How do we become better at managing a weak and painful shoulder?
Since qualifying as a physiotherapist I’ve become increasingly interested in shoulder related pain, specifically associated with rotator cuff issues. This is a common shoulder complaint, which results in many individuals seeking advice and support from physio’s. After assessing and treating a number of individuals with this type of injury, I can advocate the importance to manage such a condition from a non surgical approach.
Rotator Cuff Anatomy
The rotator cuff is a group of 4 small muscles & tendons (supraspinatus, infraspinatus, teres minor and subscapularis) that attach from the scapula (shoulder blade) to the humerus (upper arm bone). For reference, tendons attach muscle to bone, permitting movement when the muscles contract. The primary role of the rotator cuff muscles are to stabilise and rotate the shoulder joint. Just like other tendon injuries, the rotator cuff is susceptible to becoming injured if overloaded. Of the four rotator cuff muscles, the supraspinatus is the most commonly injured muscle / tendon and pain is typically located over the deltoid, upper arm.
Pain in this region is thought to involve other structures that lie within the subacromial space, including the supraspinatus tendon, the long tendon of the biceps brachii and the subacromial bursa (tiny fluid filled sacs which helps reduce friction between the tissues of the body). Due to the complexity of the shoulder joint and given the number of structures involved. It is often unclear what the direct cause is (REF). However, common symptoms associated with such an injury include:
- Pain in the upper arm when lifting or reaching overhead
- Minimal pain at rest except when lying on the affected side
- Changes in load from a specific activity or repetitive use
What does the research say?
There is a great deal of uncertainty when it comes to understanding this type of injury, given the number of diagnostic terms (for example; subacromial impingement, subacromial pain, rotator cuff related shoulder pain etc) that physio’s would use to describe such an injury (REF). Therefore, causing all sorts of confusion, both for the patient and therapist. I am a strong believer that therapists need to be more open and honest with our patients. This study I read excellently summarises what this injury is “an issue with the muscles and tendons of the shoulder, they’re lacking strength, capacity, tolerance, and fitness, that’s why they complain when they lift your arm”(REF).
As well as changes in your job or activity demands (sudden increase in load), your psychological state, environment, amount of sleep, nutrition, alcohol intake, smoking and physical activity levels are also key areas that must not be overlooked when an injury has developed. After all, a full history of your problem is key to determine an appropriate treatment programme.
Management from a physio perspective
“Loading through exercises (including progression & regression) within an acceptable symptom response” has been advocated as the most effective way to treat a weak and painful shoulder (REF). This recommendation was agreed upon by eight physiotherapists who are experts within the field of shoulder injuries. I believe this statement to be true and a strong advocator of such an approach, especially when treatment programmes are individualised and goal focused.
Exercising through loading of the rotator cuff muscles/tendons helps alleviate pain and ultimately improve function. This will need to be completed over a 12 – 24 week-period to see such changes to occur. Consistency and resilience are the key qualities I want individuals to adopt when overcoming an injury whereby changes are not expected to be quick hence why therapists must continue to encourage, reassure and guide.
Types of Exercises
Exercises must be challenging and aim to address specific functional limitations. Individuals must be provided with a range of exercises, following isometric, eccentric and plyometric principles that are adjusted to meet the needs of the individual, whether that be based on ability or symptom irritability. More importantly exercises can be regressed and progressed depending on the key factors already mentioned. There are plenty of exercises that can be performed and some of these will be demonstrated via social media in the near future, so please keep a look out.
Alternative management for a weak and painful shoulder
Asides from exercise being the first line of treatment. Other avenues for a physio to consider could be a referral for an MRI scan to identify any structural damage to the soft tissues. However, this is often only considered when there is an identification of a more serious or sinister problem e.g. a fracture or tumour. This is normally recognised early on from an initial assessment, where a full subjective and objective screen has been completed by a healthcare professional.
“A steroid injection would not be considered straight away unless the pain was severe or not improving with exercise over an acceptable period of time” (for example; 6-12 weeks) (REF). Beyond a period of physiotherapy management, further investigation or orthopaedic opinion could be considered for individuals whose symptoms are not improving after a considerable period of engagement in an exercise programme. Anxiety levels must be monitored and addressed throughout an individual’s journey to ensure chronic problems don’t permit.
Summary
Since qualifying I’ve become more aware of the benefits exercise and movement through load can have on recovering from a weak and a painful shoulder. There appears to be a lot of uncertainty surrounding this type of injury and while acknowledging the latest research. However, a simple approach to manage this injury can be achieved through exercise, advice, education and reassurance. Avoiding other alternative treatments (e.g. steroid injections), which are often unwarranted, costly and will only provide short-term relief. To end on a more positive note it is great to be able to reflect upon my own experience and foresee the true benefits of physiotherapy for individuals suffering with a weak and painful shoulder.
Thanks for reading
Ollie Curtis (Chartered Physiotherapist)
