Scapula Strengthening

Posterior Capsule/Deltoid Stretch

Shoulder Impingement Syndrome

What is it?

• Injury to the rotator cuff tendon(s) when there is narrowing between the head of the humerus and the coraco-acromial arch (the arcomion & the coracoacromial ligament attaching to the coracoid process) thus causing subacromial crowding. ^[1,2,3,4]
• Resulting in micro trauma, ischemia, swelling / inflammation further impingement
• Primarily affects the supraspinatus tendon but can also affect the infraspinatus^[1,2,3]

Causes of Subacromial Crowding^[1,2,3,4]

Congenital Variations

• Size or shape of the coracoid or acromion processes (boney areas)
• Coracoacromial ligament / subacromial bursal thickness
• Degree of mid-back ‘thoracic’ kyphosis; excessive curve further facilitates rounding of the shoulder blade ‘scapula’ thus decreasing subacromial space

Developmental or degenerative Factors

• Post traumatic / post surgical rotator cuff scarring
• Post trauma ‘sprain’ of acromialclavicular joint separation, laxity in ligaments
• Osteophyte formation
• Calcium deposit in rotator cuff tendon

Traumatic factors

• Disruption of ligament, cartilage and rotator cuff or biceps tendons in shoulder
• Shoulder subluxation / dislocation

Biomechanical factors

• Weakness of depressors of glenohumeral head (rotator cuff muscles) due to nerve injury or disuse
• Capsular restriction due to tightness / adhesions
• Weakness of shoulder blade muscle stabilizers altering alignment / movement
• Rotator cuff muscle imbalance
• Adhesive capsulitis ‘frozen shoulder’

Classification of impingement in 3 stages^[1,8]

Stage 1

• Any age: (usually under 30 years) repetitive shoulder use “overhead athletes”
• Reversible rotator cuff injury
• Local tenderness to palpation
• Restricted range of motion and weakness
• Tendinosis / tendinopathy of rotator cuff tendon which can become fibrotic

Stage 2

• Usually 30 to 40 years of age
• Pathology not reversible by time or / and modifying activity alone
• Local tenderness to palpation and with movement, crepitus with movement
• Loss of active & passive range of motion

Stage 3

• Usually greater than 40 years
• Some degree of irreversible pathology
• Continued increase pain on palpation and with movement
• Loss of active range of motion greater than passive motion
• Atrophy ‘loss in size’ of rotator cuff and shoulder musculature

Signs & Symptoms to look out for^[1,2,3,4,8]

• Pain in lateral upper arm, deltoid insertion, subacromial area (below boney process)
• Can be from repetitive arm, shoulder use (athletics: tennis, swimming, throwing overhead, computer use, overhead motion)
• Inability to lower arm from 90 degrees slowly or smoothly with or without pain
• Painful arc: catching of swollen rotator cuff tendon(s) or bursa

Other Possible Diagnosis^[1,2,3.4]

• Torn labrum (cartilage)
• Instability (due to torn ligament)
• Rotator cuff / Long head Biceps tendonitis, Bursitis
• Cervical (neck) pathology: disc / nerve root
• Adhesive Capsulitis (Frozen Shoulder)

Treatment & Management

Research studies, using randomized control trials, reveal that treatments consisting of manual therapy, using joint mobilizations, and specific prescribed Physiotherapy exercises are most effective for recovery versus strengthening exercises alone.^[3,5,6]Treatments are aimed towards restoring joint alignment and mobility by breaking up joint capsule restrictions (scar tissue) and correcting muscle imbalances and kinesthetic & proprioceptive awareness.^[5,6] Activity modification can also aid in the management of or / and further prevention of the pathology from occurring.

The use of non-corticosteroid medication & corticosteroid injections has a role in the treatment of inflammation and pain control.^[7]

When conservative treatment fails and the shoulder impingement is causing considerable pain & dysfunction, arthroscopic surgery followed by manual therapy and exercise has shown to be effective.^[8]

For more information about shoulder impingement or shoulder injuries please contact InSync Physio.

References

1. ^ Pyne. Diagnosis and Current Treatment Options of Shoulder Impingement. Current Sports Medicine Reports. 251 – 255, 2004 March.
2. ^ Fu et al. Shoulder Impingement: A critical review. Clinical Orthopaedics and Related Research. 269: 162 – 173, 1991 August.
3. ^ Kamkar et al. Nonoperative Management of Secondary Impingement Syndrome. Journal of Orthopaedics and Sports Physical Therapy. 17(5): 212 – 224, 1993 May.
4. ^ Payne et al. The Combined Dynamic & Static Contributions to Subacromial Impingement: A Biomechanical Analysis. The American Journal of Sports Medicine. 25 (6): 801 – 808. 1997.
5. ^ Senbursa et al. Comparison of Conservative Treatment with & without Physical Therapy for patients with Impingement Syndrome: A prospective, randomized clinical trial. Knee Surgery, Sports Traumatology, Arthroscopy. 15(7): 915 – 921. 2007.
6. ^ Bang et al. Comparison of Supervised Exercise with & without Manual Physical Therapy for patients with Shoulder Impingement Syndrome. The Journal of Orthopaedic and Sports Physical Therapy. 30(3): 126 – 137. 2000.
7. ^ Akgun et al. Is Local Subacromial Corticosteroid Injection Beneficial in Subacromial Impingement Syndrome? Clinical Rheumatology. 23(6): 496 – 500. 2004.
8. ^ Brox et al. Arthroscopic Surgery versus Supervised Exercises in patients with rotator cuff disease (stage 2 impingement syndrome): A Prospective, randomized, controlled study in 125 patients with a 2-½ year follow-up. Journal of Shoulder and Elbow Surgery. 8(2): 102 – 111. 1999.

Shoulder Pain: Posterior Deltoid and Capsule Stretch

Exercises to Improve Shoulder Mechanics

Shoulder Pain – Rotator Cuff Tendinitis

The most common shoulder pain located in the front of the shoulder, or pain that occurs when lifting or grabbing things above shoulder height is due to problems with the Rotator Cuff. Common symptoms of rotator cuff injury or strain are pain and difficulty raising the arm. It is painful for many people to lie on the shoulder when in bed, and many waking up at night with pain in the shoulder.

It is painful for some people to attempt and reach behind their backs. Reaching outward and upward can be painful and some feel a lack of strength when attempting to lift objects. The pain may also be associated with degeneration or inflammation of the Rotator cuff tendons leading to Rotator Cuff Tendinitis and what is called ‘Shoulder Impingement Syndrome’, which is caused by repetitive arm movements or long periods with the arm in the one position such as prolonged mouse and keyboard use on computers that irritates and inflames the shoulder bursa. The Bursa are the lubricated bag-like tissues that act to minimize friction and help protect the muscles and tendons when they move against each other.

The rotator cuff is a set of tendons, which surround the head of the humerus (the upper arm bone) to hold it secure in the socket and help the shoulder joint function properly. The rotator muscles and tendons help the arm to rotate at the shoulder joint and to provide a full range of movement.

The rotator cuff can be injured with a fall onto the arm or by jerking a load over head, or when the arm is pulled downward. Injuries to the rotator cuff can cause a tear that may require surgical treatment as they don’t heal readily.

The rotator cuff can also degenerate slightly with age or repetitive use. The pain of Shoulder Impingement Syndrome is due to a pinching action or a rubbing (an impingement) by the tendons causing irritation to the shoulder bursa. People who work a lot with their arms overhead, poor posture and various athletes who use repetitive throwing motions, swimming and tennis, can cause inflammation of the shoulder tendons and bursa. Poor alignment of the shoulder joint can restrict arm movement arm and decrease circulation.

Symptoms of this type of shoulder pain, typically occurring in the front of the shoulder area, are a sharp pain when you lift your arm to front or the side of your body, pain and/or general soreness that developed after repetitive movement or prolonged computer activity and shoulder pain when trying to sleep, especially when lying on the sore shoulder.

People at risk for this affliction include athletes involved in throwing and racket sports such as tennis players, baseball pitchers, swimmers as well as people who use their computers for long periods who repetitively reach forward to move their mouse or to type on their keyboard. People who have poor posture when at the computer (such sitting with rounded shoulders or lower arms not parallel with the desk, and who don’t support their wrists may pinch one or more of the tendons in the shoulder region) run the risk of developing these problems especially in old age. Anyone who reaches over head frequently and regularly can develop this problem. This includes swimmers, waiters, window cleaners, painters.

Common Causes of Rotator Cuff Tendinitis (Impingement Syndrome) are:

• Maintaining your arm in a fixed position for prolonged time periods, such as working on computers, office work or hairstyling, especially with poor posture.
• Sleeping on the same arm or shoulder each night.
• Playing sports that require the arm to be raised above head-height repeatedly such as tennis, swimming,baseball (particularly pitching) and lifting heavy weights above your head.
• Job that require activities requiring the arm to be held overhead for many hours a day (such carpenters, glazers, interior decorators and painters)
• Degeneration, lack of stretching, lack of exercise, or poor control of your shoulder and shoulder blade tendons and muscles.
• Poor posture and non-ergonomic seating positions, may over many years cause degeneration or fraying of the tendons that develops into rotator cuff tendinitis, or even tears.

Ways to Prevent Shoulder Pain includes:

• Adopting proper postures and using ergonomic workstation designs.
• Practicing proper postures when working at desks and when using computers.
• Doing ergocises to strengthen and regularly stretch the muscles of the shoulders and scapular.
• Taking regular breaks from computer work and regular stretching exercises when working.
• Anti-inflammatory drugs.

Self Treatment Strategies

If you have developed shoulder pain that matches these symptoms and is relatively mild and not long lived, it is worth trying some simple treatments at home.

• Rest.
• Strengthening and stretching ergocises for the neck, shoulders and back.
• Installing ergonomic workstation devices and aids and getting advice on posture.
• Minimizing or avoiding overhead activities at least for a week or more until the pain declines.
• Applying ice for 10-16 minute intervals for about 3-6 times per day.
• Massaging the area to alleviate pain.
• Specific rehabilitative exercises recommended by a doctor.
• Professional massage therapy and chiropractic manipulation and professional physiotherapy for restoring muscular balance and flexibility.

How You Can Effectively Treat Frozen Shoulder (Capsulitis)

Frozen shoulder affects the joint capsule – a water tight compartment that holds the synovial fluid of the glenohumeral joint. A build up of scar tissue forms within and around the joint capsule, and restricts the shoulder’s physical ability to move without pain. Some of the tissue that surrounds the capsule forms two ligaments called the coracohumeral ligament and the glenohumeral ligament.

When you injure your shoulder you experience pain and stop moving it. However, this lack of movement is thought to allow the scar tissue to accumulate within the joint capsule as the damaged tissue heals. This is the reason that physical therapy and other means to reduce scare tissue are so important in recovery of all shoulder ailments or surgeries.

What confuses medical professionals is that some people who develop frozen shoulder have no other conditions. It starts as a stiffness in the shoulder, and progresses into pain and loss of ROM (range of motion) within the shoulder joint. Because of the pain and stiffness, the sufferer uses the shoulder less making the condition worse.

One of the most common, yet least often diagnosed causes of Frozen Shoulder Syndrome is myofascial trigger points in the muscles around the shoulder. Trigger points are knots or tender areas that form in overworked or injured muscles and which lead to pain and loss of mobility. Many people don’t think of Frozen Shoulder Syndrome as a particularly serious condition, but if you’ve actually suffered from it and have been unable to do everyday tasks such as getting yourself dressed, or have been in too much pain to sleep, it’s not something to be taken lightly.

A frozen shoulder is a persistently painful stiffness of the shoulder joint, which can sometimes lead to complete loss of movement. As well as a great deal of pain, people that suffer from frozen shoulder syndrome often experience a real loss of independence; imagine not being able to reach up to put on your seatbelt, never mind actually drive a car.

What Causes Frozen Shoulder Syndrome?

The tissue around the shoulder joint is known as a capsule. This is fully stretched when your arm is above your head, and hangs down when the arm is lowered. Many doctors believe that a frozen shoulder is caused by a thickening, swelling and tightening of this capsule of tissue, perhaps caused by scar tissue, which leaves little space for the bone of the upper arm to move in the shoulder socket, restricting movement and causing pain.

Frozen shoulder syndrome occurs in three phases:

Stage 1: The freezing or painful phase

Adhesive capsulitis causes pain and the shoulder to become immobile, or frozen. During this stage you develop pain and stiffness in the shoulder joint. As the pain increases, movement becomes more difficult and the shoulder is used less. Often your back and neck muscles start to ache as they work harder to compensate for fewer shoulder movements. This stage can last from a few weeks to a few months.

Stage 2: The frozen or stiffening phase

In the next stage, you will notice that the stiffness remains but the pain does not become worse and may even start to decline. This stage usually lasts anywhere from 4 months to nearly a year.

Stage 3: The thawing phase

Finally, you will find that the full range of movement begins to return to the shoulder joint. This stage usually takes a minimum of 5 more months but may take as long as 2 years.

Muscles Where Trigger Points Can Develop

The shoulder joint is very complex because it is designed to move in so many directions. There are around twenty muscles involved in shoulder movement and trigger points can develop in any of these.

A trigger point in one muscle puts increased strain on the other muscles as they try to compensate, meaning that they also develop trigger points. As each of the muscles that take part in shoulder movement develop their own trigger points, pain will spread around the shoulder area and movement will become more and more restricted.

Muscles that will most commonly develop trigger points leading to a frozen shoulder are the four rotator cuff muscles:

• Subscapularis
• Teres Minor
• Infraspinatus
• Supraspinatus

One of the difficult things about myofascial trigger points is that the pain can be referred from a muscle somewhere else in the body. With Frozen Shoulder Syndrome it would seem logical to focus on the muscles in the shoulder, but actually the pain could be caused by trigger points in muscles in the upper back, neck, chest or shoulder.

Exercises for Frozen Shoulder Syndrome

Stretching and exercising for a frozen shoulder should be done with caution, as it may just injure the muscles further, worsening trigger points and increasing pain and stiffness. Identifying and massaging out the trigger points causing the problem is essential before stretching and exercise is attempted.

Frozen shoulder syndrome is often treated with painkillers or corticosteroid injections, and sometimes even surgery. However, in many cases, trigger point massage by an experienced trigger point therapy provider such as Balance in Motion can greatly relieve and often completely cure Frozen Shoulder.

Once you have started therapy, you can aid your recovery by following an exercise regimen at home:

Back Shoulder Stretch. In a standing position, try to rest the hand of the problem arm on the opposite shoulder. Place the unaffected hand on the elbow of the problem arm and very gently pull it towards you. Hold for a few seconds, release and repeat five times.

Pendulum Swing. In a standing position, place your unaffected hand on the edge of a table and lean forward, letting your problem arm hang down vertically. Swing the arm forward and backward, side to side, and around in circles in both directions. Repeat each movement five times.

Umbrella Push. Sit down with your elbows into your sides, holding an umbrella in both hands out in front of you. Use your unaffected arm to push your problem arm so it turns outwards, keeping the elbow of your problem arm tucked into your side. Return to centre and repeat five times.

Hand Behind Back. In a standing position, hold your problem arm around the wrist behind you with your unaffected hand. Gently stretch the problem arm towards the opposite buttock and then slide it gently upwards as far as possible. Release and repeat five times. This is a more advanced exercise for when movement begins to return.

Shoulder Strengthening Tips

Have you had issues with shoulder weakness in the past? Do you want to work on creating a strong base and strengthening the muscles of your shoulder blades to give you that strong stable base of support for your rotator cuff and to help keep the shoulder blade and rotator cuff muscles working in together properly?

Whether it’s stronger shoulders for rock climbing, throwing & laying out in Ultimate frisbee to assisting with pain control from shoulder impingement from day to day lifting, this is a great exercise for you. Yes, you also need to stretch out other muscles that most like be tight, such as the Lats, delta, pecs or biceps.

Check out the exercise above!

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