The shoulder joint is a complex joint consisting of a large ball at the top of the arm bone (the ‘humerus’) and a small shallow socket (the glenoid) which is part of the shoulder blade. Sitting above the ball is a roof formed by a bony part of the shoulder blade at the back (the ‘acromion’) and a ligament at the front. The space in between the ball and the roof is called the sub-acromial space, See picture.
The rotator cuff muscles pass through the sub-acromial space. Their role is to move the arm and keep it sitting in the correct position on the socket as it moves. A fluid filled sac (the ‘bursa’) sits on top of the tendons of the rotator cuff muscles and protects them from the acromion. When the arm is at shoulder height the sub acromial space narrows. When the arm is in positions above and below this, the sub-acromial space is much larger.
Common shoulder problems
Frozen shoulder / Adhesive Capsulitis
What is it?
Frozen shoulder, or ‘adhesive capsulitis’ is the name used to describe pain and stiffness in the shoulder joint. The bag/lining around the joint is called the capsule which is normally loose to allow lots of movement. In a frozen shoulder the capsule becomes inflamed, tight and painful. Certain movements become difficult, especially reaching behind the back, behind the head and reaching up. The shoulder may be painful to lie on and disturb your sleep.
It is more common in people aged 40 to 60 and/or in people who have diabetes.
It may be triggered by an injury to the shoulder or come on for no particular reason.
It usually goes through three stages:
1)The shoulder becomes very painful.
2)The joint then becomes stiff.
3)The pain then eases and the movement gradually returns.
Frozen shoulder does get better by itself, though this can take anything up to eighteen months, and in some cases even longer.
Painkillers and anti-inflammatory tablets may be beneficial especially in the early stages (discuss with your Pharmacist or GP).
If the pain is severe and medication does not help, it may be possible to inject the shoulder joint with Corticosteroid.
You should try to keep the shoulder as mobile as possible, especially as the pain starts to settle. The following exercises should help. Try to exercise the shoulder regularly (2-3 times a day). It may be easier to exercise after a warm bath or shower. The shoulder may ache after the exercises for up to an hour but you can be reassured that this is not causing damage. If the shoulder is very painful after exercise, reduce the amount you are doing or ask a health care professional for advice.
If you are unable to cope with your pain or restriction of movement/function you may be referred to a physiotherapist or surgeon to discuss further treatment options such as hydrodilatation injection (stretching the capsule) or capsular release surgery.
Rotator cuff related shoulder pain (RCRSP)
What is rotator cuff related shoulder pain?
Rotator cuff related shoulder pain (RCRSP) is the medical name for pain arising from the sub acromial space; it is often commonly referred to as ‘impingement’. It is very common and affects one in five people at some point in their life, most commonly in middle age, and often in people who do heavy manual work.
RCRSP is often due to inflammation of the rotator cuff tendons and bursa, though there are many possible causes. Once enlarged and inflamed the tendons can cause pain, commonly when lifting the arm at shoulder height, which narrows the sub acromial space.
Why does it happen?
The tendons of the rotator cuff are susceptible to wear and tear. This, in conjunction with a period of increased demand (e.g. painting the ceiling, washing the windows or pruning the hedge) can be enough to trigger off a process of inflammation, swelling and pain.
Sometimes arthritis in the joint between the collar bone and shoulder blade – the acromioclavicular joint (ACJ) – can also contribute to shoulder pain.
Most RCRSP will settle with a period of rest, activity modification (taking a break from the activity that makes symptoms worse) and simple pain killers (take advice from your GP/Pharmacist).
Some gentle exercises can help stimulate the tendons to recover and prevent stiffness in the shoulder joint.
Osteoarthritis is ‘wear and tear’ arthritis where the cartilage lining the joint becomes worn, causing inflammation, pain and stiffness. Osteoarthritis is more common in the ageing population and those who have had trauma (e.g. a break/fracture) to their shoulder in the past.
It is important to try and continue with gentle exercise to help maintain movement and stimulate the natural lubricating fluid of the joint.
If pain is not adequately controlled with simple pain killers, then consult your GP/Pharmacist. They may consider stronger pain relief or a steroid injection. You may also benefit from using a hot pack on your shoulder (Click here for more information on applying a hot pack)
Dislocation / Instability
The shoulder joint allows a large range of motion. Having shoulder “instability” means that the ball can either dislocate (be pulled out of joint) or sublux (where the ball moves further in the socket than it should). This can be either traumatic (as a result of injury/accident) or non-traumatic (where repetitive movements cause some stretching of the soft tissues around the shoulder).
Most shoulders dislocate forwards and/or downwards, and most commonly following trauma or injury. When this happens, the cartilage rim at the front of the shoulder (the labrum) can be damaged (known as a Bankart lesion) and there is an increased risk of the shoulder dislocating again. If the shoulder dislocates backwards the labrum can be damaged at the back of the joint (reverse Bankart lesion).
Traumatic and non-traumatic instability of the shoulder will be managed differently.
Following a first-time traumatic dislocation, your arm may be put in a sling for a week for comfort. It is important to do some gentle exercises to keep your muscles healthy and to stop your shoulder becoming stiff during this time. It is expected that the shoulder will be painful in the first few weeks so consult your GP/Pharmacist regarding appropriate pain relief. You may also benefit from regular application of an ice pack for 15-20 minutes every 3 hours. (Click here for more information on applying an ice pack)
It is important to avoid positions that could cause re-dislocation THE MOST IMPORTANT POSITION TO AVOID is holding the arm out at 90 degrees to your side with your palm facing forwards (see picture below), especially if force is being applied (e.g. holding a door open for someone)
If you are having ongoing symptoms of your shoulder feeling unstable or if it is ‘coming out of joint’ with no history of trauma, ask your GP / physiotherapist for advice.
Rotator Cuff Tears
Like all joints, movement of the shoulder is controlled by muslces and in the shoulder, these are known as the rotator cuff. The rotator cuff help to keep the ball at the top of the arm centered on the socket. It is common for muscles of the rotator cuff to be subject to wear and tear and eventually fail. We commonly see this even with people with no pain.