There are many different kinds of shoulder pain, and most of them are quite common. You could dislocate your shoulder by side-swiping a tree while mountain biking, or maybe you’ve developed shoulder pain over time. This could be a number of conditions, like frozen shoulder or shoulder impingement syndrome, and many can be helped by physical therapy.
To tell us more about different types of shoulder pain and how it can be treated, we’re joined today by Jill McDougall, physical therapist at the UVM Medical Center.
Listen to the interview at the link below, or read the transcript that follows.
What types of shoulder injuries or pain do you see most often?
I think the most common type of shoulder pain I see is either in patients who have recently had shoulder surgery or patients that have shoulder impingement syndrome. It’s pain in the top of the shoulder or the front of the shoulder. It can radiate down the arm, and it happens when the tendons of the rotator cuff, which is a group of four muscles that attach around your shoulder, become pinched or impinged under one of the bones in your shoulder, the acromion. Over time, the pinching, which initially consists of inflammation, can turn into, with continued rubbing, fraying of the tendons or even lead to a tear of the rotator cuff.
I do see a small percentage of patients with frozen shoulder, who have developed that over time. I see lots of sprains and strains, or fractures and dislocations, and I see rotator cuff tears or labral tears.
What is frozen shoulder?
Frozen shoulder happens when the joint capsule of the shoulder, which is like a shrink wrap that surrounds all of the bones and tendons and other structures in the shoulder joint, the shrink wrap itself becomes irritated. If you were to unzip the shoulder and look inside, things are red and hot and very angry looking. It starts out initially as a lot of pain with movement in any direction, and over time, the inflammation continues and things scar down or freeze and tighten up, severely limiting movement.
It’s usually a two year process, from the start of the inflammation to the very end, when the shoulder has gone through the freezing or scarring down process, and then has begun to thaw out or loosen up, and the patient regains movement again.
Does frozen shoulder resolve itself on its own? Is it something that has to be treated?
Yes and yes. Sometimes, there’s some newer research that shows that getting a corticosteroid injection or taking oral steroid medication early enough on in the process, when things are still acute and inflamed and in the very early stages, can minimize or shorten the duration of the symptoms that happen with frozen shoulder. There are some treatments, like physical therapy, that are of limited benefit, but most of the time, it’s time that is the main treatment for frozen shoulder, and it just needs to run its course.
People don’t love hearing that. A lot of the times, by the time they’ve been referred to see me, I’m the one that ends up telling them that, but a lot of the time, they’ve heard that from their doctor as well, which is why I don’t see a ton of patients with frozen shoulder unless it’s in the very early stages.
You mentioned shoulder impingement syndrome. Can you talk about how that’s different from frozen shoulder?
Shoulder impingement syndrome is more like a typical tendonitis, so usually we can determine a cause of the impingement, either a patient started a new activity that they do a lot of, like re-wiring all the lights that are up high overhead, or they’ve got a job that involves repetitive throwing or overhead activity, and other times, the cause can just happen gradually with time, and patients will tell me, “Yeah, it’s been going on for awhile, and then, I think when I put in my garden for this year, it was the straw that broke the camel’s back, and now I have pain all the time.”
How do you treat shoulder impingement syndrome?
Treatment is usually twofold. We try to do things to get rid of the inflammation, and from a physical therapy standpoint, that can be using heat and ice or both. It can be using what we call modalities, which are things like electrical stimulation or lasers or DP using ultrasound. Sometimes, soft tissue work or massage can be helpful, and those types of things can reduce the inflammation. Rest is part of that as well.
The second arm of treatment involves figuring out what the cause of the impingement was and treating that, and the causes can be anything from one part of the shoulder being too tight and bringing the shoulder out of its normal position and causing pinching on those tendons, or it can also happen if the shoulder muscles aren’t in balance, so one group of shoulder muscles is stronger than the other, and they end up pulling the shoulder out of its normal movement pattern or its normal position and causing the pinching of those tendons too.
And if you don’t do both for treatment, then the impingement or the inflammation starts all over again.
Do some people come back with the same conditions over and over again, or can it happen in the different shoulder?
Yes, it does. It can happen in the other shoulder, or it can happen by coming back again, and it’s part of either A, we’re all human and nobody wants to do their exercises, or fix their posture over the rest of their lifetime, or they have a job or they’re an athlete in a sport that involves a lot of overhead activity, and that repetitive strain, we haven’t taken that away with physical therapy treatment, so their work or their sport is beating up their shoulder over time.
Sometimes if it’s caught early enough or if they are, I guess, genetically lucky that the stretching and the strengthening are enough to correct the shoulder position, then the impingement no longer happens, and their rotator cuff tendons stay healthy over time, and one course of treatment is all they need. Other patients, either the stretching and the strengthening aren’t enough to correct the shoulder position, or they are in … just the way that their body is set up would, because of genetics, they’re not a great candidate for correction with physical therapy, or there can be other outside health factors that can contribute to ongoing impingement, so if a patient has diabetes, is a long term smoker, doesn’t maintain a healthy body weight, those types of things can also contribute to how chronic the impingement syndrome is.
Who is at the greatest risk to develop one of these conditions?
Patients that are most at risk of developing these types of common shoulder conditions are either A, in a high risk sport or profession. Sports and professions involving overhead activity are most at risk, so in sports, people that do throwing sports or racket sports or anything over head, like volleyball players. Those are more likely to develop impingement or rotator cuff injury. Professionally, I see lots of electricians or people that paint or construction workers or anybody that has a job with a lot of overhead or shoulder intensive activity, jobs like meat cutters or people that just have, or that work on, a line in a factory and use their arm extended out in front of them, are also at risk of developing impingement syndrome.
What can those people do to prevent shoulder pain or any of these conditions?
One is to try to catch the problem early, so go to see your doctor or a physical therapist when you first start having shoulder symptoms.
When should you go see your doctor?
I think it’s a little bit different for everybody. Patients tend to fall into two groups. I have the patients that get on the internet and Google treatment, and they use things like heat and ice, and they try some of the stretches they find online as soon as their symptoms start, and they’re pretty successful in nipping it in the bud and not needing to go on to see their doctor or their physical therapist. Most of the things that you’ll find online to try for self treatment are, at best, they work well, and at worst, they’re at least not causing any damage, so those are usually pretty safe things to try.
If the symptoms persist beyond a week or they don’t get significantly better, with either trying some simple stretches or trying heat or ice, then I think it’s definitely worth talking to your doctor, or if you have insurance that will allow you to go to a physical therapist without needing a referral from your doctor, you can go right to a physical therapist and just have them evaluate you and see if it’s something that might be helped by physical therapy.
And is it heat or ice, heat and ice?
That’s a gray area. In general, ice works best for acute symptoms, so symptoms that have been there for less than a week. Ice also works well if the pain happens during activity. Heat tends to work better for symptoms that have been present for longer than a week or two, or are in the chronic stages, and heat tends to work better if the pain feels more like it’s stiffness or that soreness at the end of the day or soreness that happens when you wake up and haven’t moved your shoulder well. Those are just general guidelines. I do have patients where I think they fall in the acute category, I try ice with them, and it makes them worse, and heat works better for them, so there’s no harm in trying either, but in general, if it’s acute or short duration symptoms, ice works a little bit better to start with.
When you do work with patients in physical therapy, what kind of exercises do you do with them?
It depends on the type of shoulder injury. For shoulder impingement syndrome, it’s usually we do an evaluation, and we stretch what’s tight, and we strengthen what’s weak and try to establish normal shoulder mechanics or movement patterns to reduce that impingement. If someone has a fracture or an acute injury like a rotator cuff tear or a labral tear, we first work on getting things to settle down with either active rest or immobilization, and restoring range of motion first, so it’s stretches to get their shoulder moving again, and then we work back into strengthening once the acute injury has settled down or begun to heal.
Do you find that people sometimes ask, “Can I just have surgery to fix is?” Or are most people open to physical therapy?
Physical therapy is a time commitment, and even doing exercises on your own and waiting to see if they get better, it’s a time commitment, and it’s not always a short road. It’s not always an easy road, so a lot of patients do hesitate to go that route first, and I get asked the question all the time, “Why can’t I just get an MRI,” or “Why won’t they just let me go see a surgeon?”
The answer that I usually give them is the one that I hear from the surgeons themselves, which is a lot of the time, surgery isn’t the answer for the type of shoulder problem that they’re having, and even though they’re in pain or there is a finding that shows up on the MRI, surgery’s not likely to make it better, so the risk of things getting worse in doing surgery is greater than the reward might be of having that quick fix, so that’s why surgeons or your doctor will recommend conservative treatment like rest or medication or exercise or physical therapy first in those cases. There are some problems where that is torn or that is fractured that’s not going to get better with physical therapy, and then that’s where patients tend to go straight to the surgeon or straight to get the MRI to see what’s going on.
If I had to give a recommendation about preventing shoulder pain or reducing the likelihood of you developing shoulder pain, it would be to remember that evolution hasn’t caught up with what our bodies have to do in today’s society. We’re meant to be cavemen that are out, and hunting and gathering and moving around all the time, and we’re meant to only live to be about 35, and our bodies are still engineered that way. We’re living now in a society where we live to be quite a bit older than that. We’re stuck in a desk at a cubicle, hunched forward, looking at a computer screen for a lot of that day, and we go home and the things that we do for fun are, for kids often, in front of a laptop or a video game, and for adults too, they’re on their iPad or they’re watching TV.
Those things, in terms of shoulder pain, are big contributors to why shoulder pain develops. We’d end up with a forward head and a rounded shoulder posture. Our upper backs become more rounded out. Those put the bones in the shoulder in more of a position to start pinching on those rotator cuff tendons, and then not being as active as we were back in pioneer, and then, before that, cavemen days, the weakness develops and we get those imbalances in shoulder strength that I spoke about earlier, so I think working on posture, working on stretching things that get tight because of either repetitive movements or sustained positioning of those activities, and then working on strengthening, strengthening the right muscle groups, can be hugely helpful in preventing shoulder pain.