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Shoulder Injuries

Shoulder Injuries

The shoulder is a complex joint that needs to allow for the large range of movement the arm enjoys, as well as provide enough strength and stability to allow humans to push, pull and carry heavy objects exceeding their own body weight. Whilst the joint allows a greater range of movement than any other in the body, this flexibility means that a shoulder injury is fairly common.

About the Shoulder

The shoulder is made up of three bones - the clavicle, scapula and humerus. What we would normally refer to as the shoulder joint is where the head of the humerus (upper arm) attaches to the scapula (shoulder blade). The rounded head of the humerus forms a ‘ball and socket joint’ with the scapula. This allows for rotation at the joint as well as hinge-like movement of the arm up and away from the body. The shoulder is kept stable by muscles and tendons that are collectively known as the rotator cuff. Despite the actions of the muscles, tendons and ligaments of the shoulder to provide stability, the large range of motion means the joint is more susceptible to dislocations and other painful conditions when compared to other joints in the human body.

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Types of Shoulder Injuries

Some of the more common causes of a shoulder injury include:

Frozen Shoulder

Causes

Frozen shoulder, also referred to as shoulder contracture or adhesive capsulitis, is caused by the thickening and inflammation of the flexible tissue that encapsulates the joint of the shoulder. The cause of the ailment is not known but the factors that can contribute to developing the ailment include having had shoulder surgery previously, suffering from a shoulder injury in the past, health conditions such as a stroke or heart disease, diabetes or a condition called Dupuytrens contracture, where small lumps created by thickened tissue appear in the fingers and hands.

Symptoms

Sufferers of this ailment will experience pain and stiffness of the shoulder, and the symptoms may worsen over a period of a few months or years. Typically, pain is experienced for the first few months and is then followed by increasing stiffness that can affect your ability to function normally and complete everyday activities. In the most severe cases, a sufferer is unable to move their shoulder at all.

Diagnosis

It's estimated that in the UK alone up to one in 20 people will suffer from shoulder pain caused by frozen shoulder. Generally, sufferers of the condition are between the ages of 40 and 60 years old and many of them go undiagnosed as the shoulder pain they experience is not serious enough to warrant a visit to the doctor or they simply use a shoulder support to alleviate the pain and the condition disappears.

This type of shoulder pain is more commonly found in woman than men and, if the pain persists, a visit to the GP is recommended. If frozen shoulder is identified and diagnosed early, shoulder pain can be kept to a minimum and a treatment plan implemented to prevent long term stiffness and discomfort.

Management

The shoulder pain caused by frozen shoulder is often not severe enough to cause a patient to visit a doctor or seek help. They may simply just live with the slight irritation until it eventually goes away. For those that are suffering from more severe shoulder pain, appropriate treatment methods may be sought and a shoulder support, brace or pain killers may be recommended.

A shoulder support is one of the more common types of treatment as painkillers will only temporarily alleviate the pain, whereas a support will ensure that the pressure and wear and tear on the area is minimised. 

Physiotherapy and gentle exercise may also be recommended in an effort to strengthen the shoulder and thus alleviate the pain; however, if this and other types of treatment are inefficient after six months or more, surgery may be recommended, depending on how far the symptoms have progressed.

Dislocated Shoulder

Causes

Injuries to the shoulder are unfortunately common in many sports, especially contact sports, such as wrestling or rugby. They can also occur in snowboarding, roller skating and other extreme sports.

One of the most common kinds of shoulder injury is the dislocated shoulder. The shoulder is perhaps the easiest joint in your body to dislocate, because it is a ball and socket joint, and the socket is very shallow. The joint is designed to move in many different directions, but it is not a very stable joint, and it is easy for it to accidentally pop out. If you are lucky, the joint can simply be re-seated, but in some cases, the supporting tissues may be damaged as a result of the shoulder injury.

Symptoms

It is fairly easy to tell when a shoulder is dislocated, because it will look square, instead of round. In some cases, you will see a bulge under the skin at the front of your shoulder, which is the top of your arm bone. You will experience loss of mobility, and the arm will most likely be very painful.

Diagnosis

If you think you have suffered a dislocated shoulder, you should seek professional medical advice immediately. It is possible to suffer serious nerve damage as a result of a dislocated shoulder, so you should go to A&E and explain what has happened.

Management

A doctor will manipulate the bone back into place, and assess the extent of your injury to determine whether further physiotherapy is needed. If the dislocation occurred as a result of trauma, you may need to have an X-ray to make sure that you have not broken any bones.

In some cases, you will be given an ultrasound scan to find out whether you have damaged your rotator cuff during the dislocation. This injury is common in older people, but it can also occur in athletes if they put a load on their joints in an unusual manner.

If you have suffered from serious tissue damage then your shoulder injury may be treated with a shoulder support. Note that the support is there to prevent further damage to your shoulder and you should still rest the joint and avoid load-bearing physical activities until your doctor has given you the all-clear. Some people are prone to shoulder dislocations, and can even dislocate their shoulder in multiple directions. If you are prone to such injuries you may want to work on strengthening the supporting muscles in addition to wearing a shoulder brace.

For more information on dislocated shoulders, visit the NHS website.

Broken Collar Bone

Causes

The collarbone is a slender bone that runs from the breastbone, just below the neck, to each of the shoulders. It is connected to the shoulder blades and the breastbone by ligaments. A broken collarbone is a common injury and is most likely to occur when someone falls heavily onto their shoulder or onto an outstretched arm. It may also be known as a fractured or broken clavicle.

Symptoms

Acute shoulder pain is the first likely sign that you have fractured your collarbone. There may also be swelling and bruising and a bump along the collarbone itself at the site of the fracture. In the unlikely event that the fractured pieces of bone have pierced the skin, there may also be some bleeding. The shoulder, no longer supported by the collarbone, may also have collapsed downwards. In addition, there may have been a snap or grinding sound as the bone fractured. You will want to hold your arm, keeping it still, in order to lessen the pain.

Diagnosis

It is important to see your GP straight away so they can tell you if there has been a fracture. You will be referred to a hospital for an X-ray to confirm the injury.

Management

Broken collarbones are usually allowed to heal naturally which is likely to take between six to eight weeks. A fractured clavicle often heals quickly for children, usually over a period of two to three weeks because there is unlikely to be much displacement of the two fractured pieces of bone.

You will be fitted with a triangular sling that will hold the broken bone in place and support your arm while the break heals. You will also be given painkillers to reduce your shoulder pain. Other forms of treatment include:

Surgery: This may be necessary if the fracture is severe where the fractured pieces overlap significantly or have broken the skin. In these cases, the bones are often held together with a plate and screws

Physiotherapy: While collarbones usually heal relatively quickly, it can take six to eight weeks for the shoulder and arm to recover their full strength. A physiotherapist will show you some gentle exercises to do at home to maintain movement in your elbow, wrist and hand joints while the bone is healing. This will also help to relieve shoulder pain and build up strength in the affected shoulder once again.

Shoulder Support: You may find that wearing a shoulder support helps to reduce any shoulder pain and anxiety that you might feel when you return to sport.

Rotator Cuff Calcific Tendonitis

Rotator cuff calcific tendonitis, also referred to as calcific tendinopathy, is a condition that is caused when calcium builds up in your rotator cuff, putting pressure on the tendon. This leads to chemical irritation as well as restricted movement. In severe cases, you can suffer from subacromial impingement because the calcium deposit hampers the range of motion of the tendon and causes problems when you try to lift your arms overhead.

Causes

Calcific tendinopathy is most common in people with diabetes and people who are between the ages of 30 and 60. The condition includes several stages. During the precalcification stage, many people do not notice any adverse symptoms.

Symptoms

You can experience a high level of shoulder pain making it a struggle to move the shoulder through your full range of motion, hindering your day-to-day life.

Diagnosis

The calcific stage is the most painful; however, the calcium deposits are easy to see on an X-ray, so it is fairly easy to diagnose the condition. Over time, the calcium deposits should spontaneously break down, which is a sign you are entering the postcalcific stage, and pain should begin to subside.

Management

Physiotherapy is rarely used to treat calcific tendonitis specifically, but it can help to reduce some of the stiffness associated with the condition. Instead, people are advised to rest, ice their tendon, use medication and perform gentle mobility exercises. In the rarest of cases, surgical intervention may be recommended; however, because the condition is self-limiting, the shoulder pain usually resolves itself within a month or two.

Surgery may be required if other treatments do not show results, or if the pain associated with the condition becomes so severe that it interferes with day-to-day activities, such as dressing and combing your hair. In those cases, a surgeon may choose to excise the calcium deposit through a small incision into the shoulder or by using shoulder arthroscopy. There is some risk of infection with any form of invasive surgery, and physiotherapy will be required to restore mobility and strength to the affected shoulder.

One option that is becoming increasingly popular as a treatment for chronic calcific tendonitis is shockwave therapy. This helps to break down the deposits through a series of microtraumas and stimulates blood flow to the affected joint so that the calcium deposits can be properly broken down.

A good shoulder support will reduce the amount of shoulder pain that you feel, but it will not treat the cause of the shoulder pain itself. If you find that your condition does not improve after a few weeks, talk to your doctor.

Rotator Cuff Injuries

A rotator cuff injury is either a tear to or inflammation of the muscles and tendons in your shoulder.

It commonly causes shoulder pain and occurs when the small muscles around the shoulder joint become inflamed. These muscles work together to stabilise the ball in the shoulder joint. Many sufferers find that wearing a shoulder support helps them to cope with this injury, giving the sufferer increased confidence.

There are four rotator cuff muscles that you can injure:

  • Supraspinatus
  • Subscapularis
  • Infraspinatus
  • Teres minor

Supraspinatus is the most commonly damaged, with suffers typically experiencing supraspinatus tendonitis. However, your doctor is unlikely to treat one muscle in isolation but will look at all four.

Causes

The rotator cuff muscles can become inflamed, resulting in tendonitis. If the inflammation continues, small partial tears can form that may become complete tears that go all the way through one or more of the muscles.

Shoulder tendonitis or inflammation usually begins in one of three ways:

  1. If you repeatedly reach above your head, perhaps reaching high shelves, or throwing a ball through a basket, the rotator cuff can become squashed against the arc of bones and ligaments known as the coracoacromial arch that stretches over it. This is known as primary impingement. Osteoarthritis can reduce the space between the arch and the rotator cuff that will also cause inflammation.
  2. Some people find that their shoulders are lax, resulting in instability of the shoulder joint. This can be caused by an injury or have been present since birth. It may also be caused by stretching above the head repeatedly. As a result, the rotator cuff will have to work hard to stabilise the ball joint in the shoulder and with time will become increasingly less able to prevent the ball joint from rubbing against the coracoacromial arch. This is known as secondary impingement.
  3. When we throw balls hard in tennis, cricket or other sports, the rotator cuff can become inflamed. Over time, this may result in tissue breakdown. 

Symptoms

Shoulder pain, loss of full movement and weakness are typical symptoms. In the early stages of inflammation to the muscles, shoulder pain may only be felt when you reach over your head. However, if one of the rotator muscles is torn, the pain may be severe enough to stop you sleeping at night.

Diagnosis

An MRI or ultrasound scan can be used to determine if any of the rotator cuff muscles are torn. A doctor will also look for signs of instability in the shoulder.

Management

If the pain is bearable, your doctor may recommend exercises to build strength in the muscles and ice packs to reduce the inflammation. Corticosteroid injections may also be offered. Surgery may be used if the rotator cuff muscles are badly torn. A small amount of bone may be shaved away to create more space around the shoulder joint so that the rotator cuff can move more freely.

Tears are likely to be repaired surgically, but physiotherapy is also effective when the muscles are only inflamed and there is no tear. Anti-inflammatory gel can reduce shoulder pain, while wearing a shoulder brace can provide support and reassurance.

For more information on rotator cuff injuries, visit the BUPA website.

Shoulder Bursitis

Sometimes known as shoulder impingement syndrome, shoulder bursitis is an inflammation of the subacromial bursa - a sac of fluid designed to prevent friction in your shoulder joint.

Repeated shoulder movements can result in this sac becoming squashed, inflamed or irritated, resulting in varying degrees of shoulder pain. A good shoulder support can help to relieve this.

Causes

There are two levels of shoulder or subacromial bursitis - primary and secondary. In primary cases, the space holding the sac could be very small, resulting in undue pressure, particularly with repeated overhead movements used in basketball or shelf stacking, for example.

Secondary cases are also caused by the same kind of repeated overhead activity, but are found in those with shoulder instability. This means the rotator cuff becomes very weak and cannot stop your upper arm from squashing your subacromial bursa.

The condition usually appears gradually from these types of movements, but can appear suddenly after a fall, or in those who suddenly use their shoulders when they aren't used to it (so decorating or playing a new sport, for example).

Symptoms

The symptoms of the condition are shoulder pain and a reduced range of motion. You might find it is too painful to do things like washing your hair or reaching for a high cupboard, and you may also notice some shoulder pain in the morning if you have slept on the affected side.

Diagnosis

Your GP will refer you for an X-ray and MRI scan that will determine the extent of your shoulder injury and if you do have subacromial bursa.

Management

If it is caught early enough then you will be able to manage the symptoms using physiotherapy and ice treatment. Try to apply ice wrapped in a cloth or towel to your affected shoulder for 20 minute periods, every few hours. This can help to reduce any inflammation and swelling. Your physiotherapist can then give you a series of exercises to help restore the full range of movement in your arm. If your condition has progressed, you may need a corticosteroid injection, which can slow inflammation.

One of the best ways to prevent recurrence of a subacromial bursa is to continue to do your shoulder stability exercises, focusing on keeping your range of motion full and active, helping your shoulder to withstand more strenuous activities and sports.

As with any type of shoulder pain, the key is to strengthen and support your joint as much as possible to prevent the onset or return of the injury. You could try using a shoulder support during sports or household activities to help keep your joints strong and supported.

Shoulder Separation

Shoulder separation is a common sporting injury, resulting in damage of the ligaments in the acromioclavicular (AC) joint. The condition causes acute pain.

  • Type 1: A mild ligament sprain.
  • Type 2: Where greater force has been applied, the AC joint may separate slightly but remains intact.
  • Type 3: This is the most severe, where the joint dislocates and the ligaments rupture, causing the collar bone to move around.

Causes

Injury can occur as a result of a fall or a collision where the tip of the shoulder is exposed to additional force. On impact, the ligaments are stretched in the opposite direction to the collar bone and the shoulder blade is forced downwards. This causes the shoulder blade and the collar bone to separate. There will be immediate shoulder pain and a shoulder support will be required.

Symptoms

The collar bone will be painful, especially on movement. A type 3 separated shoulder may result in a lump where the collar bone has dislocated and moved upwards.

Diagnosis

Diagnosis can be confirmed with an X-ray to determine the extent of separation that has occurred.

Management

In the first few days following an AC joint sprain, medication may be required to relieve shoulder pain. Non-steroidal anti-inflammatory drugs (NSAIDs) are usually recommended to reduce inflammation and minimise discomfort.

Applying wrapped ice to the area can also help with pain and reduce bruising and swelling. Never place ice directly on to the skin. The ice pack can be used for about twenty minutes and repeated every two to three hours.

It can be beneficial to tape the collar bone to push it downwards and back into a more natural position. Tape should be applied only by a chartered physiotherapist. Placing the shoulder in a support brace will ensure the joint can be rested. When wearing a shoulder sling, exercises to maintain the movement of the fingers, wrist and elbow should be carried out about once every four hours. If shoulder pain is minimal, a resistance band can be used for strengthening exercises.

Symptoms of type 1 injuries typically take seven to 10 days to subside. Some gentle exercises can be initiated to gradually increase the range of movement. Patients should wait until there is full movement without pain before undertaking any heavy lifting.

A type 2 injury will take longer to heal. The shoulder support may be required for approximately two weeks. After the first week, it is important to remove the sling and complete some simple exercises to increase the range of movement in the shoulder. These should be performed within the limits of any pain. Contact sports and heavy lifting are best avoided for six weeks while the injury heals. A shoulder sling can be worn to prevent a relapse.

A type 3 injury may require surgery and recovery time is significantly longer.

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