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Shoulder Pain Blog

August 15, 2016

Shoulder dislocation versus shoulder separation … are they the same?

Most people think that these two conditions are the same, but dislocations and separations of the shoulder are actually two very different injuries.

What is a shoulder dislocation?

A dislocation involves the ball-and-socket joint of the shoulder. It occurs when the ball portion of the joint (the top of the humerus/upper arm bone) leaves the socket of the shoulder blade. The structure of the shoulder joint allows for great mobility, but it also makes it unstable, which is why it is the most frequently dislocated joint in the body. The humerus can slide too far forward (anterior dislocation), downward (inferior dislocation), or backward (posterior dislocation). Most commonly, dislocations will occur anteriorly. Sometimes the humerus will return to the socket on its own (this is called self-reduction), but if it doesn’t, you will have to go to the hospital to get it reduced. It is important that it is reduced by a doctor and not on your own, by a coach, or parent because there are a lot of important structures that surround the area which could become damaged if it’s not reduced properly.

What is a shoulder separation?

A shoulder separation involves the joint between the highest point of your shoulder blade (called the acromion) and your collar bone (clavicle). This joint is called the acromioclavicular joint (AC joint) and sits over top of the ball-and-socket joint. With a shoulder separation, the clavicle is pulled away from the acromion, and this can result in sprains, or even tears, of the ligaments surrounding the joint. Depending on which ligaments are affected, the separation can be graded on a scale of 1-3.

What causes a dislocation or a separation

Both injuries typically result from a trauma to the shoulder joint. They most often occur in teenagers and young adults (typically in their 20’s) who participate in sports or other physical activities that put them at risk of injury. Sports that involve forceful contact (e.g. hockey, football) or have the risk of high impact falls (e.g. skiing, gymnastics) most often result in these injuries.

A shoulder dislocation usually occurs when the arm is forcefully pulled or when the arm is out to the side and is jarred (such as during a trip and fall). or when the arm is out to the side and meets extreme resistance (i.e. a trip and fall). Less commonly, it could occur as a result of a car accident, following stroke (due to paralysis of muscles), or even an epileptic seizure.

A shoulder separation most commonly occurs as a result of a fall directly on the AC joint or a blow directly to the AC joint (e.g. being body checked into the boards in hockey).

What are the signs and symptoms of a dislocation or separation?

 

Dislocation:

  • Feel a shift or “clunk” at the time of the injury
  • Intense pain
  • Unable to move the joint
  • Visible deformity/the joint looks out of place (may have a bump in the front of the joint or the back of the joint, depending on which way it has dislocated)
  • Swelling/bruising
  • Numbness/tingling
  • Muscle spasm

 

Separation:

  • Intense pain
  • Tenderness of the collar bone
  • Swelling/bruising
  • Visible deformity (there is a bump or the collarbone appears shifted upwards)

 

How are they diagnosed?

Both will show up on an x-ray. Oftentimes, an x-ray for a shoulder separation will involve you holding a weight in the arm to try and pull the AC joint apart for more clear imaging.

As physiotherapists, we do have some tests that we can perform in clinic to help us try to diagnose either condition, but ultimately an x-ray will help confirm the diagnosis of either one of these injuries.

What should I do for treatment?

There is typically an initial period of immobilization immediately following the injury. Dislocations could result in wearing a sling for 4-6 weeks, and separations could mean wearing a sling for 1-2 weeks, or not at all (depending on the severity).

Research shows that the first line of treatment for either condition should be conservative therapy/physiotherapy. In both cases, it is recommended that the physiotherapy begin immediately following the injury.

Dislocations

Physiotherapy

The initial goals of treatment will be pain control and education with respect to promoting the ideal healing environment. Progressive exercises are given to gradually increase range of motion without stressing the area of the shoulder joint that has been compromised in the dislocation. The next phase of exercise focuses on strengthening and proprioception of the shoulder joint, and this is the most important when it comes to preventing future dislocations.

Specific strengthening exercises for the rotator cuff and surrounding musculature will be provided, and will be done in a safe progressive order, avoiding positions that stress the vulnerable area of the shoulder.

Proprioception is your awareness of where your body is in space, and what movements it is performing. Specific exercises help to awaken this sense and fires up the nerves from your shoulder to your brain. Physiotherapy will help your brain re-learn where your shoulder is in space, help it remember how to move, and how to respond to movement. These are unique exercises which can also help to predict those at risk for recurrent dislocations.

Surgery

With some first-time dislocations, surgery may be considered as a first line of treatment. Typically most surgeons will want to see how the shoulder responds to conservative therapy before doing surgery. Surgery is more commonly an option for those who suffer from repeated dislocations. While every surgeon can have a slightly different approach, rehabilitation is intensive after this type of surgery. The use of sling for a full 6 weeks, and then gradual range of motion and strengthening is typical. Return to moderate level of activities takes approximately 3-4 months, and return to sport can take longer.

Separations

Physiotherapy

In most cases, the collar bone will be left to “settle” on its own through the use of a sling. It is quite rare to see surgery for a shoulder separation. As a result, most people are left with a lifetime “bump” above the shoulder joint. We can usually tell in your 40’s who played hockey in their 20’s. Separated shoulders plague hockey players because of the impact of falling onto the ice or being checked into the boards with the force through their shoulders.

After a brief period in a sling (which may not be required based on severity of injury), patients will receive conservative treatment/physiotherapy to address pain and gradually restore range of motion while allowing healing of the ligaments of the AC joint. Pain is often the limiting factor, and even with a low grade separation (Grade 1), the pain can be quite intense. People often cannot lift their arm to shoulder height for 1-2 weeks after this type of injury.

Commonly physiotherapy can progress clients through range of motion and early strengthening within the first 4-6 weeks. Advanced strengthening and return to sport takes another 2-4 weeks. Many hockey players, with the assistance of tape for support, are able to return to play at 5-6 weeks following a separation, depending on the severity.

Surgery

Surgery is not common for separations in the shoulder. In more severe cases they may consider surgery, in particular if there are any concerns that the collar bone could move and compromise the nearby lung.

What does physiotherapy have in common for both?

1. Initial education on important healing factors, positions, pain control and activities to avoid
2. Progressive but controlled range of motion exercise programs that protect the area while it heals
3. Progressive strengthening to strengthen surrounding musculature to prevent reoccurrences
4. Advanced exercises that are sport specific (throwing, swimming, overhead sports), to minimize future reoccurrences
Give one of our clinics a call today if you have been diagnosed with, or suspect that you have, a shoulder dislocation or separation.

 


I Have a Frozen Shoulder? But Spring Just Started!

Despite its name, frozen shoulder actually has nothing to do with being cold. It does, however, mean that your shoulder mobility becomes very limited, much like if it were frozen in place. The medical term for frozen shoulder is “adhesive capsulitis”.

Our shoulders are ‘ball and socket’ joints which are surrounded by a structure called a joint capsule. This capsule is like “Saran-Wrap” that holds the fluid in the joint and can help to stabilize the shoulder. With frozen shoulder, this capsule becomes inflamed (“capsulitis”), shrinks, and becomes stuck to the shoulder joint itself. As a result, this can severely limit the range of motion of the shoulder.

 

illustration of the shoulder joint

(image taken from: https://orthoinfo.aaos.org/en/diseases–conditions/frozen-shoulder)

The progression of frozen shoulder can be broken down into three stages:

⦁ Freezing Stage

This is the initial stage of the condition and when most people start to notice changes and seek treatment. It is often characterized by intense pain with movement, especially fast movements, but only mild restrictions in range of motion.

⦁ Frozen Stage

It is in this middle stage where you will see the most restriction in your shoulder range of motion. The pain does not worsen, and may even decrease slightly, but the shoulder will feel very stiff and be difficult to move.

⦁ Thawing Stage

This is the final stage of the condition. The pain in the shoulder lessens and the range of motion will gradually begin to improve.

What caused my frozen shoulder?

Frozen shoulder usually occurs one of two ways: 1) insidiously (for no known reason); or 2) as a progression of another injury.

⦁ Insidious Onset

There is limited research and understanding as to why frozen shoulder occurs. One theory currently being investigated is that it may be related to changing hormone levels as we reach middle age. This can affect both sexes, but it does tend to be more common in women (up to 70% of people with frozen shoulder are female).

Another theory states that it can be more likely to develop in individuals with certain diseases. These can include:

⦁ Diabetes (10-20% of people with diabetes develop frozen shoulder)
⦁ Hyper- or hypothyroidism
⦁ Cardiovascular disease
⦁ Tuberculosis
⦁ Parkinson’s disease.

⦁ Progression of Another Injury

A more common cause of frozen shoulder is immobility of the joint that can result from another injury. A lot of times when we have shoulder pain or an injury, we tend to stop using it and restrict its movement to avoid causing further pain. While rest is often required to help with healing, prolonged immobilization can increase the risk of developing frozen shoulder. This prolonged immobility may be a result of:

⦁ Rotator cuff injury
⦁ Broken arm
⦁ Stroke
⦁ Surgical recovery

It’s important that you see a physiotherapist when you start to experience shoulder pain. Your physiotherapist can provide you with some gentle exercises that will help to maintain your mobility, while minimizing pain, thus reducing the risk of frozen shoulder.

Can my frozen shoulder be treated?

If you do nothing to treat it, a frozen shoulder can recover on its own, but this process can take 2-5 years. There are, however, other treatment options that can reduce pain and help shorten this recovery time.

X-ray or Ultrasound Guided Cortisone Injections

If it’s caught at the right time, a series of cortisone injections into the joint space within the capsule can help to decrease the inflammation and stretch out the capsule in order to decrease pain and help increase range of motion. This should be completed by an Interventional Radiologist who will use either an x-ray or ultrasound imaging machine to help make sure that the injection goes into the right spot. It is often encouraged that these injections are followed by physiotherapy treatment so that the therapist can perform manual techniques to further stretch the joint and provide appropriate exercises to maintain the increase in mobility.

Physiotherapy

The physiotherapists at EPA can provide certain modalities to help with controlling pain. These may include:

⦁ Acupuncture
⦁ Intramuscular stimulation (IMS)/dry needling
⦁ Therapeutic ultrasound
⦁ Interferential current (IFC) or TENS

Your physiotherapist can also provide specific manual therapy techniques and individualized exercises to help improve your mobility and speed up your recovery time.

If you suspect that you have a frozen shoulder, give one of our clinics a call and book an appointment with one of our many qualified therapists.

You can also visit http://myshoulderpain.ca/ for more information about shoulder treatment options.

 


What does it mean when I’m told that I have shoulder impingement syndrome?

 

Shoulder impingement syndrome is a term used to describe what happens when certain structures within the shoulder joint become intermittently jammed or compressed during movement. The structures most often involved include the subacromial bursa and/or the rotator cuff tendons.

The ball and socket joint of the shoulder sits beneath another joint called your acromioclavicular joint (AC joint). The space between the two is referred to as the ‘subacromial’ space. It is within this space that the impingement of the bursa and tendons can occur, thus resulting in pain.

 

diagram of ball and socket joint

(image taken from: https://www.howtorelief.com/shoulder-impingement-syndrome-symptoms-causes-diagnosis-treatment/)

With normal shoulder function, the subacromial space should remain large enough throughout movement that impingement does not occur. However, for some of us, this is not the case. Most often, affected individuals will experience pain when they reach overhead, behind their back, or across their body. It is with these movements that impingement is most likely to occur. Over time, if these mechanical issues are not addressed, then it can lead to other conditions such as bursitis or tendonitis of the rotator cuff.

 

What is causing my shoulder impingement?

 

Shoulder impingement can be divided into two main categories:

  • Primary (Structural) Impingement

This type of impingement is a result of structural differences in the shoulder joint. Not all joints are created equally, and as a result, some of us will just naturally have a narrower subacromial space than others. This could be caused by a decreased angle of the AC joint, or osteoarthritis which could result in the growth of bony spurs in the subacromial space. As a result of these structural changes, the bursa and rotator cuff tendons will be more susceptible to being trapped within the space during day-to-day movements.

 

  • Secondary (Dynamic) Impingement

This type of impingement is usually a result of poor posture, joint hypermobility/instability, and/or trauma that results in muscular weakness. These issues can all result in the shoulder blade not sitting in its proper orientation, or the ball not sitting properly centred in the socket. This can ultimately result in narrowing of the subacromial space as you move through range because your body lacks the control to help stabilize the joint.

 

What are some symptoms of shoulder impingement?

 

Common symptoms include (but are not limited to):

  • Pain in the shoulder that occurs when working at shoulder height, overhead, or when reaching behind your back (e.g. reaching into a cupboard, pulling on a pair of pants, tucking in your shirt, reaching into the back seat of the car)
  • Pain can radiate as far down the arm as the elbow
  • Pain while sleeping on that side
  • Pain or weakness with lifting, pushing, and pulling
  • Pain reaching across the body (e.g. reaching for a seatbelt)

 

How is shoulder impingement diagnosed?

 

At Eramosa Physiotherapy Associates, our staff is well trained in the assessment of shoulder impingement syndrome. At your first appointment, your physiotherapist will run through a series of observations and tests that can help to identify the cause of your impingement. Based on your findings and your goals, you and your therapist will develop a personalized treatment plan that will help to reduce your pain and restore your function.

In some cases, your therapist or your family doctor may recommend an ultrasound of the shoulder joint. An ultrasound can be helpful in identifying shoulder impingement, as well as other conditions such as bursitis, tendonitis, and rotator cuff tears. Talk to your therapist or doctor to see if an ultrasound is appropriate for you.

 

Can my shoulder impingement be treated?

 

Physiotherapy has been shown to be very effective in the management of shoulder impingement syndrome. At Eramosa Physiotherapy Associates, we pride ourselves in being specialists in the management of shoulder injuries and consistently monitor the scientific research to keep up-to-date on methods of treating shoulder pain. Your treatment program (as designed with your therapist) may include: ultrasound, TENS, taping of the shoulder joint, manual therapy techniques to improve range of motion, and a progressive home exercise program that is tailored to your specific findings. Whether you’re an athlete, student, office worker, or manufacturing worker, we can help you!

If you suspect that you have shoulder impingement syndrome, give one of our clinics a call and book an appointment with one of our many qualified therapists.

 

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