Do you want to know how to prevent shoulder pain?
I know you're thinking whether you will be able to ever get your shoulder pain free or not. Every time you move your arm overhead there is a constant, nagging, irritating shoulder pain that gives you a feeling that all those medications, random arm mobility exercises are not getting you anywhere. But, know what? Let me tell you one thing that you aren't alone. It feels frustrating and afar away from getting your shoulder completely pain free, but you're closer than you think. Let me show you how you can rid shoulder pain by learning more about it.
Stiff and painful Shoulder doesn't necessarily mean shoulder is frozen.. Many physicians and physical therapists usually lump adhesive capsulitis and frozen shoulder together. Frozen shoulder is the term used to describe any shoulder that is stiff (most of the shoulder pain conditions causes limitation in shoulder joint mobility) whereas adhesive capsulitis is the inflammatory condition in which capsule enclosing the glenohumeral joint (main shoulder joint) undergoes gradual inflammatory process usually after trauma to shoulder joint.
Below you will learn:
How Shoulder works and What is Shoulder pain?
Shoulder Joint also known as glenohumeral joint is the ball and socket joint formed by head of the arm bone (humerus) and cup shaped part of the shoulder blade (glenoid cavity).
Shoulder joint is extremely mobile joint where mobility is much more than stability (stability compromised).
Static stability is provided by numerous ligaments around glenohumeral joint region whereas dynamic mobility and stability is maintained by group of 4 important muscles called Rotator Cuff muscles (Supraspinatous, Infraspinatous, Teres Minor, Subscapularis). These muscles stabilizes shoulder blades during three dimensional shoulder joint movement.
Failure of these muscles to provide enough stability to shoulder blades results in numerous pain conditions in shoulder region.
During overhead arm elevation various joints of shoulder complex (shown in the image above) move in association with one another to provide complete freedom of movement in the shoulder joint. If any of these joints are not moving properly along with weakness of rotator cuff muscles and other stabilization muscles results in musculoskeletal reason for shoulder pain (most common).
Shoulder Pain Statistics
Self reported prevalence of shoulder pain is estimated to be between 16% and 26%; it is the third most common cause of musculoskeletal consultation in primary care, and approximately 1% of adults consult a general practitioner or physical therapist with new shoulder pain annually.
Common Shoulder Pain Conditions:
There are many musculoskeletal conditions which results in shoulder pain. Your physical therapist or doctor help you understand about the conditions based on clinical assessment.
- Supraspinatous Impingement
- Rotator Cuff Tear/ Tendonitis
- Biceps Tendon Injuries
- Shoulder Joint Instability and dislocations
- Bursitis: Subdeltoid and Subacromial Bursitis
- Frozen Shoulder (Usually lumped with condition known as Adhesive Capsulitis)
- Shoulder Osteoarthritis
- Thoracic Outlet Syndrome
Sources of Referred Pain in the Shoulder Area:
Sometimes, the pain in the shoulder doesn't come because of problem in the shoulder. In this case pain is getting referred to shoulder from somewhere else also known as Referred pain.
Are you wondering how to differentiate whether your shoulder pain coming from shoulder joint itself or elsewhere? Let me explain, Shoulder pain that starts from shoulder joint worsens with activity or arm movement whereas shoulder pain arising due to other sources like phrenic nerve (nerve to primary breathing muscle: Diaphragm), gallbladder and heart doesn't change or worsen with shoulder activities ,it remains same irrespective of body positions or arm movement.
List of sources that refer pain in the shoulder:
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- Cervical region neck between C3-C4, C4-C5
- Nerve roots C4 or C5
- Cervical C4 nerve pain is felt over top of the shoulder (upper trapezius to tip of the shoulder (C4 dermatome)
- C5 nerve root (Cervical or Neck) pain is perceived over deltoid muscles and lateral arm (C5 dermatome)
- Diaphragm (Primary Breathing muscle) nerve pain (phrenic nerve: C3- C5) is felt over top of the shoulder region (upper trapezius)
- Chest pain and myocardial infarcts (Heart Attacks) is perceived in the left armpit and chest region.
- Gallbladder pain is felt at the tip of the shoulder and posterior shoulder blade (Scapula) region.
Shoulder Clinical Assessment and Diagnosis
It's great to keep a note about how your pain started and nature of the pain. These information along with clinical assessment done by your physical therapist or doctor help in making accurate diagnosis about your problem. List of few tests done by physical therapist:
- Active and Passive Range of Motion of Glenohumeral Joint
- Accessory Joint Mobility of Shoulder Complex: Glenohumeral Joint, Acromioclavicular Joint, Sternoclavicular Joint and ScapuloThoracic Joint (Not a true joint).
- Special Tests to rule out any pathological mobility of Shoulder blade and Shoulder joint.
- Differential diagnosis to differentiate shoulder pain from other sources like Thoracic Outlet, Cervical Nerves, Cardiac region, Diaphragm and Gall bladder.
Required Medical Imaging
Based on the impression made by your physical therapist or doctor. They might ask you to get one of the below mentioned investigation test to rule out the issue area in the shoulder. (Only in the required cases)
- X ray: To see any bony changes in case of Osteoarthritis, Shoulder Subluxation/dislocation.
- MRI: To visualize soft tissue changes including muscles, ligaments, and joint capsule.
- Diagnostic Ultrasound: It helps in visualizing swelling in the shoulder muscle tendons (tendon injuries)
- ESR: In case of Polymyalgia rheumatica and Shoulder Inflammatory/Infective conditions.
- CT scan: Recommended in very limited cases.
Shoulder Pain Prognosis
Prognosis of shoulder pain mainly depends on the cause of the pain and when it is diagnosed. Early detection is important in the case of critical conditions (infections or cancers) for treatment to be effective and prevention of disability.
Natural recommended treatment for Shoulder Pain
Treatment mainly depends on the diagnosis of the shoulder pain. Most of the musculoskeletal causes of shoulder pain (involves poor sitting or standing posture, faulty mechanics of shoulder blade, weakness and inflexibility of muscles around glenohumeral joint) can be rectified with customized shoulder/shoulder blade flexilibility, stability and strengthening exercises.
- Rotator Cuff Injury or Tendonitis: This one is quiet popular as it is the most common of all shoulder injuries. It results from repetitive stress to tendons, ligaments and rotator cuff muscles causing wear and tear of the rotator cuff tendons. Assessment of scapular alignment helps in designing the correct exercise program for rotator cuff and other supporting muscles. Release of tight scapular internal rotators using foam roller or tennis ball followed by strengthening of weak scapular stabilizers and outer rotators results in great reduction in shoulder pain.
Shoulder Soft tissue Manual Therapy
- Biceps Tendon Injuries: Scapular corrective and strengthening exercises based on scapular dysfunction assessment. Tendon release, tendon stretching and other biceps tendon offloading techniques helps in healing the tendon faster.
- Shoulder Joint Instability and dislocations: It's great to have flexibility but hyperflexility around the joint especially shoulder is not fun, as it predisposes you to get shoulder dislocation injuries. In case of shoulder instability, gradually progressive shoulder and scapular stability exercises need to be initiated. In case of dislocations, joint needs to be relocated first before starting with any shoulder movement or exercises.
- Bursitis (Subdeltoid and Subacromial Bursitis): Bursa are the fluid filled spaces which provides space for muscle tendons to easily slide through during overhead arm activities. Sometimes, due to misalignment of shoulder blades there is repetitive stress and inflammation of the muscle tendons and these spaces. Best physical therapy techniques to alleviate pain in case of bursitis are trigger point release using tennis ball, myofascial release using foam roller, scapular alignment and corrective exercises with cold compression therapy (ice pack application) to reduce the shoulder inflammation.
- Shoulder Osteoarthritis: Age relative degenerative changes of osteoarthritis can be slowed down with right scapular and shoulder stabilization and strengthening programs.
- Thoracic Outlet Syndrome: Conservative treatment is found to be very effective in treating thoracic outlet syndrome than surgery. Based on the diagnosis, stretching of the tight neck and strengthening of the weak neck and shoulder girdle muscles help in relieving thoracic outlet pain symptoms in the shoulder.
Physical Therapists are the movement experts who can help you reduce shoulder pain and show you exactly how you can prevent common shoulder injuries by using various strengthening, stability and stretching programs so that you do not have any functional limitations which can hold you back to perform optimally.
Quick Takeaways and Action Steps:
- Longer you take to act towards your pain longer it takes to heal.
- Discuss with your Physical Therapist about the reason for your shoulder pain and learn about the activity modifications to avoid sudden, sharp pain.
- Learn the correct exercises by your Physical Therapist as most of the shoulder pain conditions can be rectified 90% with correct form and type of exercises.
- Continue with your exercise program given by your physical therapist minimum 3-4 times a week even when you are pain free (as a maintenance program).
References:
1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1283277/
