Shoulder
Description: The rotator cuff consists of 4 muscles and their associated tendons. Their main job is to provide stability to the shoulder by keeping the ball of the shoulder fitting snugly in the socket. Tendonitis of one or more of the rotator cuff muscles is often associated with repetitive activities which wear down the tendon and cause it to become inflamed. However, tendonitis can also be caused by traumatic injury to the tendon, such as a fall or catching oneself from falling. If the condition is left untreated, the tendonitis may progress to a partial or full thickness tear of the rotator cuff, often requiring surgery.
Symptoms: Rotator cuff tendonitis may cause sharp, burning pain in the shoulder or upper arm. These symptoms are often aggravated by periods of repetitive activity such as painting, overhead throwing, or lifting. Pain may also be experienced when dressing, grooming, sleeping on the affected shoulder, reaching high over head, or reaching behind the back. Functional weakness is usually present with lifting during everyday activities, particularly between waist and shoulder height.
Treatment: Treatment usually begins with modifying daily activities to avoid provocation of pain. Modalities such as ice or heat, electrical stimulation, ultrasound, and iontophoresis (anti-inflammatory medication delivered by electrode) are used to control pain and inflammation. Stabilization exercises for the shoulder blade are started early to reduce strain on the rotator cuff. Depending on the severity of symptoms and limitations, exercises may be performed in a pool or on land. A gradual progression of exercises allows for strength and mobility to be restored while the tendon heals.
Description: This injury typically occurs as a direct result of trauma to the ligaments and capsular tissues that surround the ball and socket (glenohumeral joint) of the shoulder. Some common mechanisms of injury include being hit behind the arm while the shoulder is positioned in an overhead throwing motion and falling onto an outstretched arm. This condition contributes to a sense of instability in the shoulder combined with an inability to perform certain daily activities and sports. Those who experience a shoulder dislocation are typically evaluated by a physician for reduction and to rule out fracture or cartilage (glenoid labrum) damage.
Symptoms: A shoulder dislocation is almost always caused by trauma. Pain is diffuse around the shoulder joint and is usually present any time the shoulder is not supported or is actively moved. Sleeping on the involved side is usually very uncomfortable.
Treatment: Physical therapy is often ordered to help restore shoulder motion and to strengthen the muscles that cross the shoulder to prevent recurrence of dislocation. The involved upper extremity is usually immobilized with a brace or sling, depending on the severity. Modalities such as ice or heat, electrical stimulation, ultrasound, and iontophoresis (anti-inflammatory medication delivered by electrode) are used to control pain and inflammation. Exercises usually begin in a pool and consist of gradual active motion and stabilization. When adequate stability is achieved, a land-based exercise program is initiated. Exercises are progressed based on the stability of the joint and the patient's symptoms. Activity and sport-specific exercises help decrease the likelihood of re-injury when a return to previous activities is possible.
Rotator Cuff (shoulder) Impingement
Description: This condition involves a progressive, mechanical impingement of the rotator cuff tendons beneath the bony architecture (coracoacromial arch) of the shoulder joint. The resultant impingement of the cuff tendons results in significant shoulder pain increased with the performance of overhead and functional activities. Common causes of cuff impingement include bone spurs and rotator cuff tendon thickening. Weakness of the shoulder blade muscles can alter the mechanics of the shoulder, causing impingement of the muscles during arm elevation.
Symptoms: The severity and nature of the impingement determine the motions that become problematic. With mild impingement, pain may not be felt until the arm is elevated past the height of the shoulder. In severe cases, raising the arm just a few inches can cause pain. The shoulder may also become very painful at rest or during rotational movements if rotator cuff tendonitis is present. Sleeping on the shoulder can also be quite painful.
Treatment: The most important factor to consider when treating shoulder impingement is the source of the compression. Usually, the shoulder blade muscles become very weak, allowing the ball of the upper arm bone to press into the structures above it during elevation. Re-education of shoulder muscle firing can help alter these faulty patterns. Strengthening the shoulder blade muscles is also very important. Modalities such as electrical stimulation, ultrasound, heat/ice, and iontophoresis (anti-inflammatory medication delivered by an electrode), can help control pain and inflammation. After symptoms have begun to subside, exercise is gradually progressed towards more dynamic and functional movements. Work, sport, and/or leisure activities are incorporated into the exercise program as well.
Adhesive Capsulitis (Frozen Shoulder)
Description: This condition involves stiffening ("freezing") and inflammation of the soft tissues (joint capsule and ligaments) that surround the shoulder joint. The stiffening of these structures creates severe loss of functional shoulder movement, pain surrounding the joint, and an inability to sleep on the affected side. The incidence for this condition is approximately 2% within the general population and from 10-35% within the diabetic patient population. Other common factors related to an increase in the prevalence of this condition include cervical spine (neck) disorders, hypothyroidism, and prolonged post-surgical or post-traumatic immobilization of the shoulder. A frozen shoulder can sometimes develop after a small shoulder injury. This is thought to be due to a excessive inflammatory response of the body to the injury.
Symptoms: The main symptoms of a frozen or freezing shoulder are pain and significant loss of range of motion. Reaching overhead, to the side, and behind the back can be extremely difficult. Pain is present during any activities which require use of the involved arm, and can be especially severe at night.
Treatment: The time for complete resolution of shoulder range of motion can vary between 8 to 15 months. When deciding on a treatment plan, it is important to know which of the freezing phases the shoulder is in. Recent research has shown that the "Total End-Range Time", or TERT protocol, is a preferred method of addressing the pathology. In general treatment includes an active warm-up such as in a pool or on an exercise bike, heat or ultrasound to the shoulder, joint mobilizations to break up adhesions, active range of motion and stabilization exercises, stretching, and ice after treatment.
Rotator Cuff Tear (Partial Thickness or Full Thickness)
Description: Injuries to the rotator cuff muscles and tendons can range from partial fraying of the soft tissues to complete rupture of the muscles or tendons. Common causes of injury include direct trauma to the shoulder, repetitive overhead lifting, and participation in sports that require overhead throwing. In addition to these causes, some patients experience a cuff tear simply as a direct result of a degenerative process with no specific trauma or activity associated with the injury.
Symptoms: A common presentation for a patient with a rotator cuff tear includes an individual 40 years of age or older with reports of constant, lateral shoulder pain affecting the ability to sleep accompanied with functional weakness limiting his or her ability to lift the arm against gravity. Pain is often felt on the side of the arm where the deltoid muscle attaches to the upper arm bone, even though the actual tear is closer to top of the shoulder. Pain can be present with any and all shoulder movements. Reaching overhead or to the side are the most commonly affected motions. Pain at night is a very common complaint of people with rotator cuff tears.
Treatment: Activity modification is necessary in the early treatment phase to allow for healing of the involved structures. Modalities such as electrical stimulation, ultrasound, heat/ice, and iontophoresis (anti-inflammatory medication delivered by an electrode), can help control pain and inflammation in the shoulder. Exercises which strengthen the shoulder blade muscles can help alleviate strain on the rotator cuff. As the injury heals, exercises are progressed to allow for improved performance of sport, leisure, and other daily activities.
Acromioclavicular Joint Injuries
Description: The acromioclavicular (AC) joint is the connection between the collar bone and the shoulder blade. It is commonly injured as a result of either a direct force to the tip of the shoulder or through an indirect force sustained during a fall on an outstretched hand. This resultant force results in disruption to the capsule and ligaments that supports the bony architecture of the AC joint. It is also possible for the AC joint to become painful due to degenerative arthritis or overuse.
Symptoms: The patient with an acute AC joint injury will typically cradle the involved arm against the body with the uninvolved hand for support. This posture helps to decrease the pull of the weight of the arm against the ligamentous and capsular tissues that have been disrupted. Pain can be aggravated by all shoulder movements as well as by deep breathing.
Treatment: Bracing or taping is sometimes necessary to minimize irritation at the AC joint. Modalities such as electrical stimulation, ultrasound, heat/ice, and iontophoresis (anti-inflammatory medication delivered by an electrode), can help control pain and inflammation in the AC joint. Pool therapy is often started early to work on increasing pain-free mobility. After symptoms have begun to subside, exercise is gradually progressed towards more dynamic and functional movements. Work, sport, and/or leisure activities are incorporated into the exercise program as well.
Description: Shoulder bursitis is present when a fluid-filled sack (bursa) in the shoulder becomes inflamed an irritated. The cause of the inflammation may be an injury to or fall on the shoulder, but in many cases, a direct cause cannot be determined. Abnormal mechanics of the shoulder joint can cause irritation of the bursa, which then becomes inflamed and painful.
Symptoms: Bursitis is typically identified by localized pain or swelling, tenderness, and pain with motion of the tissues in the affected area. Shoulder bursitis may cause aching and/or burning pain in the shoulder or upper arm. These symptoms are often aggravated by periods of repetitive activity such as raking leaves, overhead throwing, or lifting. Pain may also be experienced when dressing, grooming, sleeping on the affected shoulder, reaching high over head, or reaching behind the back. Strength of the involved upper extremity is usually decreased because of pain in the shoulder.
Treatment: Treatment usually begins with modifying daily activities to avoid provocation of pain. Modalities such as ice or heat, electrical stimulation, ultrasound, and iontophoresis (anti-inflammatory medication delivered by electrode) are used to control pain and inflammation. Stabilization exercises for the shoulder blade are started early to reduce strain on tissues near the inflamed bursa. Depending on the severity of symptoms and limitations, exercises may be performed in a pool or on land. A gradual progression of exercises allows for strength and mobility to be restored while the inflammation decreases. If conservative treatment is not successful, physicians may decide that injections of anti-inflammatory medications are necessary. As a last resort, a surgical procedure called a subacromial decompression may be performed to alleviate symptoms.