Shoulder & Elbow Pain

Frozen shoulder or Adhesive capsulitis is often miss used as a diagnosis for shoulder pain. Most shoulder problems will result in some degree of reduced shoulder movement. This can often be thought to be a frozen shoulder. A true frozen shoulder can happen for several reasons. A previous injury can trigger it such as a traumatic event. It can also be a complication after having shoulder surgery for another reason. However, it is quite common for it to start completely out of the blue.

There are certain risk factors that can increase the likelihood of you having a frozen shoulder. Age, Gender and underlying health conditions may contribute to increasing the risk of a frozen shoulder.

It can be difficult to initially diagnose an acute frozen shoulder as the symptoms can change and go on for many months. Often ruling out other problems can indicate a frozen shoulder.

With a true frozen shoulder, often, it will be very painful initially and it has several stages. The initial pain is due to the internal capsule that seals the joint and keeps the fluid inside becoming inflamed. This is what causes the pain and may disturb your sleep. Sometimes the pain can still be there even when you’re not moving the arm. This stage can vary in the length of time but can go on for many months.

The second stage is when the capsule which can still be inflamed can become tight and thickened. This then starts to limit shoulder movement. Again, this stage can still be quite painful. Often the loss of movement will be specific to certain directions (tasks such as reaching behind you back or reaching up high may become very restricted). Again, this stage can last many months.

The next stage can often result in the pain significantly reducing and even can even be painless. However, often shoulder movement is still very restricted making function tasks still difficult.

The final stage of recovery is regaining movement but the whole process from start to finish can often be at least 18 months. This timeframe is very variable based on the individual.

What makes this condition difficult to diagnose is because the symptoms can go for so long and change.  Due to this you may also have lost significant strength and flexibility of the shoulder.

Early diagnosis is key to aid identifying treatment options and a physiotherapist can help with this. If a true frozen shoulder is suspected, it may benefit from an injection to help relieve the pain or a procedure called Hydrodilatation. If you have had one of these surgical treatments, then physiotherapy is key to improve and maintain your shoulder movement. Physiotherapy alone is not often very successful in the treatment of frozen shoulder which is why diagnosis is key.

Shoulder impingement is a very common cause of shoulder pain.  As you lift your arm, the rotator cuff tendon passes through the subacromial space. This is a narrow passageway and subacromial impingement occurs when the tendon catches on the acromion bone at the top of this passageway.

This can be caused by various things, firstly the subacromial bursa (fluid-filled sac that allows smooth gliding of the rotator cuff under the acromion with overhead movements) can become inflamed; or the rotator cuff tendon can become thickened or torn due to an overuse injury or ‘wear and tear’ with age; or alternatively bone spurs can develop on the front and side of the acromion irritating the tendon.  In other cases the acromion is curved or hooked instead of flat which is usually something you are born with.

Symptoms of shoulder impingement can start suddenly or develop gradually.  They include pain in the top or outer side of the shoulder, pain that is worse when you lift your arm, weakness in your arm and pain at night time affecting your sleep. Your shoulder does not usually become stiff.

Physiotherapy is a key part of the management of sub-acromial impingement and involves working on postural exercises, shoulder blade positioning and strengthening weakened rotator cuff muscles. Treatment involves avoiding things that make the pain worse particularly repeatedly lifting your arm above your head.  Try to carry on with your normal daily activities where possible so your shoulder does not become weak or stiff and avoid a sling if possible.  Using ice packs and both painkillers and anti-inflammatory medication can also be helpful. Physiotherapists can diagnose shoulder impingement and suggest exercises to help improve your pain and range of movement. The treatment depends on what caused the symptoms in the first place.

Often with the right management shoulder impingement improves within a few months.  Steroid injections can be considered to reduce inflammation and control pain if the rest and exercises on their own don’t help. Although rarely required surgery (Arthroscopic Subacromial Decompression) is sometimes used to reduce the effects of impingement but increasing the amount of space between the acromion and the rotator cuff tendons allowing easier movement and less pain and inflammation.

The rotator cuff is a group of four muscles, which originate from the shoulder blade (scapula) and attach to the main bone of the upper arm (humerus). They form a cuff around the humerus and provide stability and strength as the arm moves through all planes of movement. Problems most commonly arise with the rotator cuff tendons and is seen in 30% of the overall population.

Repetitive over-head sports like swimming, tennis, and activities like painting can cause overload of the rotator cuff tendons. This can lead to tendon thickening, inflammation and pain.

Pushing a significantly heavier weight in the gym or moving to a new house / carrying heavy furniture can also be enough to start a tendon reaction too. A fall onto the shoulder can cause a tear to the rotator cuff, either in the muscle or in the tendon. As we get older, the rotator cuff tendons degenerate, and this can lead to tendon dysfunction and sometimes tears.

Pain typically affects the outer aspect of the shoulder and can refer lower down the arm. Movements like reaching the arm forwards and out to the side, reaching behind and carrying weight can cause pain and weakness depending on the severity of the injury.

Physiotherapy is the main stay of treatment for rotator cuff problems. Initially, treatment is targeted to reducing pain and inflammation, later towards restoring shoulder range of movement and then strengthening the rotator cuff and other shoulder and scapula muscles. In cases of some rotator cuff tears, surgery may be necessary to restore shoulder function.

Each year, 5 in 1,000 people see their GP about tennis elbow. The condition causes pain around the outside of the elbow and is known clinically as Lateral Epicondylitis. Muscles that control the elbow, wrist and hand attach to both the inner elbow and outer elbow via large, strong tendons. Pain around the inner aspect of the elbow is clinically known as Medial Epicondylitis.

Overuse/overload of the outer tendon of the elbow is what causes Tennis elbow, and overuse/overload of the inner tendon of the elbow is what causes Golfer’s elbow. Symptoms are sometimes caused by Tennis and Golf, but not always! Other strenuous and repetitive activities can lead to tendon strain, local inflammation, irritation, and sometimes micro-tears. Gripping objects, twisting movements such as opening a jar, bending/straightening the elbow and pushing a heavy door are all activities that may aggravate the pain.

Treating Tennis and Golfer’s elbow with Physiotherapy involves a combination of:

1. Relative rest of aggravating activities.
2. Treatments to help settle pain and inflammation.
3. Gradual tendon strengthening exercises.

Some cases may require further interventions including Shockwave Therapy or corticosteroid injections. Recovery can be lengthy; however, 9/10 cases are fully recovered within a year.

The Acromioclavicular joint (ACJ) is a small joint at the top of the shoulder that joins the shoulder blade (scapula) and the collar bone (clavicle). It has strong ligaments around it, and a small cartilage disc at the joint line, where the bones meet. The disc helps to distribute load through the joint and shock absorb.

ACJ pain is often very localised to a small area over the joint. The ACJ can be injured from a traumatic event, such as a fall, but can also be injured by overuse training in the gym (using heavy weights repetitively). Movements such as overhead activities can be painful along with lying on the shoulder directly. Often there is a lack of control around the surrounding shoulders muscles which can exacerbate the symptoms.

By improving the strength and control around the surrounding muscles with Physiotherapy, this can reduce the symptoms and help the biomechanics of the joint. Some ACJ injuries require further intervention which can include joint injections, and sometimes surgery is indicated, depending on the degree of injury and initial response to Physiotherapy.

Shoulder fractures commonly occur at four main sites: the upper arm (Humerus), the socket of the shoulder (Glenoid), the shoulder blade (Scapula) and the collar bone (Clavicle).

A fracture-dislocation can occur when there is both a break(s) in the bone and a dislocation of the shoulder joint. Some fractures are non-displaced, where sections of bone remain near their normal position. Some are displaced fractures, where the broken sections of bone are twisted or angled into an abnormal position (requiring surgery to fix). Close to 80% of all shoulder fractures are non-displaced.

The signs and symptoms of shoulder fractures may include bruising around the shoulder (possibly further down the arm over time), swelling in the shoulder and arm, significant pain with simple shoulder movements and a visible deformity of the shoulder joint. Scapula fractures are usually traumatic (e.g. following a fall). A simple x-ray can be used to determine the type and severity of the injury.

Most injuries can be treated without surgery but may take up 12 weeks, or more to fully heal. Physiotherapy guides individuals through the recovery process following a shoulder fracture. Treatment includes gradually increasing shoulder movement, using hands on treatments, and working on specific exercises to gain shoulder strength and facilitate a smooth return to full function (and where appropriate, to higher level activities and sport).

Shoulder instability occurs when the bones, muscles, ligaments and other tissues of the shoulder can no longer provide the necessary control of the ‘ball’ (Humerus) in the ‘socket’ (Glenoid) of the shoulder joint. This can lead to near or full shoulder dislocations, which can cause bony, cartilage and nerve injuries at the same time.

Dislocations can happen during sport (traumatic tackle), during day to day tasks (carrying heavy shopping bags), or even sometimes on-demand, for those people with very mobile/flexible shoulders.

Symptoms of dislocation include numbness in the arm (a dead arm sensation), swelling, decreased shoulder muscle strength, and altered shoulder movement. Scans may be required to assess for joint damage and a specialist orthopaedic shoulder consultant may need to be involved.

Surgery could be required if there is significant joint damage, or of a person is young and at risk of further dislocation. If no major injury to bones and other tissues has been identified, Physiotherapy including hands on treatment and shoulder specific exercises can help to correct any altered movement patterns and to promote muscle activation and strengthening. This can facilitate return to higher level sport post full, or near dislocations.