Shoulder Pathology

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The Physio Files

November 2003 Physion Files Index
Research Update
Orthotic Prescription & Physiotherapy

New Developments

Published Date : 01:43PM 19 Sep 2007

X-Rays and ultrasound scan clear, but pain persists

There are many structures in and around the shoulder or glenohumeral joint that could cause pain.? The more common sources of pain include the supraspinatus tendon, long head of biceps, sub-acromial bursa, subscapularis tendon and bursa and the network of capsular ligaments that span out to encompass the acromio clavicular joint and coracoid process, usually affected by trauma.

Tears or chronic inflammatory degenerative lesions in these structures usually show up on ultrasound scanning, depending on the extent of the lesion and the competency of the sonographer.? However, there are several other shoulder conditions where no obvious clinical signs are detected on X-rays or ultrasound.

Impingement Syndrome

Pain may also arise from an impingement syndrome, where the structures in the sub-acromial space, mainly the sub-acromial bursa are repeatedly ?squashed? on any elevation movements of the arm.? Impingement syndrome is usually caused by biomechanical disturbances in the muscles/joints and nerves that contribute to normal shoulder function.? Patients usually present with a painful arc on abduction or hitching of their shoulder on elevation movements.? Impingement tests usually reproduce shoulder pain.

Shoulder Instability

Shoulder instability occurs when the neuromuscular and or ligamentous system around the shoulder malfunctions, causing weakness of the shoulder and pain.? This pain may be due to minor repeated subluxations as the rotator cuff muscles struggle to maintain the stability of the humeral head in the labrum, which may be congenitally shallowed.? Laxity of the glenohumeral ligaments, either due to trauma or congenital factors may also result in instability.? The patient may present with a history of repeated subluxations and have weakness on testing of the scapular stabilising muscles.? Apprehension test is usually positive.

Frozen Shoulder

Frozen shoulder or adhesive capsulitis is a condition that has a higher incidence in females over 50 and its aetiology is not fully understood.? The capsule of the glenohumeral joint gradually becomes tight and restricts shoulder range of movement and there is associated loss of function and pain.? Depending on the stage of the pathology, the patient may present with a significant restriction in shoulder range of movement and pain in the upper arm.

Cervical Referral

Cervical referral is another common cause for shoulder pain.? The C4 and C5 segments can refer pain into the glenohumeral joint related to the dermatomal distribution of their nerve roots.? This may be secondary to cervical degeneration which? causes hypomobility of associated facet joints in the neck.? Patients may present with cervical stiffness and the cervical spine should be assessed if shoulder tests are negative.

The important Rotator Cuff muscles of the shoulder

Physiotherapists are well-trained clinicians, who use a battery of diagnostic tests and pattern recognition to determine the source of pain.? Clinical reasoning skills are also important in differential diagnosis.? Treatment will usually include joint and soft tissue mobilising of the shoulder joint, cervical and thoracic spine as indicated.? Neural stretching techniques can also be effective and a strengthening program focussing on scapular stability and movement control is usually essential to regain normal function.

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