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Rotator Cuff Injury by Evan Yang (Physiotherapist)

Overview of the shoulder

The shoulder is the most mobile joint in our body. Whilst this beneficially allows for multidirectional use, it also means that the shoulder is the least stable of all joints in the human body. Due to the lax nature of the shoulder joint, it becomes more reliant on the surrounding structures to provide stability, namely the muscles, ligaments and tendons.

 

The Rotator Cuff Muscles

There are four rotator cuff muscles that surround the shoulder joint. The primary purpose of these muscles is to stabilise the shoulder, keeping the ball of your humerus in the shoulder socket. Each muscle of the rotator cuff contributes largely to the multidimensional movement of the shoulder.

The supraspinatus, infraspinatus and teres minor muscles all attach to the back of your shoulder.  This is where they are involved in outwards rotational movements and moving the arm away from the body. The subscapularis muscle is the largest of the four rotator cuff muscles. It attaches to the front of the shoulder blade and is important for inwards rotational movements.

There is a lot of evidence that highlights how dysfunction of the rotator cuff can result in reduced ability to use shoulder in functional tasks.  This includes shoulder pain and impaired quality of life. If you do end up with shoulder pain or reduced shoulder movements, it is important to get this assessed by a Physiotherapist.  They are the best person to determine the type of injury and the best treatment plan.

 

What is a Rotator Cuff Tear?

rotator cuff repair

One of the most frequent injuries that occur in the shoulder is a rotator cuff tear. It is important to determine whether the tear is partial or a full-thickness tear. Symptoms that can identify a rotator cuff tear include shoulder pain, difficulty using the arm for functional tasks, reduced strength in the shoulder, increased stiffness in the shoulder, pain that worsens at night, or an audible sound when moving the arm that sounds like cracking or popping. It is important to recognise that pain is not always present. A study conducted by Itor (2013) highlighted how only one-third of individuals have pain with a rotator cuff tear.

The size of the rotator cuff tear is important to consider when determining whether to have surgery on your shoulder or not. Partial and even full-thickness tears are often

managed conservatively. Intrinsic and extrinsic factors such as the patient’s age, their medical history and their current shoulder pain, movement and strength are all important to consider when calculating the best treatment approach (Edwards et al., 2016).

 

Treatment:

 

Surgical Management:

Some rotator cuff injuries are most suitable for surgical management. There are three surgical techniques that are most common.

Open Rotator Cuff Repair:

This technique is the most invasive.  It involves a large incision (usually several centimetres long) conducted to separate and reattach a larger shoulder muscle (the deltoid) to repair the tear. This surgical approach is primarily used for individuals who have complicated rotator cuff injuries.

Arthroscopic Rotator Cuff Repair

This technique is the least invasive of the three procedures. They are generally conducted on individuals with smaller tears (equal or less than 3 centimetres).  People who undergo arthroscopic surgery generally have lessrotator cuff pain and a shorter recovery time period.

Mini-Open Rotator Cuff Repair

This is a newer surgical technique that involves an keyhole (arthroscopic) incision to evaluate the rotator cuff tear and remove loose cartilage. A further incision (around 4 to 6 centimetres) is then conducted to repair the injury.

In nearly all cases, all three surgical approaches require a period of time in a sling. The open rotator cuff repair often requires individuals to have their shoulder immobile in a sling for more than a month. Whilst unlikely, some surgical cases can take up to 2 years to properly rehabilitate. Thus it is crucial to see a physiotherapist as soon as appropriate to prevent stiffness, regain movement, improve strength, improve quality of life and recover movement automatism.

 

Conservative Treatment:

 Most rotator cuff injuries are recommended to undergo conservative treatment. Physiotherapy will be aimed at increasing strength and movement of the shoulder,  improving the quality of life and reducing pain. Physiotherapy will also be involved in realigning the shoulder structures and recovering movement automatism. A physiotherapist will involve a combination of manual therapy techniques and exercise to maximise these outcomes.

Other forms of conservative management include rest, thermotherapy (use of heat or cold) and NSAIDs (non-steroidal anti-inflammatory drugs). Corticosteroid injections are also a common practice, however  caution  should be taken if you are considering this management route.

Recent studies have highlighted how conservative treatment has a high likelihood of improving functional use and reducing pain.  It is important to have your shoulder assessed by a physiotherapist and orthopaedic surgeon before deciding on taking the surgical route.

If you have had recent shoulder pain or a recent shoulder operation make an appointment below at one of our clinics at Total Physiocare Heidelberg, Reservoir, Footscray and Kew.

 

 

Book an appointment today for your assessment!

Blog by Evan Yang (Physiotherapist)

Shoulder Impingement

What is shoulder impingement? – Blog By Ryan Harris

Shoulder impingement is not a specific condition, rather more of a symptom of possible shoulder injuries. It can be a symptom in a rotator cuff injury, labral injury, shoulder instability, biceps tendinopathy, improper scapula control and bone spurs.
Impingement is the term used to describe the compression of the rotator cuff tendons and the bursa in the subacromial space. Consequently, with repetitive compression, the rotator cuff tendons can become irritated and inflamed which cause them to thicken. This thickening can cause further problems as it decreases the room in the subacromial space further.

 

Causes

In a normal shoulder, the rotator cuff muscles work together to centre the humeral head in the glenoid during movement.

There are two main types of impingement:

  • Primary impingement (structural)

Primary impingement occurs as a result of structural changed in the shoulder joint causing the subacromial space to be smaller. The presence of a hooked arcomion is one example of a possible structural change. The subacromial space is now smaller and as a result, the risk of irritating and compressing the underlying tissues increases.

  • Secondary impingement (movement).

Secondary impingement occurs as a result of a dysfunction within the normal shoulder mechanics during movement. As a result, it is common in patients who have repetitive overhead movements, acute trauma and/or poor posture. Identifying the underlying cause of the impingement is important for treatment.

Symptoms

Common symptoms of shoulder impingement include:

  • Anterior and/or lateral shoulder pain with overhead activity,
  • A painful arc of shoulder pain that starts just before your arm reaches shoulder height,
  • Reaching behind the back.Impingement Shoulder Syndrome

Treatment

After a thorough assessment from your physiotherapist to determine the underlying cause of your impingement, a structured treatment plan will be developed focusing on:

  • Early stage pain relief and protection,
  • Restoring the full range of motion of the shoulder,
  • Scapular Control,
  • Rotation Cuff Strengthening,
  • Thoracic Mobility and Manual Therapies,
  • Maintenance of other joints. E.g. Neck,
  • End stage: Returning to sport specific activities.

Subacromial Decompression

After a period of conservative treatment, surgery may be appropriate.

A subacromial decompression is routinely used to increase the subacromial space which allows the underlying tissues to move through without restriction. The release of ligaments and the shaving of bone spurs is how this is accomplished.

After a subacromial decompression it is necessary to continue to see a physiotherapist to regain function of the shoulder and for prevention of other conditions.

 

At Total Physiocare, we have a wealth of experience in sporting injuries and management.

Book an appointment today for your assessment!

Blog by Ryan Harris (Physiotherapist)

Shoulder Dislocation & Stabilisation

The shoulder joint (also known as the glenohumeral joint) is the most commonly dislocated joint in the human body. This joint is the most mobile joint in the body with an extended range of motion which allows the arm to move in many different directions. Shoulder dislocation occurs when the head of the upper arm (humerus) is forced completely out of its socket (glenoid labrum). The humerus needs to be relocated as soon as possible in order to achieve the best possible outcome in the future. The most common form of dislocation is anterior dislocation where the humerus is forced forwards out of the joint. This injury is commonly seen in young adult men who have sustained high energy injuries to the shoulder joint. Most commonly these injuries occur in contact sports including basketball, football and wrestling.

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Management after a dislocation differs and is dependent on a range of factors including age and participation in sports. People under the age of 20 are 68% more likely to experience a future dislocations and therefore this needs to be taken into consideration when determining the appropriate course of treatment.

Best current evidence demonstrates that immobilisation of the injured shoulder in a sling after relocation for 2-6 weeks combined with physiotherapy is the best course of treatment following a first time dislocation. Physiotherapy treatment can be commenced immediately after the injury and involves:

  • Postural retraining
  • Strengthening of the shoulder muscles
  • Range of motion exercises (reducing stiffness)
  • Taping
  • Facilitating return to sport/ function

Surgery is an option and recommended only in cases where the ligaments or bones within the shoulder joint are damaged. Common associated injuries within the shoulder include:

  • Bankart lesions: a tear in the ligaments in the front of the shouldershd2
  • Bony Bankart lesions: fracture of the front of the shoulder socket
  • Hill Sach’s lesion: fracture of the top of the humerus (arm bone)

Surgery can also be performed for patients who experience recurrent dislocations. In these cases surgeons will perform key hole surgery to tighten the ligaments in the shoulder in the aim of increasing the stability of the shoulder.

  • Capsular plication: tightening of the capsule to bring the humerus closer to the socket
  • Capsular shift: tightening of the capsule
  • Bankart lesion repair: repair of the torn ligaments in the front of the shoulder joint
  • Hill Sach’s lesion repair: fracture in the humerus is filled in with ligaments, bone or metal implants

There are different post-operative protocols after the above surgeries and all involve intensive physiotherapy management following the procedures. At Total Physiocare we can assist you in your recovery and rehabilitation following shoulder dislocation and these associated surgeries.

Post compiled by Alice Smith.

What is a frozen shoulder “Adhesive Capsulitis” ? and how to manage it?

Painful Shoulder? Frozen Shoulder?

What is adhesive capsulitis?

Adhesive capsulitis, colloquially referred to as frozen shoulder, is a debilitating and painful condition that affects the shoulder joint and can contribute to significant disability.

shoulder

It is often prevalent in adults (40 – 60 years old) and is more common in women.

As the name frozen shoulder implies, this condition is principally characterised by partial or complete stiffness of the glenohumeral (shoulder) joint. Such capsular stiffness limits both the passive and active movements of the shoulder. In the early stages of the condition, significant shoulder pain often accompanies the joint stiffness.

Classification:

There are two forms of adhesive capsulitis; primary and secondary:

  1. Primary – the cause of the shoulder stiffness and pain is unknown, and may occur spontaneously
  2. Secondary – the condition is associated to precipitating factors affecting the shoulder such as prior injury or trauma, shoulder surgery, disuse or prolonged immobilisation.

shoulder anatomy

Frozen shoulder is also increasingly prevalent in those with diabetes, thyroid diseases, high cholesterol or heart disease.

With adhesive capsulitis, the shoulder joint capsule and surrounding ligaments become inflamed, thickened, scarred and stiff. These factors reduce the normal elasticity of the joint which contribute to the pain and restricted mobility.

Recovery:

The condition is discussed in three phases:

  • Acute (Freezing) stage – characterised by pain restricted mobility
  • Chronic (Frozen) stage – characterised by rigid shoulder with limited mobility with pain at the end of the available movement
  • Recovery (Thawing) stage – characterised as pain eases and shoulder range of motion begin to improve

The recovery of adhesive capsulitis can be tiresome process, often resolving between one to two years.

Treatment and Physiotherapy:

Physiotherapy can be beneficial in treating adhesive capsulitis to facilitate and restore shoulder joint range and prescribe a functional and task specific rehabilitation plan. Physiotherapy advice surrounding the condition and pain management strategies is also advised throughout the progression of the condition.

Image result for treatment of frozen shoulder

Other strategies may include capsular release surgery, joint manipulation under anaesthetic, corticosteroid injection, or hydrodilation procedure however results are highly variable and should be discussed and advised by your physiotherapist. Of note, 60-80% of patients respond favourably to conservative management.

At Total Physiocare we are treat hundreds of shoulder conditions and many post-surgical shoulders to prevent the onset of frozen shoulder and restore normal shoulder movement and function.

This was compiled by our Physiotherapist Christian Bonello.