Shoulder pain: possible causes and remedies

Most people tend to refer to the shoulder in general and complain of “shoulder pain”; in reality, the shoulder is a complex joint, one of the most complex in the human body, which by its very nature is frequently exposed to the risk of injury and general aches and pains.

The joints makin

g up the shoulder combine with tendons and muscles that enable us to perform a wide range of arm movements, from the simple gesture of scratching our back, to throwing a ball in certain sports. For this reason, what is commonly perceived as shoulder pain may affect those who regularly practise sports but also the less sporty of us.

It is estimated that shoulder pain represents 16% off all pain complaints related to the musculo-skeletal apparatus, peaking among those aged 45 to 65 . Often a simple dysfunction can compromise this delicate balance, such as a muscle that is too stiff or too weak, or stiffness in the joints making up the shoulder.

Anatomy notes: how the shoulder is built

The shoulder is a complex joint formed by the union of four bones: the humerus, the scapula, the clavicle (collarbone) and the sternum. These four bones form 4 joints between them:

• The glenohumeral joint  (between the humerus and the scapula),
• the acromioclavicular joint (between the scapula and the clavicle),
• the sternoclavicular joint (between the sternum and clavicle),
• the scapulothoracic joint (posterior between the scapular and the thoracic cage).

All these joints (except the scapulothoracic joint) are supported and reinforced by the so-called passive stabilisers, i.e. ligament complexes.

Often a simple dysfunction can compromise this delicate balance, such as a muscle that is too stiff or too weak, or stiffness in the joints making up the joint.

The stability of the Glenohumeral joint, the mainstay of the joints, is further strengthened by a muscle complex of vital importance, known as the Rotator Cuff. Often the key culprit of shoulder pain, due to tendinopathies, inflammation and injuries, the Rotator Cuff is made up of four muscles: the Supraspinatus, the Infraspinatus, the Sub-scapular, and the Teres Minor. These muscles constitute the main dynamic stabiliser of the shoulder, keeping the head of the humerus in the glenoid cavity and enabling rotations of the arm segment.

The other muscles that move the shoulder or contribute to its movement are: the Trapezius, the Deltoid, the Levator scapulae, the Rhomboids, the Pectoralis minor and the Pectoralis major, the Serratus Anterior, the Latissimus dorsi, the Teres Major, the Bicep and the Brachial Tricep.

In addition to these joints, some authors also include the Acromio–humeral interval, considered the sliding surface holding a number of structures, such as the tendon of the Supraspinatus muscle, the long head of the Brachial Bicep and the Subacromial Bursa.

Causes of shoulder pain

Given the complexity of the shoulder joints and muscles, the causes of pain in the shoulder can vary greatly:

• Rotator Cuff disorders (tendinopathy, calcification, muscular injuries, vascular disease, overload, muscle weakness, etc.)
• Sub-Acromial Impingement
• Inflammation of the long head of the Brachial Bicep
• Joint stiffness
• Bursitis
• Shoulder Instability
• Acromioclavicular or Glenohumeral arthritis
• Adhesive Capsulitis (Frozen Shoulder)
• Postural problems (forward shoulder posture, curved spine etc.)
• Cervical Radiculopathy

Types of shoulder pain

Both the distribution and intensity of shoulder pain can vary greatly.

In some cases the pain may be localised and intense at the front of the shoulder, such as the case of inflammation of the long head of the Brachial Bicep or a problem with the Acromioclavicular joint.

In other cases it may be felt at a deeper level and more widespread throughout the shoulder, such as the case of bursitis or the case of a dysfunction of the glenohumeral joint.

Other times pain may present when a patient tries to lift the arm above the height of the shoulder (Sub-Acromial Impingement), or the pain may spread from the neck to the arm (Cervical Radiculopathy).

Therefore, a diagnosis of the shoulder by an Orthopaedic specialist and an examination by the Physiotherapist are essential to understand the underlying cause and plan targeted treatment.

Remedies and Treatment

Treatment involving surgical intervention is reserved for patients with serious injuries to the muscles making up the Rotator Cuff or when conservative treatment has failed.

In all other cases, Physiotherapy is the most recommended treatment.

Treatment varies depending on the cause of shoulder pain, and to identify the best approach, the specialist may need to carry out some instrumental tests, such as X-rays, ultrasound or MRI.

The physiotherapy that follows diagnosis involves various methods, the most important of which are:

–             Instrumental Therapy (TECAR, LASER, shock wave) to reduce inflammation, muscle contracture, and to stimulate tissue regeneration.

–             Manual Therapy, aimed at recovering the range of movement and passively mobilising stiff joints

–             Therapeutic exercise, to restore strength, resistance, proprioception and muscle-tendon flexibility.

As regards therapeutic exercise, a fundamental area to focus on is the exercises for the Rotator Cuff muscle group. These are specific exercises to strengthen the inner and outer rotator muscles of the shoulder, and they move progressively from isometric exercises (contraction without moving the ends of joints) to exercises with resistance bands and then on to weights.

Conclusions

In the case of shoulder pain, identifying the cause of pain is fundamental. Thanks to clinical examinations and instrumental tests, the specialist will then decide on the ideal rehabilitation plan in collaboration with the physiotherapist. Rehabilitation must be strictly personalised, taking into account the various clinical features of the individual patient, and should be planned over a medium to –long term (even 3-4 months).

The therapeutic exercise must be started as soon as possible both when adopting a conservative approach and in the post-operative period, in order to achieve the best result and avoid secondary damage caused by immobilisation.

To ensure successful treatment, the physiotherapist must use a wide range of specific isometric, isotonic, proprioceptive techniques, with eccentric/concentric methods, aimed at getting the shoulder to work through 360° both from the point of view of the joints and the muscles.