Physiotherapy and rehabilitation
We will present the most common shoulder injuries in detail. Every pathology or shoulder injury comes with a description of general facts, causes that led to the development of the injury, characteristics of the symptoms, diagnosis, and the course of treatment.
The shoulder joint is the most commonly dislocated joint of the human body, often caused by sports activities or falling. The mechanism of injury is usually trauma. Some common situations that may cause shoulder dislocation include:
Spontaneous shoulder dislocations that represent a bigger biomechanical issue are also possible.
In 97% of cases, the shoulder dislocation is anterior.
30% of shoulder dislocations are also accompanied by fractures. Accompanying complications, such as the Hill-Sachs lesion which is a compression fracture and the Bankart lesion where the cartilaginous area of the shoulder joint is injured as a consequence of the head of the humerus hitting the cartilaginous lining.
A rotator cuff injury accompanies approximately 35 to 86% of shoulder joint dislocations.
If the shoulder joint is dislocated before the age of 20, the injury recurs in 80% of patients, whereas dislocating the shoulder joint after 40 years of age, recurs in only 30% of patients.
Shoulder dislocation is characterised by sharp paint, the sensation of movement, a change in the external shape of the joint, and functional limitations of mobility and strength. The entire joint is painful in all directions of movement.
By the means of clinical examination, x-ray imaging, and magnetic resonance imaging, we confirm or deny the possibility that the dislocation was accompanied by lesions of the bony part of the joint, tendon tears or joint capsule injuries.
It is important to undergo diagnostic testing with a specialist since shoulder joint dislocations may be accompanied by varying degrees of structural damage. Recurring shoulder dislocations leave long-term consequences and lead to permanent shoulder instability and limited function, which is why it is important to carefully analyse the dislocation with the performed diagnostics. Diagnostic examinations include x-ray imaging of the skeleton and magnetic resonance imaging. In certain cases, computed tomography (CT) or MR arthrography may also be required.
After a shoulder dislocation, the doctor usually repositions the joint, which is followed by a 7-day rest and then gradual application of individual physiotherapeutic exercise.
First shoulder dislocation is usually treated conservatively. After the second dislocation, the likelihood of a third one increases to 90%, which is why in this case, it makes sense to stabilize the joint operatively.
By implementing an individual exercise programme, we establish a normal range of motion of the shoulder girdle, improve stability and restore strength to the hand in the basic directions of movement.
Shoulder impingement syndrome is a pathology of the shoulder joint that develops when compressing the soft structures (points of growth of muscles, supraspinatus and rotator cuff tendons, bursa and joint capsule) in the subacromial space (between the head of the humerus and the acromion).
A common cause of shoulder impingement syndrome is weakness of the muscle groups of supraspinatus and infraspinatus in combination with a too strong deltoid muscle, which causes the head of the humerus to move towards the acromion of the scapula. Muscle imbalances along with poor posture are in general the main cause of the development of shoulder impingement syndrome. The upwards movement of the head of the humerus causes suboptimal biomechanical movement within the shoulder girdle, limited mobility, and more friction between the joint structures, which leads to inflammation and pain. Anatomical factors and the type of sports activity also affect the development of shoulder impingement syndrome.
The tendon of the supraspinatus, subacromial bursa or the long head of the biceps is compressed most often. As a consequence of compression, they become inflamed and further reduce the subacromial space. In the long term, there is a possibility of rupture of the inflamed and compressed tendons if the joint is not treated properly.
Shoulder impingement syndrome is characterised by symptoms such as muscle weakness, limited joint mobility, sports- or work-specific pain that appears only with certain movements, popping within the joint, and pain that radiates to the neck and down the arm. The pain is typically dull, persistent, and more intense at night.
It is important for the patient to make an appointment for a diagnostic examination, where the doctor performs clinical tests and confirms the diagnosis of shoulder impingement syndrome. It is also reasonable to perform magnetic resonance testing (MRI) to exclude potential additional injuries and an ultrasound to determine the exact spot of inflammation.
During the first phase of rehabilitation, we perform various instrumental and soft manual techniques that improve the mobility of the shoulder and open up the subacromial space.
The second phase of rehabilitation includes corrective exercises for body posture and gradually we eliminate the muscle imbalances that caused the development of shoulder impingement syndrome. Rehabilitation begins with mobility exercises and special exercises which relax the shortened muscles and strengthen the weak muscle groups.
It is important to establish the correct movement of the scapula and the optimal anatomical position of the shoulder joint if it is faulty.
The duration of rehabilitation depends on the level of physical activity, the diagnosis of the cause and intensity of the pain along with symptoms of inflammation. In the period of 2 to 4 months, we can usually eliminate the symptoms and the causes for the development of shoulder impingement syndrome.
Frozen shoulder (adhesive capsulitis) is an umbrella term for the group of symptoms of the shoulder joint, which appear as stiffness, pain, and limited capacity of movement. Frozen shoulder syndrome is the second most common pathological condition of the shoulder joint. The frozen shoulder syndrome is caused by overuse, a longer period of immobilisation and after illnesses such as:
In general, not all causes for the development of the pathology are known. The frozen shoulder appears more often among women, and it generally affects the age group of 40 to 65 years.
It is typical for the frozen shoulder syndrome to appear slowly and gradually which is also characteristic of rehabilitation, which is time-consuming.
The patients describe the syndrome as a gradual increase in pain and a decrease in shoulder mobility. It oftentimes causes smaller issues when performing daily tasks and taking care of personal hygiene. The movements behind the back are most affected. Usually, the range of motion is affected in at least two directions, achieving less than 25% of healthy function.
External rotation and/or abduction of the shoulder are affected most often. With inadequate treatment, the pathology rapidly worsens. The progression of the frozen shoulder includes three phases; it begins with pain while resting and sharp pains in the final ranges of motion; gradually, the pain subsides and the loss of movement control and mobility in the shoulder joint follows.
The main means of rehabilitation are special exercises.
It is vital to avoid painful movements in the early phase of rehabilitation, but at the same time strengthen the movements that are not symptomatic.
Movement accelerates the regeneration of joint structures, but at the same time, overuse may cause inflammation, which prolongs the rehabilitation timeline. It is recommended to perform a combination of exercises with instrumental therapy that warms up or activates the tissue before rehabilitation exercises. The shoulder joint is a ball-and-socket joint, which is why it is necessary to perform a lot of circular motions at an asymptomatic pace and extent (2 to 3 times per day).
Passive stretching of the joint and mild mobilisation with manual techniques are also recommended. In the middle and late stages of rehabilitation, we gradually increase the burden while performing strength exercises and applying more aggressive stretching. It is vital to establish muscle balance and teach the patient the correct exercise techniques.
Spontaneous treatment lasts from 1 to 4 years, until the functional condition of the shoulder does not reach the condition before the injury.
The rotator cuff is made up of four muscles; the supraspinatus, subscapularis, infraspinatus and teres minor, which all attach to the upper part of the humerus and provide stability during movement of the shoulder joint.
Rotator cuff tendon injuries are the leading cause of shoulder joint pain, which can happen due to weakened tissue as a consequence of degenerations, acute overload, or micro-injuries that form as a consequence of falls, blows to the shoulder, or muscle imbalances.
Degenerative changes most commonly begin in the supraspinatus muscle tendon, after the age of 40. Before that, they may appear in professional sportspeople or when suffering extreme overloads as a variation of “overuse injuries” and due to traumatic injuries. Rotator cuff tendon pathologies grow more common with age; they cause lower tensile strength in tendons and therefore increase the likelihood of inflammation and injuries.
In general, the supraspinatus muscle is the most commonly injured rotator cuff muscle. The symptoms of a rotator cuff injury include shoulder pain that varies in intensity and location, accompanied by movement-specific weakness (depending on the injured muscle).
The supraspinatus muscle injury is characterised by pain on the outer surface of the upper part of the humerus and pain when performing movements above the head. After injuring the rotator cuff tendons, further straining of the shoulder worsens the pain; in advanced tendon damage, the pain may also persist at night. The mobility of the shoulder joint also decreases.
The treatment of rotator cuff tendon damage begins with diagnostic testing that includes x-ray imaging (RTG) and/or magnetic resonance imaging (MRI).
In early and mild issues with the rotator cuff, it is enough to perform an ultrasound of the shoulder, however, in some cases, an MR arthrography and/or CT arthrography are also necessary.
Rotator cuff tendon injuries are mostly treated conservatively – first with a phase of rest and the elimination of inflammation, and then with progressive rehabilitation training that strengthens the affected shoulder movements and improves muscle imbalance. Partial and/or full tendon tears in the older population are successfully treated with physical therapy, however, large-scale tears or full rupture of rotator cuff tendons in younger people require surgical treatment to ensure full recovery of function.
Among rotator cuff muscles, the supraspinatus muscle tendon is the most prone to injuries.
The function of the supraspinatus muscle is abducting the arm and assisting in raising the arms above the head. The activity of supraspinatus is vital for ensuring stabilisation when repeatedly lifting the arm (throwing and serving the ball, breaststroke swimming).
Supraspinatus tendon injuries are characterised by limited mobility above the head and when abducting the arm, accompanied by pain that increases with overload. In sportspeople, supraspinatus tendon injuries are a consequence of overuse that causes inflammation, suffering a blow, or performing explosive movements.
If a one-time force is great enough, it is possible to fully rupture the tendon where the supraspinatus muscle grows attached to the humerus. Suffering tears of the supraspinatus tendon is more common in middle-aged recreational or professional sportspeople since the tendon has already changed with age and is less resistant to heavy loads.
In general, the pathological conditions of the supraspinatus tendon grow more common with age since the tendon thickens and narrows the subacromial space, which is often the cause of inflammation and pain.
The rehabilitation of a supraspinatus tendon injury first involves inflammation management and accelerating the healing during the first phase of treatment, as well as the application of progressive special exercises during the second phase of treatment.
In the initial phase of physical therapy, the exercises are performed with the hand below the level of the head, and we gradually increase the asymptomatic range of movement.
This is followed by establishing the full range of motion with mobility exercises, and strengthening the obtained movement amplitudes with strength exercises that eliminate muscle imbalance and enable additional stabilisation of the shoulder joint. If the shoulder joint does not respond to conservative treatment, surgical release of space below the outgrowth of the scapula or surgical treatment of the affected part of muscle or tendon are recommended.
The AC joint is a joint between the clavicle and the scapula (a pointy outgrowth on the scapula) and it participates in elevation movements.
The stability of the AC joint is possible due to many ligaments, namely the ligament between the acromion and the clavicle (the acromioclavicular ligament) and the coracoid and the clavicle (two ligaments – the trapezoid and the conoid ligaments that form the coracoclavicular ligament).
The injuries to the AC joint usually occur when falling to the side on the shoulder with the arm either next to the body or to the front (falling while skiing, cycling, riding a motorcycle, riding a push scooter…).
The diagnosis is made by a specialist performing a manual examination since the AC joint tends to be externally changed and painful to the touch when injuring it.
With a stable AC joint of normal shape and palpation sensitivity, we suspect either joint wear or damage to the joint disc of the AC joint.
When the AC joint is overloaded, the bone part of the clavicle can also break down, which is confirmed by MR imaging.
The first three stages of AC joint injury can be successfully treated by physical therapy that includes irradiation with a high-energy laser, magneto-therapy, and the application of exercises for the stabilisation of the joint. In the event of joint wear, that is accompanied by acute symptoms, a block is injected into the shoulder. Higher stages of the AC joint injury require surgical treatment. The surgical technique depends on the specifics of the AC joint injury and on the stage of joint instability.
A special exercise regime often has a successful treatment prognosis by improving the symptoms and shoulder stability in milder AC joint injuries.
SLAP lesion is an injury to the upper part of the labrum of the shoulder (cup-shaped cartilage). The shoulder labrum is a connective-cartilaginous structure that deepens and enlarges the joint surface of the glenoid and contributes to the stability of the shoulder joint.
The long head of the biceps, which ensures the glenohumeral shoulder stability, grows attached to the superior (upper) labrum. SLAP lesions are rare, they only appear in 6% of the patients who underwent arthroscopy of the shoulder joint.
Throwing sports are a predisposition for SLAP lesions; they appear in sportspeople who perform overhead throws (volleyball, handball, American football…), when falling on the extended arm or directly on the shoulder (martial arts, downhill), and when suffering direct blows to the shoulder. Otherwise, they are more common in men above 30 years of age.
The symptom of SLAP lesions is dull pain inside the joint that is difficult to define. It is most commonly localised towards the back of the shoulder.
The pain often appears quite some time after the injury. A mechanical jump may accompany the labrum injury, similar to the meniscus injury. During movement, popping/snapping may appear. Weakness of shoulder girdle muscles and loss of joint mobility may also appear.
After the clinical examination, it is important to assess mobility and the functional state of the shoulder joint using clinical tests. In patients with a suspected SLAP lesion, it is necessary to perform magnetic resonance or MR imaging.
In the first three months after the injury, the treatment of SLAP lesions is conservative. The goal of conservative therapy is to alleviate the pain, reduce the inflammation, restore shoulder mobility and strengthen the glenohumeral muscles and muscles around the scapula and thus improve static and active stability of the shoulder girdle.
In the case that conservative treatment fails to improve the symptoms, it is recommended to undergo arthroscopic shoulder surgery. The surgical technique depends on the specifics of the injury. In the event of a younger patient whose tendon of the long head of the biceps is less than 30% injured, the labrum is attached to the tendon. In older patients, tenodesis is usually performed.
Shoulder instability presents itself as the inability to keep the head of the humerus in the joint fossa (glenoid) of the scapula during movement.
Shoulder instability develops when the structures that provide stability to the shoulder joint are injured. Shoulder instability is oftentimes a consequence of weak, degenerated, or acutely injured rotator cuff muscles, however, it can also be a consequence of traumatic tears or stretches of the passive shoulder stabilisers – ligaments.
When it comes to muscle instability within the shoulder girdle, it is oftentimes the strong, externally visible muscles that do not increase the stability of the shoulder, but in most cases, prevent the deep muscles from stabilising the joint.
Layman’s opinion that strengthening the surface muscles increases shoulder joint stability is erroneous because it only makes the instability worse. Along with shoulder joint instability, scapular instability is also common. When both instabilities are present, exercises for improving shoulder joint stability are not effective until the stability and gliding of the scapula improve.
Treatment of shoulder instability depends on:
At the beginning, the most common type of treatment is conservative treatment with physical therapy that along with special therapeutic exercises includes irradiation using a therapeutic laser.
With recurrent shoulder dislocations and unresponsiveness of the shoulder to conservative treatment,surgical joint stabilisation is usually advised.
Special exercises aim to strengthen stabiliser muscles, correct muscle imbalance and establish the correct rhythm of the scapula.
Calcification in the shoulder is a common pathological condition of the shoulder joint, affecting mainly the population between 30-50 years of age, but more often occurring in women. Risk factors for shoulder calcification include diabetes mellitus, previous injury to the shoulder, especially to the muscles and tendons of the rotator cuff, or shoulder dislocation, incorrect posture, prolonged immobilisation of the arm, e.g. after a fracture.
There are two types of calcinations in the shoulder, degenerative calcinations in the shoulder and reactive calcinations in the shoulder. The former is typical of the elderly and occurs gradually due to loss of quality of the collagen fibres of the connective tissue of the shoulder and the gradual formation of micro-damages. Reactive calcification of the shoulder occurs as a result of previous injury, trauma, thyroid problems or in association with other typical risk factors.
Calcification in the shoulder, if not treated with appropriate physiotherapy, can develop into frozen shoulder syndrome, which causes more severe shoulder pain.
Shoulder calcification is characterised by a trophic cycle that can last up to 5 years, or up to 8 years if hormonal disturbances are present and no treatment is provided.
Calcification of the shoulder is characterised by pain that is aggravated by resting and not moving the shoulder, typically nocturnal pain that interferes with sleep and causes intense pain when lying on the affected shoulder. Pain due to calcification of the shoulder usually starts suddenly, is sharp and restricts the movement of the arm above the head. Often, the standing position is more favourable than the supine position for patients with calcification of the shoulder.
Calcification of the shoulder is characterised by intense pain in the front or back of the shoulder, often radiating to the upper arm, possibly to the level of the elbow and wrist. If you also have tingling sensations in your fingers, this is not a problem related to shoulder calcination, but carpal tunnel syndrome is suspected.
Calcification of the shoulder occurs in 3 stages, the third stage is the most painful, when calcium crystals are released from the tendon into the surrounding area. Physiotherapy and kinesiology are usually performed during the third phase of shoulder calcification, as most of the time it is asymptomatic, meaning that we have no contact with the patient before that time.
A reliable diagnostic method for examining the shoulder where calcinations are suspected is ultrasound (US) by a specialist radiologist. Ultrasound imaging can pinpoint the location of calcium crystals and their size, and can also be used as a method of monitoring the progress of conservative treatment of shoulder calcination.
The treatment of shoulder calcification is complex, requiring an integrated conservative approach combining physiotherapy and kinesiology. Surgical treatment is only performed in 5-10% of patients when physiotherapy treatment is unsuccessful after at least 9 months of continuous rehabilitation.
The primary method of physiotherapy for the treatment of shoulder calcification is shockwave therapy combined with active shoulder mobilisation and rotator cuff strengthening exercises. TECAR and LASER therapy are also used, as well as electrotherapy, which must be high-pitched; at the Medicofit clinic we use HiTop. Treatment of shoulder calcifications must ultimately include exercises to develop the strength of overhead pushing and pulling, as failure to gain strength in the final ranges of overhead movements risks the recurrence of calcifications.
It is important that the treatment is combined with each therapy, shock waves must be precisely dosed in intensity and must not trigger an intense pain response to the therapy, despite being one of the more invasive methods of instrumental therapy. Deep shock waves are the most effective means of conservative treatment of shoulder calcification, but they should always be accompanied by specific exercises that strengthen key muscle groups.
