Physiotherapy and rehabilitation
Below we present in detail the most common shoulder joint injuries. Every shoulder pathology or injury has a description of general features, the cause of the injury, the characteristics of the symptoms, diagnostics, and the course of treatment.
The shoulder joint is the most frequently dislocated joint in the human body, which usually occurs during sports activities or falls. The mechanism of injury is usually trauma. Frequent situations where shoulder joint dislocations happen are:
Spontaneous shoulder dislocations can also happen, but they represent a major biomechanical problem.
In 97% of cases, the shoulder joint is dislocated in the anterior region.
Fractures are involved in 30% of shoulder dislocations. Common associated complications are Hill–Sachs lesion, where a compression fracture occurs upon dislocation, and Bankart lesion, where damage occurs to the cartilage area of the shoulder joint and is the result of the humeral head striking the cartilage lining.
Rotator cuff injury is involved in approximately 35–86% of shoulder dislocations.
If a shoulder dislocation occurs before the age of 20, it recurs in 80% of patients; after the age of 40, shoulder dislocation recurs in only 30% of patients.
A shoulder dislocation is characterised by sudden, sharp pain, a feeling of displacement, a changed external appearance of the joint, and functional limitation in mobility and strength. The entire joint is painful and symptomatic in all directions of movement.
Clinical examination, X-rays and magnetic resonance imaging exclude or confirm the possibility that the dislocation has caused concurrent lesions of the bone segments of the joint and rupture of tendons or damage to the joint capsule.
It is important to have a diagnosis performed by a specialist, as shoulder dislocation can involve varying degrees of structural damage. Recurrent dislocations of the shoulder joint have long-term consequences and lead to permanent shoulder instability and limited function, which is why a detailed analysis of the dislocation with diagnostics is important. Diagnostic tests include X-rays of the skeleton and magnetic resonance imaging. In some cases, computed tomography (CT) or MR arthrography is also necessary.
After a shoulder dislocation, a doctor usually repositions the joint, which is followed by seven days of rest and then the gradual application of individual physiotherapy training.
The first dislocation of the shoulder is usually treated conservatively. After a second shoulder dislocation, there is a 90% chance of a third dislocation, so surgical stabilisation of the joint makes sense in this case.
By applying individualised training, we establish a normal range of motion in the shoulder girdle, improve stability, and restore strength to the arm in the basic directions of movement.
Shoulder impingement syndrome is a pathology of the shoulder joint that occurs when soft structures (muscle attachments, supraspinatus and rotator cuff tendons, bursa and joint capsule) are compressed in the subacromial space (between the humeral head and the acromion).
A common cause of shoulder impingement syndrome are weak supraspinatus and infraspinatus muscle groups combined with a too strong deltoid muscle, which causes the humeral head to move towards the acromion of the scapula. Muscle imbalances, in addition to poor posture, are generally the main culprits for shoulder impingement syndrome. The movement of the humeral head upward causes biomechanically suboptimal movement in the shoulder joint, limited mobility, and increased friction between joint structures, which leads to inflammation and pain. The development of shoulder impingement syndrome is also influenced by anatomical factors and the type of sports activity.
The most common occurrence is compression of the supraspinatus tendon, subacromial bursa, or the tendon of the long head of biceps, which become inflamed as a result of the compression and further reduce the subacromial space. In the long term, there is a likelihood of rupture of inflamed and constricted tendons if the joint is not rehabilitated properly.
Shoulder impingement syndrome is characterised by symptoms that include muscle weakness, limited joint mobility, sports-specific or job-specific pain that is only present with certain movements, popping within the joint, and radiating pain that spreads into the neck and down the arm. The pain is characteristically dull, persistent, and more pronounced at night.
It is important that the patient books a diagnostic examination, at which the doctor performs clinical tests and confirms the diagnosis of shoulder impingement syndrome. It also makes sense to perform magnetic resonance imaging (MRI) to exclude potential residual or concomitant injuries and ultrasound (US) to precisely determine the site of inflammation.
In the first phase of rehabilitation, we perform various instrumental and soft manual techniques to increase shoulder mobility and open the subacromial space.
In the second phase of rehabilitation, we perform corrective training for posture and gradually eliminate the muscle imbalances that caused the occurrence of shoulder impingement syndrome. Rehabilitation begins with mobility training and special exercises to relax shortened muscles and strengthen weak muscle groups.
It is important to establish correct movement of the scapula and the optimal anatomical position of the shoulder joint if it is damaged.
The length of rehabilitation depends on the level of physical activity, the diagnosis of the cause, and the severity of pain and inflammatory symptoms. Usually, the symptoms and causes of shoulder impingement syndrome are eliminated within 2–4 months.
Frozen shoulder syndrome (adhesive capsulitis) is a term for a group of symptoms in the shoulder joint that manifest as stiffness, pain, and limited range of motion. Frozen shoulder syndrome is the second most common pathological condition of the shoulder joint. Frozen shoulder syndrome occurs with overuse, a prolonged phase of immobilisation, and after diseases such as:
In principle, not all causes of the pathology are known. Frozen shoulder syndrome occurs more frequently in women and mostly affects the 40–65 age group.
Frozen shoulder syndrome typically occurs slowly, gradually, which is also characteristic of rehabilitation, which is also time-consuming.
Patients describe the condition as a gradual increase in pain and loss of mobility in the shoulder. They often have minor issues with everyday tasks and personal hygiene, with the movements performed behind the back most often affected. Usually, the range of motion in at least two directions of movement in the shoulder is less than 25% of healthy function.
The most frequently affected are external rotation and/or abduction of the shoulder. The pathology quickly worsens if not treated properly. The progression of frozen shoulder occurs in three stages, starting with pain at rest and sharp pain in the final ranges of motion, gradually the pain subsides, and loss of motor control and mobility in the shoulder joint occurs.
The main means of rehabilitation is special training.
It is crucial to avoid painful movements in early rehabilitation, but still intensively strengthen movements that are not symptomatic.
Movement accelerates the regeneration of joint structures, but at the same time overloading can cause inflammation, which prolongs the rehabilitation timeline. A combination of training with instrumental therapy is recommended, which warms up or activates the tissue before rehabilitation training. The shoulder joint is a ball-and-socket joint, so it is crucial to perform many circular movements at an asymptomatic pace and volume (two to three times a day).
Passive range of motion exercises and mild mobilisation of the joint with manual techniques are also recommended. In mid-stage and late-stage rehabilitation, we increase the load during strength exercises and use more aggressive range of motion exercises. It is crucial to establish muscle balance and teach the patient the correct technique for performing the exercises.
Spontaneous healing takes one to four years until the functional state of the shoulder returns to a state similar prior to injury.
The rotator cuff is made up of four muscles – the supraspinatus, subscapularis, infraspinatus, and teres minor – which attach to the upper part of the humerus and provide stability to the shoulder joint during movement.
Injuries to the rotator cuff tendons are the leading cause of shoulder joint pain, which can occur due to weakened tissue resulting from degeneration, acute overuse, or microinjuries resulting from falls, impacts, or muscle imbalances in the shoulder.
Degenerative changes most often begin to develop in the tendon of the supraspinatus muscle, usually after the age of 40, but can occur earlier in top athletes or with extreme overuse as a variation of overuse injury and with traumatic injuries. With age, rotator cuff tendon pathologies become more common, causing lower tensile strength of the tendons and thus greater exposure to inflammation and injury.
The supraspinatus muscle is generally the most frequently injured muscle of the rotator cuff. Symptoms of rotator cuff injuries include shoulder pain of varying intensity and location, accompanied by movement-specific weakness (depending on the injured muscle).
An injury to the supraspinatus muscle is characterised by pain on the outer surface of the top part of the upper arm and pain when performing overhead movements. After rotator cuff tendon injuries, the pain intensifies with continued load on the shoulder; in advanced tendon damage, the pain may also be present at night, and the mobility of the shoulder joint is also reduced.
Treatment of rotator cuff tendon injuries begins with diagnostics, which includes X-rays and/or magnetic resonance imaging (MRI).
For early and mild rotator cuff problems, a shoulder ultrasound (US) is sufficient, but in some cases, MR arthrography and/or CT arthrography are also necessary.
Rotator cuff tendon injuries are mostly treated conservatively – first with a phase of rest and resolving the inflammation, and then with progressive rehabilitation training that strengthens the affected shoulder movements and improves muscle symmetry. Partial tendon tears and/or complete tendon tears in the elderly are successfully treated with physical therapy, but for larger tears or complete tears of the rotator cuff tendons in younger patients, surgical treatment is necessary to fully restore shoulder function.
Among the rotator cuff muscles, the tendon of the supraspinatus muscle is most frequently injured.
The function of the supraspinatus muscle is abduction and assistance in raising the arm above the head. Supraspinatus activity is crucial for providing stabilisation during repetitive arm lifts (throwing a ball, serving, breaststroke).
Supraspinatus tendon injuries are characterised by limited movement above the head and in extension, with pain symptoms that increase with load. In athletes, supraspinatus tendon injuries are the result of overuse that causes inflammation, impacts, or explosive movements.
With a sufficiently large one-time force, it is also possible to completely tear the tendon with which the supraspinatus muscle attaches to the humerus. Supraspinatus tendon tear is more common in middle-aged recreational or top athletes, as the tendon is already affected by age-related changes and is less resistant to heavy loads.
In general, pathological conditions of the supraspinatus tendon become more common over the years, as the tendon gradually thickens and constricts the subacromial space, which is often the cause of inflammation and pain.
Rehabilitation of a supraspinatus tendon injury primarily involves managing inflammation and promoting healing in the first phase of treatment, and applying progressive specialised training in the second phase of treatment.
In the initial phase of physical therapy, we perform arm exercises below head level and gradually increase the asymptomatic range of motion.
This is followed by establishing a full range of motion through mobility training and strengthening the acquired amplitudes of movement through strength training, which eliminates muscle imbalances and enables additional stabilisation of the shoulder joint. If the shoulder joint does not respond to conservative treatment, surgical release of the space under the scapula process or surgical treatment of the damaged part of the muscle or tendon is recommended.
The AC joint is the joint between the clavicle and the scapula (the beak-like process of the scapula) and is involved in elevation movements. The stability of the AC joint is provided by several ligaments, specifically the connection between the acromion and the clavicle (acromioclavicular ligament), and the coracoid and the clavicle (two ligaments – the trapezoid and conoid ligaments, which make up the coracoclavicular ligament). AC joint injuries usually occur when falling on the shoulder to the side with the arm at the side of the body or in front (falling while skiing, cycling, riding a motorcycle, scooter, etc.).
The diagnosis is made by a specialist with a manual examination, as the AC joint is usually externally altered and painful to the touch when injured.
In the case of a stable and normally shaped AC joint that is tender to palpation, we suspect wear of the joint or damage to the AC joint disc. Overuse of the AC joint can also lead to the breakdown of the bony part of the clavicle, which is confirmed by MRI.
The first three grades of AC joint injury are successfully treated with physical therapy, which includes high-energy laser irradiation, magnetic therapy, and joint stabilisation training. In the case of joint wear accompanied by acute symptoms, a nerve block is injected. Higher grades of AC joint injury require surgical treatment, and the surgical technique depends on the specifics of the AC joint injury and the degree of joint instability.
A specialised training regimen often has a successful treatment prognosis by improving symptoms and shoulder stability in milder types of AC joint injury.
A SLAP lesion is an injury to the upper part of the shoulder labrum (joint capsule). The shoulder labrum is a connective-cartilaginous structure that deepens and enlarges the articular surface of the glenoid and contributes to the stability of the shoulder joint.
The long head of the biceps attaches to the superior (upper) labrum, providing anterior glenohumeral stability of the shoulder. SLAP lesions are rare, occurring in only 6% of patients who have undergone shoulder arthroscopy.
Throwing sports are a predispositions for the occurrence of SLAP lesions. They develop in athletes who perform overhead throws (volleyball, handball, American football, etc.), in falls on an outstretched arm or directly on the shoulder (martial arts, downhill), in direct blows to the shoulder, but are otherwise more common in men over the age of 30.
Symptoms of SLAP Lesions are a dull, hard to define pain inside the joint, which is most often localised more to the back of the shoulder. Pain often only appears a long time after the injury. When the labrum is injured, there may be mechanical skipping, similar to what happens with a damaged meniscus. A popping/grinding sound may occur during movement. Shoulder girdle muscles becomes weak and the joint loses mobility.
During a clinical examination, it is crucial to assess the mobility and functional status of the shoulder joint through clinical tests. In patients with a suspected SLAP lesion, magnetic resonance imaging (MRI) is essential.
Treatment of a SLAP lesion is conservative in the first three months after the injury. The purpose of conservative therapy is to reduce pain and inflammation, restore shoulder mobility, and strengthen the scapular and glenohumeral muscles, thereby improving static and active stability of the shoulder joint.
If conservative treatment does not improve symptoms, arthroscopic shoulder surgery is recommended. The surgical technique depends on the specifics of the injury. If the patient is younger and does not have more than 30% of the long head tendon of the biceps damaged, the labrum is fixed to the tendon. Tenodesis is often performed in older patients.
Shoulder instability manifests as the inability to maintain the head of the humerus in the glenoid cavity of the scapula during movement.
Shoulder instability occurs when the structures that provide stability to the shoulder joint are damaged. Shoulder instability is often the result of weak, degenerated or acutely injured rotator cuff muscles, but it can also be the result of traumatic tears or strains of the passive stabilisers of the shoulder – the ligaments.
Disproportionate muscles of the shoulder girdle often involve strong, outwardly visible muscles that do not increase shoulder stability, but in most cases prevent the deep muscles from stabilising the joint.
The layperson’s opinion that strengthening the superficial muscles improves the stability of the shoulder joint is erroneous, as it further increases instability. Instability of the shoulder joint is often accompanied by instability of the scapula. When both instabilities are present, exercises to improve shoulder joint stability are not effective until stability and scapular sliding are improved.
Treatment for shoulder instability depends on:
Initially, conservative treatment with physical therapy is most often performed, which, in addition to special therapeutic training, includes irradiation with a therapeutic laser.
When shoulder dislocations occur and the shoulder does not respond to conservative treatment, surgical stabilisation of the joint is generally recommended. Specialised training is aimed at strengthening the stabiliser muscles, correcting muscle imbalances, and establishing the correct rhythm of the scapula.
Shoulder calcification is a common pathological condition of the shoulder joint, which mainly affects the population in the 30–50 age group, and occurs more often in women. Risk factors for the development of shoulder calcification include diabetes, previous shoulder injury, especially to the muscles and tendons of the rotator cuff, or shoulder dislocation, incorrect posture, and prolonged immobilisation of the arm, e.g. after a fracture.
There are two types of shoulder calcification: degenerative calcification of the shoulder in reactive calcification of the shoulder. The first is typical for the elderly and occurs gradually due to the loss of quality of collagen fibres in the connective tissue of the shoulder and the gradual formation of microinjuries. Reactive calcification of the shoulder occurs as a result of previous injury, trauma, thyroid problems, or in conjunction with other typical risk factors.
If not treated with appropriate physiotherapy, shoulder calcification can develop into frozen shoulder syndrome, which causes more severe shoulder pain.
The condition of shoulder calcification is characterised by a three-phase cycle that can last up to five years, and if hormonal disorders are present and no treatment is performed, it can last up to eight years.
Shoulder calcification is characterised by pain that worsens with rest and immobility of the shoulder. Night-time pain is typical, disrupting sleep and causing intense pain when lying on the affected shoulder. Pain from shoulder calcification usually begins suddenly, is sharp, and limits movement of the arm above the head. Often, a standing position is more pleasant for patients with shoulder calcification than a lying position.
Shoulder calcification is characterised by intense pain in the front or back of the shoulder, which often radiates into the upper arm, possibly to the elbow and wrist. If you also have tingling in your fingers, it is not a problem related to shoulder calcification, but there is suspected carpal tunnel syndrome.
Shoulder calcification develops in three phases; the third phase is the most painful, when calcium crystals are released from the tendon into its surroundings. Physiotherapy and kinesiology are usually performed in the third phase of shoulder calcification, as it is asymptomatic in most cases before this stage, which means that we do not have contact with patients at that time.
A reliable diagnostic method for examining the shoulder where calcifications are suspected is an ultrasound examination (US) by a radiology specialist. Ultrasound imaging precisely determines the location of calcium crystals and their size, and can also be used as a method of monitoring the progress of conservative treatment of shoulder calcification.
Treatment of calcifications in the shoulder is complex, and requires a comprehensive conservative approach combining physiotherapy and kinesiology. Surgical treatment is only performed in 5–10% of patients when physiotherapy treatment is unsuccessful after at least nine months of continuous rehabilitation.
The primary physiotherapy method for treating shoulder calcification is extracorporeal shockwave therapy combined with active shoulder mobilisation and rotator cuff strengthening exercises. TECAR and LASER therapy are also used, as well as electrotherapy, which must be high-tone – at MEDICOFIT clinic, we use HiToP. Treatment of shoulder calcifications should also include exercises to develop overhead pushing and pulling strength in the final phase, as failure to gain strength in the final ranges of overhead movements poses a risk of recurrence of calcifications.
It is important that the treatment is combined in every therapy, extracorporeal shockwaves must be precisely measured in intensity and must not trigger an intense pain response to the therapy, despite the fact that they are among the more invasive methods of instrumental therapy. Extracorporeal shockwaves are the most effective means of conservative treatment of shoulder calcification, but they must always be accompanied by special exercises that strengthen key muscle groups.
