normal on x-ray. A true frozen shoulder is extremely painful, and often disabling. Although not fully understood, it is an inflammatory condition that affect the overall capsule of the shoulder. The contracture, hence freezing, comes from a proliferation of collagen, fibrosis with a reduction of the shoulder joint. Women between the ages of 50-60 years are four times more likely to get this condition. Physiotherapy for frozen shoulder can be helpful with pain management and education.
A stiff shoulder requires a healthy amount of movement, and gentle strengthening exercises to regain previous range of movement. For some, joint mobilisation, manual therapy, strengthening exercises, massage, passive stretching, and trigger point dry needling can help to reduce overall stiffness.
Shoulder Osteoarthritis:
Shoulder osteoarthritis is the degeneration of the cartilage in the joint. Degeneration is common for people over 60 years of age. No one knows the real cause of shoulder joint arthritis but it can occur following recurrent shoulder dislocations, large rotator cuff tears, or a humeral head fracture. Shoulder OA mainly affects the ball and socket joint (glenohumeral joint) and the acromioclavicular joint that connects your arm with your shoulder blade. Many feel grinding or clicking when moving their arm. They can also experience a deep ache that can be sharper on movement. Pain can also be felt around the upper arm and can sometimes radiate towards the neck. This is particular with raising the arm above the head or lying on the affected side. Many who have shoulder OA also reports loosing general range of movement when trying to reach above their head or out to the side.
Imaging
X-ray imaging can determine the level of arthritis around the joint. However, is not always indicative of symptoms experienced. People with severe structural changes may experience little pain. Others with minimal structural changes may have severe symptoms. Physiotherapy is designed to assess the individual shoulder restrictions and create loading plan based on activities meaningful to the patient.
Keeping a shoulder happy!
Staying active, eating a healthy diet and maximising sleep quality is an integral part of a healthy shoulder joint. Exercises such as swimming, strength training and pilates are a few examples that can help. In some instances, ensuring objects are close to your body with lifting and evenly distributing the load between both shoulders can help. For example: avoid carrying a heavy bag on one shoulder. Avoid doing repetitive movements for a long period of time such as cutting a long hedge or painting your house. When possible, use a foot stool or ladder to lessen strain on your shoulders. Make sure you take regular breaks from these repetitive motions.
How we can help:
If you are experiencing shoulder pain or have been diagnosed with a shoulder pathology there are some modifications of movement that may reduce exacerbations. This should be discussed with your treating Physiotherapist to define what approach is appropriate for you.