Pain Syndromes and Physiotherapy

                                                                                         

The function of the human arm is to allow placement of the hand in useful positions so the hands can perform activities where the eyes can see them. Because of the huge range of positions required the shoulder is very flexible with a large motion range, but this is at the expense of some reduced strength and greatly reduced stability. A "soft tissue joint" is often a description of the shoulder, indicating it is the tendons, muscles and ligaments which are important to the joint's function. Shoulder treatment and rehabilitation is a core physiotherapy skill.

The gleno-humeral joint is made up of the ball of the humerus and the socket of the shoulder blade which is called the glenoid surface. The top of the arm bone, the humeral head, is large and carries many of the tendon insertions for the stability and movement of the shoulder. The socket or glenoid is a relatively small and shallow socket for the large ball but is deepened slightly by a fibrocartilage rim called the glenoid labrum. Above the shoulder is the acromio-clavicular joint, a joint between the outer end of the collar bone and part of the shoulder blade, a stabilizing strut for arm movement.

The glenohumeral and scapulothoracic joints of the upper limb are acted on by large, strong, prime mover muscles as well as smaller stabilisers. The major back and hip muscles keep the shoulder stable to allow strong movements, the thoracic stabilisers keep the scapula stable so that the rotator cuff can act on a stable humeral head. The deltoid can then perform shoulder movements on the background of a solid base and allow precise placement and control of the arm for hand function to be optimal.

The rotator cuff is a group of four small muscles which originate from the scapula and insert around the ball of the humeral head, the teres minor, subscapularis, infraspinatus and supraspinatus. The cuff tendons form a sheet around the ball of the arm bone and allow forces to be exerted on the humeral head by the shoulder girdle muscles. If the rotator cuff is not functioning normally the more powerful muscles tend to make the humeral head slide upwards on the socket, interfering with normal function and making a person unable to lift their arm up above their head.

The rotator cuff degenerates with age, small tears appearing across its substance which can progress to massive tears, completely interfering with muscular function of the shoulder. Rotator cuff tears are often painful but it is not clear exactly why, as many older people have tears and do not have pain. Physiotherapists work to strengthen the rotator cuff or by exercising the main shoulder muscles without gravity resistance and gradually increasing the effort. Physios also work on rehabilitation after rotator cuff surgery for rotator cuff tears, following the detailed protocols for small, medium, large or massive rotator cuff tears.

Osteoarthritis (OA) does not commonly affect the shoulder but there is a group of patients who develop severe arthritic problems in the shoulders, whom physiotherapy can help by maintaining joint ranges and muscle power. Once conservative treatments are exhausted then total shoulder replacement (TSR) is possible, either replacing the ball and socket with new components or reversing the combination. Physiotherapy post-operative management is very important as the shoulder is a "soft tissue joint" in the sense that the strength and balance of the shoulder muscles and other tissues is vital for good outcome.

Physiotherapy treatments include the assessment and management of many different shoulder pathologies such as shoulder fractures and dislocations, sub-acromial impingement, tendinitis, abnormal patterning and hypermobility. Physio treatment for fractures and dislocations depends on the severity and type of injury and follows the physiotherapy and surgical protocols. Patient education and muscle stabilising work is used for hypermobility, while biofeedback and correct muscle activity teaching is the treatment for abnormal patterning. Impingement physio is cuff strengthening and joint mobilisation, with joint injections and surgical acromioplasty if physiotherapy is not successful.

About the author:

Jonathan Blood Smyth is a Superintendent Physiotherapist at an NHS hospital in the South-West of the UK. He specialises in orthopaedic conditions and looking after joint replacements as well as managing chronic pain. Visit the website he edits if you are looking for physiotherapists in Manchester.

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