Rotator Cuff Injury

In the rotator cuff region there are four muscles, tendons and ligaments, surrounding the shoulder which provide added stability to the shoulder joint. This structure helps to keep the bone securely placed into the socket. Injury to the rotator cuffs can cause an ache like pain in the shoulder. This may lead to a feeling of muscle weakness and inability to lift the shoulder above the head.

Rotator cuff injuries are most commonly presented in people regularly exposed to overhead movements, such as painters, carpenters and builders. Individuals who suffer from this injury can usually manage their symptoms, through sports massage and specific exercises focusing on the rotator cuff muscle region. However, if not treated correctly, further injury to the area may occur such as a complete tear, which may result in surgery.

Anatomy

The rotator cuffs are made up by four muscles, these are the supraspinatus, infraspinatus, teres minor and subscapularis. These muscles aid in keeping the upper arm and shoulder into the socket with stability. They also each allow specific movements at the shoulder joint. The group of four muscles all originate within the shoulder blade, but all insert into different portions of the upper arm bone.

Supraspinatus: This muscle originates at the supraspinous fossa; the muscle belly passes laterally over the acromion process and inserts into the greater tubercle of the humerus bone. This muscle allows the first 15 degree’s movement of abduction, after this the deltoid and trapezius muscles will then allow further motion.

Infraspinatus: The origin of the infraspinatus is the infraspinatus fossa, and the insertion is also the greater tubercle of the humerus. The motion created by this muscle is lateral rotation of the shoulder, moving the arm away from the centreline of the body.

Teres Minor: A small narrow muscle on the back of the shoulder blade which sits underneath the infraspinatus. The origin is the lateral boarder of the scapula. This muscle contributes to external rotation of the arm of the body.

Subscapularis: This rotator cuff is the strongest and largest out of the three listed above. This muscle originates at the subscapularis fossa and inserts into the lesser tubercle of the humerus. The subscapularis allows greater motion at the shoulder and mainly aids in allowing medial rotation of the arm.

Symptoms

Common symptoms of possible rotator cuff injury:

  • Dull ache
  • Difficulty lifting arm over head
  • Weakness around the shoulder
  • Disturbed sleep
  • The constant need to use self-myofascial techniques

Causes

There are a few common risk factors of why rotator injury may occur:

  1. Family History: There may be family history of rotator cuff injuries which may make certain family members more prone to having the injury than others.
  2. The type of job you do: Individuals who work in construction or manual labour who have repetitive overhead movement of the shoulder could damage the rotator cuff overtime.
  3. Age: As you get older joints and muscles become weaker, meaning you may be more prone to injury overtime.

Diagnosis

To diagnose a rotator cuff injury a physical examination will be carried out by a doctor or a physiotherapist. Firstly, they may ask about your day-to-day activities which may determine the seriousness of the injury. The doctor will test the range of movement at the shoulder by getting you to perform movements such as flexion, extension, abduction, adduction and medial and lateral rotation. This will allow the doctor to determine if it is actually rotator cuff injury or whether it may be other conditions such as impingement or tendinitis.

Imaging scans such as X-Ray’s may also be used to see if there is any abnormal bone growth within the joint, which may be causing the pain.

Treatment

Treatments for rotator cuff injuries can be non-surgical or surgical. Tendinitis may occur over time from the repetitive strain placed around the joint, so it is important to treat the affected area.

  • Apply a cold compress/ ice to the effected area to reduce swelling
  • Heat packs can be used to reduce swelling
  • Resting the affected area
  • Inflammatory medication such as ibuprofen and naproxen
  • Reduce the amount of repetitive movement to the joint
  • Don’t lift the arm overhead

Exercises

  • Doorway Stretch: Stand facing an open doorway with your hands placed on the door frame at shoulder height. Step one foot forward and gently lean forward, feeling a stretch in your chest and shoulders. Hold the stretch for 20-30 seconds before releasing. Repeat the stretch with the other foot forward.
  • External rotation with weight: Hold a dumbbell or weight plate in one hand and stand with your elbow bent at 90 degrees and your upper arm against your side. Rotate your arm outwards, away from your body, while keeping your elbow tucked in. Slowly return to the starting position and repeat for 8-12 repetitions before switching arms.
  • High to low rows with resistance band: Attach a resistance band to a sturdy anchor point at chest height. Stand facing the anchor point with the band in both hands. Pull the band towards your chest, keeping your elbows tucked in and your shoulders down. Slowly release the band back to the starting position and repeat for 8-12 repetitions.
  • Reverse fly’s: Hold a dumbbell or weight plate in each hand and bend forward at the waist, keeping your back straight. Extend your arms out to the sides, keeping them parallel to the floor. Squeeze your shoulder blades together as you bring the weights up towards your body, then slowly release back to the starting position. Repeat for 8-12 repetitions.
  • Lawn mower pull with resistance band: Attach a resistance band to a low anchor point and stand with your side to the anchor point. Hold the band in one hand with your arm extended towards the anchor point. Pull the band towards your chest, keeping your elbow bent and your shoulder blade squeezed down and back. Slowly release back to the starting position and repeat for 8-12 repetitions before switching sides.
  • Isometric internal rotation: Stand with your elbow bent at 90 degrees and your upper arm against your side. Place a rolled up towel or small ball between your elbow and your side. Squeeze your elbow into your side, holding the contraction for 10-15 seconds before releasing. Repeat for 2-3 sets of 10-15 repetitions.
  • Isometric external rotation: Stand with your elbow bent at 90 degrees and your upper arm against your side. Hold a resistance band in both hands, with one end of the band anchored to a sturdy object. Rotate your arm outwards, away from your body, while keeping your elbow tucked in. Hold the contraction for 10-15 seconds before releasing. Repeat for 2-3 sets of 10-15 repetitions before switching arms.

Prevention

  1. Strengthen the rotator cuff muscles: Exercises that target the rotator cuff muscles can help to build strength and stability in the shoulder joint. Examples of such exercises include external rotation with a resistance band, internal rotation with a light weight, and scapular stabilization exercises.
  2. Warm up properly: Before engaging in any activities that involve overhead arm movements, it is important to warm up the shoulder joint with dynamic stretches and exercises. This can help to increase blood flow to the muscles and reduce the risk of injury.
  3. Practice good technique: When engaging in activities that involve overhead arm movements, it is important to use proper technique and form. This can help to reduce stress on the rotator cuff muscles and tendons and minimize the risk of injury.
  4. Use proper equipment: Using equipment that is properly fitted and designed for the activity can help to reduce the risk of rotator cuff injuries. For example, using a tennis racket with a larger grip or wearing properly fitting swim goggles can reduce the stress on the shoulder joint.
  5. Rest and recover: Resting and allowing the shoulder joint to recover after activity is important for preventing overuse injuries. Avoiding overuse and engaging in activities that strengthen and stretch the shoulder muscles can help to prevent rotator cuff injuries.

How We Can Help

We understand that dealing with a rotator cuff injury can be a challenging and painful experience. As healthcare professionals, we are dedicated to helping you manage your symptoms and regain full function of your shoulder joint.

We are pleased to offer you our services in massage therapy and sports therapy, both of which can be highly effective in treating rotator cuff injuries. Our trained and experienced therapists can work with you to reduce pain and inflammation, improve range of motion, correct muscle imbalances, and provide advice on injury prevention.

Our services are tailored to meet your individual needs and goals, and we will work with you to develop a treatment plan that is effective and manageable for you. We believe in a collaborative approach to healthcare, and we may work in conjunction with other healthcare professionals, such as physiotherapists or orthopedic specialists, to ensure that you receive the best possible care.

We take pride in providing our patients with high-quality, compassionate care, and we are committed to helping you achieve optimal health and well-being. If you are interested in learning more about our massage therapy and sports therapy services, or if you would like to schedule an appointment, please do not hesitate to contact us.

Glenohumeral Joint Instability

The glenohumeral joint (GH) is a ball and socket joint that includes a complex, dynamic, articulation between the proximal humerus (“ball”) and the glenoid (“socket”) of the scapula. The static and dynamic stabilizing structures allow for extreme range of motion in multiple planes, that predisposes the joint to instability events. Shoulder instability often occurs when the capsule (lining of the shoulder joint), ligaments, or labrum becomes stretched, torn, or detached from the glenoid, commonly after shoulder trauma or repetitive motion. A genetic condition can also cause looseness and weakness in the joint. Exercise programs that aim to strengthen the rotator cuff and scapular muscles are often the primary treatment for instability, where full range of motion usually returns after 6-8 weeks.

Anatomy

Structurally a ball and socket joint, that involves the humeral head with the glenoid cavity of the scapula, and it represents the major articulation of the shoulder girdle. The joint capsule and ligaments provide a passive restraint to keep the humeral head compressed against the glenoid. As one of the most mobile joints, the GH joint has stabilising elements, that are divided into static (capsule-labro-ligamentous complex) and active (rotator cuffs and bicep tendons).

Symptoms

The symptoms of Glenohumeral Joint Instability include but may not be limited to:

  • Pain, tenderness, swelling, and/or bruising.
  • A loose feeling, or hearing a “pop” in the shoulder joint.
  • Repeated shoulder dislocation.
  • Tingling or burning sensation in the lower arm and hand.
  • Localised numbness of the skin overlying the deltoid muscle.
  • Decreased range of arm/shoulder motion.

Causes

Glenohumeral joint instability can occur following a traumatic accident such as a fall or collision. It can also occur without significant trauma or injury, which is often genetic from those with hypermobility or connective tissue problems, or from a development of laxity in tissues of the shoulder joint. Other causes can be from repetitive motions, particularly from throwing sports, causing the shoulder to stretch over time, where normal muscle control is lost.

Diagnosis

A physical examination can confirm the impression obtained from the history and help to determine if the shoulder is loose or unstable. Radiographs or imaging, such as X-rays, MRI, or a CT scan can help to provide confirmation of traumatic glenohumeral instability present from the damaged bones, cartilage, and rotator cuff. Mobility may be restricted for two weeks, followed by physical therapy to strengthen the muscles that stabilises the shoulder.

Classifications

Polar Type I (structural instability) – typically present with a positive apprehension (anterior direction) associated with rotator cuff weakness. Posture, single leg balance, and scapula control are often disturbed. Can begin to exhibit signs of poor scapula control, abnormal muscle activation, and altered trunk stability and balance, when moving towards type II and III poles.

Polar Type II – (atraumatic instability) – present with positive anterior apprehension test, with increased laxity and excessive external rotations, and muscular balance

Polar Type III – (neurological dysfunctional or muscle patterning) – shows abnormal activation of large muscles and suppression of the rotator cuff. Mostly occurs with a history of easy shoulder dislocation.

Treatment

Treatment usually begins with physical therapy, designed to strengthen the shoulder, and maintain the joint in position.

Restricting activity that includes overhead motion may be advised to reduce symptoms. Full range of motion usually returns after 6-8 weeks.

If less invasive treatments don’t work, and in severe instances, open surgery is often necessary, where an incision is made over the shoulder and the muscles are moved to access the joint capsule, ligaments, and labrum. After surgery, full recovery often takes 4-6 months, and in some cases up to 12 months. At this stage some deep tissue massage and scar tissue work may be necesary!

Exercises

1. Shoulder Flexion (Lying Down)

  • Purpose: Improve shoulder mobility and strengthen the muscles involved in flexion, which helps stabilise the shoulder joint.
  • How to Perform:
    • Lie on your back with your arm by your side.
    • Hold a light weight or no weight at all, and slowly raise your arm straight up toward the ceiling, keeping your elbow straight.
    • Lower your arm back down slowly, and repeat.

2. Shoulder Blade Squeeze

  • Purpose: Strengthen the scapular stabilisers, particularly the muscles that control the shoulder blades, to improve overall shoulder stability.
  • How to Perform:
    • Sit or stand with your arms at your sides.
    • Squeeze your shoulder blades together, as if trying to pinch something between them.
    • Hold the squeeze for a few seconds, then relax.
    • Repeat for the desired number of repetitions.

3. Resisted Rows

  • Purpose: Strengthen the upper back and shoulder muscles, particularly the rhomboids and middle trapezius, to enhance shoulder stability.
  • How to Perform:
    • Anchor a resistance band at chest height.
    • Hold the band with both hands, and step back to create tension.
    • Pull the band toward your chest, keeping your elbows close to your sides and squeezing your shoulder blades together.
    • Slowly return to the starting position and repeat.

4. Internal Rotator Strengthening Exercise

  • Purpose: Strengthen the internal rotators (subscapularis) of the shoulder, which are crucial for maintaining joint stability.
  • How to Perform:
    • Attach a resistance band to a sturdy object at waist height.
    • Stand with your affected side closest to the band, holding the other end with your elbow bent at 90 degrees.
    • Keep your elbow close to your body, and rotate your arm inward against the resistance.
    • Slowly return to the starting position and repeat.

5. External Rotator Strengthening Exercise (with Arm Abducted 90°)

  • Purpose: Target the external rotators (infraspinatus and teres minor) to improve the stability and control of the shoulder joint.
  • How to Perform:
    • Stand or sit with your arm raised to shoulder height and your elbow bent at 90 degrees, holding a resistance band or light weight.
    • Rotate your forearm upward, keeping your elbow in line with your shoulder.
    • Slowly lower your arm back down to the starting position and repeat.

6. Standing Row (with Resistance Band)

  • Purpose: Strengthen the muscles that stabilise the shoulder, particularly the upper back and shoulder blade muscles, to improve shoulder joint stability.
  • How to Perform:
    • Anchor a resistance band at chest height.
    • Stand facing the band, holding it with both hands.
    • Pull the band toward your chest, leading with your elbows and squeezing your shoulder blades together.
    • Slowly return to the starting position and repeat.

 

Prevention

Glenohumeral Joint Instability (GJI) is a condition that occurs when the ball and socket joint of the shoulder become dislocated or partially dislocated due to trauma or other underlying conditions. GJI can result in pain, weakness, and limited range of motion, making it difficult for people to perform their daily activities. In severe cases, surgery may be required to treat the condition. However, prevention is always better than cure, and there are several steps that individuals can take to prevent GJI.

Strengthen the Rotator Cuff Muscles:
The rotator cuff muscles are a group of muscles that attach the shoulder blade to the humerus bone and help stabilize the shoulder joint. Strengthening these muscles can help prevent GJI. Exercises that target the rotator cuff muscles include external and internal rotation exercises, scapular stabilization exercises, and shoulder blade squeezes.

Improve Shoulder Mobility:
Limited shoulder mobility can lead to increased stress on the shoulder joint, which can increase the risk of GJI. Stretching exercises that target the shoulder joint, such as shoulder circles and shoulder flexion stretches, can help improve shoulder mobility and prevent GJI.

Maintain Good Posture:
Poor posture can contribute to shoulder instability and increase the risk of GJI. Individuals should aim to maintain good posture by keeping their shoulders back and down and their chest open. Practicing good posture can help improve shoulder alignment and stability.

Avoid Overuse Injuries:
Overuse injuries can cause wear and tear on the shoulder joint, leading to increased instability and a higher risk of GJI. To avoid overuse injuries, individuals should practice proper form and technique when performing exercises and avoid repetitive overhead movements.

Wear Proper Protective Gear:
Individuals who participate in contact sports or activities that involve the risk of shoulder injuries should wear proper protective gear, such as shoulder pads or braces. Protective gear can help absorb the impact of a fall or collision, reducing the risk of GJI.

In conclusion, preventing GJI requires a combination of strengthening exercises, stretching, good posture, injury prevention strategies, and protective gear. By following these steps, individuals can help reduce the risk of GJI and maintain a healthy and stable shoulder joint. It is important to consult with a healthcare professional before starting any new exercise program or if experiencing any shoulder pain or discomfort. If you are unsure what to do, please contact us and one of our Personal Trainers or Sports Therapists can help.

AC Joint Inury

The AC (acromioclavicular) joint is where the shoulder blade (scapula) meets the collarbone (clavicle). The highest point of the shoulder blade is called the acromion. Strong tissues called ligaments connect the acromion to the collarbone, forming the AC joint.

Most AC Joint injuries are treated conservatively using various combinations of strengthening exercises, following the immobilisation phase, once pain permits. Surgery is usually reserved for cases where there is a complete dislocation of the AC Joint (Grade 3), or in cases where a less severe injury fails to respond adequately to conservative treatment.

Anatomy

The Acromioclavicular Joint, or AC Joint, is one of four joints that comprises the Shoulder complex. The AC Joint is formed by the junction of the lateral clavicle and the acromion process of the scapula and is a gliding, or plane style synovial joint. The AC Joint attaches the scapula to the clavicle and serves as the main articulation that suspends the upper extremity from the trunk.

The primary function of the AC Joint is:

To allow the scapula additional range of rotation on the thorax.

Allow for adjustments of the scapula (tipping and internal/external rotation) outside the initial plane of the scapula in order to follow the changing shape of the thorax as arm movement occurs.

The joint allows transmission of forces from the upper extremity to the clavicle.

Symptoms

  • Pain at the end of the collar bone.
  • Pain may feel widespread throughout the shoulder until the initial pain resolves; following this, it is more likely to be a very specific site of pain over the joint itself.
  • Swelling often occurs.
  • Depending on the extent of the injury, a step-deformity may be visible. This is an obvious lump where the joint has been disrupted and is visible on more severe injuries.
  • Pain on moving the shoulder, especially when trying to raise the arms above shoulder height.

Causes

An AC Joint injury often occurs as a result of a direct blow to the tip of the shoulder from, for example, an awkward fall, or impact with another person. This forces the Acromion Process downward, beneath the clavicle. Alternately, an AC Joint injury may result from an upward force to the long axis of the humerus (upper arm bone) such as a fall which directly impacts on the wrist of a straightened arm. Most typically, the shoulder is in an adducted (close to the body) and flexed (bent) position.

Diagnosis

Firstly, for the diagnosis of scapula winging your doctor will look at the shoulder blades for any clear obvious signs of winging. Some patient’s scapula bone may be more visible than others and have distinct scapula winging. The doctor may also ask you to perform arm/ shoulder movements to examine the range of movement and stability at the joint.

One of the main tests that are used to aid in the diagnosis of scapula winging is the serratus anterior test. This is where the patient is asked to face a wall, standing about two feet from the wall and then push against the wall with flat palms at waist level. This test is carried out to identify if any damage is done to the thoracic nerve causing the scapula to wing.

Treatment

The traditional literature supports non-operative treatment for grade I and II injuries. Patients with grade IV, V and VI injuries benefit from operative treatment, whereas the treatment of grade III injuries remains a controversial issue. 22 Numerous surgical procedures have been described, though there is currently no gold standard for the treatment of AC injuries. The main principle of surgical therapy is accurate reduction of the AC joint in both coronal and sagittal planes. This is achieved either by primary repair or by reconstruction of injured ligaments and maintaining stability to protect this repair or reconstruction. The traditional Weaver-Dunn CA ligament transfer procedure has largely fallen into disfavour today. If the AC joint injury presents within six weeks, it is considered acute. The main goal of treatment is acromioclavicular joint stabilisation. Following techniques are used for stabilisation and reduction of AC joint pain. Whilst you are going through a rehabilitation, strength plan massage can also help with specific soft tissue techniques to eleviate pain and discomfort and inflamation such as lymphatic drainage massage.

Exercises

Initially, complete rest, immobilization and regular application of ice or cold therapy are important to reduce pain and inflammation. Mobility exercises can begin only once shoulder movement is pain-free. This will normally be 7-14 days for grades 1 and 2 sprains. Grade 3 injuries are more frequently treated conservatively, without surgery, but will require an even longer rest/healing period. If the shoulder has been immobilized for a period of time, then it may have lost mobility or range of motion.

  • Pendulum exercises can begin as soon as the ligament has healed, and pain allows. Gently swing the arm forwards, backward, and sideways whilst lying on your front or bent over as seen opposite.
  • Gradually increase the range of motion. Repeat this with your arm swinging from side to side as well. Aim to reach 90 degrees of motion in any direction.
  • Front shoulder stretch
  • External rotation stretch
  • Isometric exercises – Strengthening should initially be isometric. This means contracting the muscles without movement.

Resistance band exercises for AC joint sprain:

  • Internal Rotation
  • External Rotation
  • Abduction/lateral raise

Prevention

  • Wearing protective strapping to support a previously injured AC Joint, particularly in contact sports or sports where full elevation of the arm is not so important. Protective padding is also used in sports such as rugby.
  • Warming up, stretching and cooling down.
  • Participating in fitness programs to develop strength, balance, coordination and flexibility.
  • Undertaking training prior to competition to ensure readiness to play.
  • Gradually increasing the intensity and duration of training.
  • Allowing adequate recovery time between workouts or training sessions.

If you feel like you may have an AC Joint injury and would like to know more, please contact our specialist team made up of Physiotherapists and Sports Therapists who deal with these kind of injuries all the time. Alternatively you can make a booking online directly.

Frozen Shoulder

Frozen shoulder (also known as adhesive capsulitis or periarthritis) is used to describe the condition where the glenohumeral joint of the shoulder is stiff and painful. It occurs in about 2-5% of the general population, with a higher prevalence among elderly individuals and those with diabetes. Frozen shoulder is a benign and self limiting condition, usually lasting for 1-3 years, in 20-50% of patients the stiffness and pain only partially resolve, which leads to long lasting effects of shoulder mobility impairment and reduction in sleep quality. Commonly patients who suffer persistent symptoms (over 4-5 years) only suffer mild long term effects.

Anatomy

The hallmark pain and stiffness are caused by the formation of adhesions or scar tissue in the glenohumeral (GH) joint. The GH joint is a ball and socket joint between the scapula and humerus, connecting the upper arm to the trunk. Under normal conditions this joint is one of the most mobile in the human body, allowing for a large range of motion in multiple planes. In the case of frozen shoulder the adhesions limit this range of motion and make movement painful.

Symptoms

There are 4 recognised clinical stages of the condition:

  1. Painful stage- moderate pain and reduction of movement lasting less than 3 months
  2. Freezing stage- severe pain and reduction of movement lasting 3-9 months 
  3. Frozen stage- pain may be present but stiffness predominates lasting 10-14 months
  4. Thawing stage- minimal pain and gradual improvement in movement lasting 14-24 months

Causes

The cause of frozen shoulder is still unclear. Historically researchers into the aetiology of the condition have shown that it is characterised by a thickened, tight capsule with chronic inflammatory cells and fibroblasts found in the joint capsule. It can occur as a primary idiopathic condition or secondary to medical conditions or trauma.

Diagnosis

Frozen shoulder is diagnosed by testing positive to three characteristics:

  1. Insidious onset of severe pain over a period of months, night time pain is a common feature 
  2. Shoulder stiffness with markedly reduced external rotation 
  3. Negative radiographic findings

Some patients describe the pain as a deep ache, poorly localised and non specific without any point of tenderness. In others it presents as a pain which refers to the deltoid origin and radiates down to the bicep area. Manual testing will often return normal rotator cuff strength but a greatly reduced passive and active range of motion. 

In some cases laboratory tests may be carried out to identify or rule out underlying conditions. Radiographs of the shoulder will also return normal with a patient suffering from frozen shoulder, but may be carried out to exclude conditions such as shoulder dislocation, GH arthritis or calcific tendinopathy.

Treatment

There is no universally accepted intervention which is viewed as the most effective treatment for restoring motion and reducing pain. 

Non-surgical or conservative management is preferred with most patients improving in 6-18 months. This includes analgesics, oral steroids, physical therapies and supra-scapula nerve block. Physical therapy, from a sports massage and remedial therapist or physiotherapist, has traditionally been the first choice of treatment for frozen shoulder. The therapist can work to reduce pain, mobilise the joint and provide the patient with a supervised  stretching and strength maintenance programme.

Exercises

Exercises should be carried out under the direction of a qualified therapist and vary according to the stage of the condition. 

  1. Early Freezing Stage: Gentle and Short Duration Stretches

    1. Pendulum Exercises
      • Purpose: Promote gentle movement in the shoulder joint, reducing stiffness without causing pain.
      • How to Perform:
        • Lean forward with your unaffected arm supported on a table or chair.
        • Let your affected arm hang down loosely.
        • Gently swing your arm in small circles, or forward and back, using your body to initiate the motion.
        • Perform for 1-2 minutes, gradually increasing the range of motion as tolerated.
    2. Passive External Rotation
      • Purpose: Maintain range of motion by gently stretching the external rotators of the shoulder.
      • How to Perform:
        • Lie on your back with your arm close to your side and elbow bent at 90 degrees.
        • Use your unaffected hand to gently push your affected arm outward, rotating it externally.
        • Hold for 10-15 seconds, then relax and repeat, avoiding any pain.
    3. Supine Passive Forward Elevation
      • Purpose: Improve shoulder mobility by gently stretching the shoulder in a pain-free range.
      • How to Perform:
        • Lie on your back with your affected arm by your side.
        • Use your unaffected hand to slowly lift your affected arm overhead, keeping it straight.
        • Hold at the top for a few seconds, then slowly lower it back down.
        • Repeat, ensuring the movement remains gentle and within a comfortable range.

    Later Frozen Stage: Strengthening Exercises

    1. Isometric External Shoulder Rotation
      • Purpose: Strengthen the shoulder’s external rotators, stabilising the joint without moving it.
      • How to Perform:
        • Stand with your elbow bent at 90 degrees, and press the back of your hand against a wall or door frame.
        • Push outward against the wall without moving your arm, holding the tension for 10-15 seconds.
        • Relax and repeat, ensuring no pain occurs during the exercise.
    2. Posterior Capsular Stretching
      • Purpose: Stretch the tight posterior capsule of the shoulder, improving internal rotation and overall flexibility.
      • How to Perform:
        • Bring your affected arm across your body at shoulder height.
        • Use your other hand to gently pull your arm closer to your chest, stretching the back of your shoulder.
        • Hold the stretch for 20-30 seconds, then release and repeat.

    Thawing Stage: Combined Strength and Stretching Exercises

    1. Combined Strength and Stretching Exercises
      • Purpose: Enhance overall shoulder function by combining strengthening with stretching, gradually increasing range of motion and strength.
      • How to Perform:
        • Incorporate exercises like active external rotations, shoulder abduction, and flexion against light resistance bands or weights.
        • Alternate between strengthening movements and stretching exercises like doorway stretches or wall slides.
        • Increase the frequency and intensity as tolerated, aiming for 2-3 times daily.

Prevention

As the aetiology of the condition is still unknown advising on how to prevent an incidence of the condition is difficult. Research has suggested that prolonged immobilisation or limited use of the shoulder joint may contribute to the likelihood of developing frozen shoulder. With this in mind regular balanced exercise and stretching can help to maintain the structural support and mobility of the GH joint.

Rotator Cuff Strain

In the rotator cuff region there are four muscles, tendons and ligaments, surrounding the shoulder which provide added stability to the shoulder joint. This structure helps to keep the bone securely placed into the socket. Injury to the rotator cuffs can cause an ache like pain in the shoulder. This may lead to a feeling of muscle weakness and inability to lift the shoulder above the head. 

Rotator cuff injuries are most commonly presented in people regularly exposed to overhead movements, such as painters, carpenters and builders. Individuals who suffer from this injury can usually manage their symptoms, through sports massage and specific exercises focusing on the rotator cuff muscle region. However, if not treated correctly, further injury to the area may occur such as a complete tear, which may result in surgery.

Anatomy

The rotator cuffs are made up by four muscles, these are the supraspinatus, infraspinatus, teres minor and subscapularis. These muscles aid in keeping the upper arm and shoulder into the socket with stability. They also each allow specific movements at the shoulder joint. The group of four muscles all originate within the shoulder blade, but all insert into different portions of the upper arm bone. 

Supraspinatus: This muscle originates at the supraspinous fossa; the muscle belly passes laterally over the acromion process and inserts into the greater tubercle of the humerus bone. This muscle allows the first 15 degree’s movement of abduction, after this the deltoid and trapezius muscles will then allow further motion. 

Infraspinatus: The origin of the infraspinatus is the infraspinatus fossa, and the insertion is also the greater tubercle of the humerus. The motion created by this muscle is lateral rotation of the shoulder, moving the arm away from the centreline of the body. 

Teres Minor: A small narrow muscle on the back of the shoulder blade which sits underneath the infraspinatus. The origin is the lateral boarder of the scapula. This muscle contributes to external rotation of the arm of the body. 

Subscapularis: This rotator cuff is the strongest and largest out of the three listed above. This muscle originates at the subscapularis fossa and inserts into the lesser tubercle of the humerus. The subscapularis allows greater motion at the shoulder and mainly aids in allowing medial rotation of the arm. 

Symptoms

Common symptoms of possible rotator cuff strain include:

  • Dull ache 
  • Difficulty lifting arm over head 
  • Weakness around the shoulder
  • Disturbed sleep
  • The constant need to use self-myofascial techniques 

Causes

There are a few common risk factors of why rotator strain may occur:

  1. Family History: There may be family history of rotator cuff injuries which may make certain family members more prone to having the injury than others. 
  2. The type of job you do: Individuals who work in construction or manual labour who have repetitive overhead movement of the shoulder could damage the rotator cuff overtime. 
  3. Age: As you get older joints and muscles become weaker, meaning you may be more prone to injury overtime. 

Diagnosis

To diagnose a rotator cuff strain a physical examination will be carried out by a doctor or a physiotherapist. Firstly, they may ask about your day-to-day activities which may determine the seriousness of the injury. The doctor will test the range of movement at the shoulder by getting you to perform movements such as flexion, extension, abduction, adduction and medial and lateral rotation. This will allow the doctor to determine if it is actually rotator cuff strain or whether it may be other conditions such as impingement or tendinitis. 

Imaging scans such as X-Ray’s may also be used to see if there is any abnormal bone growth within the joint, which may be causing the pain. 

Treatment

Treatments for rotator cuff injuries can be non-surgical or surgical. Tendinitis may occur over time from the repetitive strain placed around the joint, so it is important to treat the affected area. 

  • Apply a cold compress/ ice to the effected area to reduce swelling
  • Heat packs can be used to reduce swelling 
  • Resting the affected area 
  • Inflammatory medication such as ibuprofen and naproxen 
  • Reduce the amount of repetitive movement to the joint
  • Don’t lift the arm overhead

Exercises

  • 1. Doorway Stretch

    • Purpose: Stretches the chest and shoulder muscles, helping to alleviate tension and improve flexibility in the shoulder joint.
    • How to Perform:
      • Stand in a doorway and place your arms on the door frame with elbows at 90 degrees and your hands slightly above head level.
      • Step forward with one foot, gently leaning into the doorway until you feel a stretch in the front of your shoulders and chest.
      • Hold for 20-30 seconds and relax.

    2. External Rotation with Weight

    • Purpose: Strengthen the rotator cuff muscles, particularly the infraspinatus and teres minor, which are responsible for external rotation of the shoulder.
    • How to Perform:
      • Lie on your side with your elbow bent at 90 degrees, holding a light weight in the top hand.
      • Keep your elbow close to your body and rotate your forearm upward, lifting the weight.
      • Slowly lower the weight back down and repeat before switching sides.

    3. High to Low Rows with Resistance Band

    • Purpose: Strengthen the muscles of the upper back and shoulder, improving stability and support for the rotator cuff.
    • How to Perform:
      • Anchor a resistance band above shoulder height.
      • Hold the band with both hands and step back to create tension.
      • Pull the band down and back toward your hips, squeezing your shoulder blades together.
      • Slowly return to the starting position and repeat.

    4. Reverse Fly’s

    • Purpose: Target the posterior deltoids and the upper back muscles, which help support and stabilise the shoulder joint.
    • How to Perform:
      • Stand with feet hip-width apart and a slight bend in your knees, holding a light weight in each hand.
      • Bend forward at the hips with your back flat and arms hanging down.
      • Raise your arms out to the sides until they’re level with your shoulders, squeezing your shoulder blades together.
      • Lower your arms back down and repeat.

    5. Lawn Mower Pull with Resistance Band

    • Purpose: Strengthen the shoulder and back muscles, mimicking the movement of starting a lawn mower, which engages the rotator cuff.
    • How to Perform:
      • Anchor a resistance band at ground level.
      • Stand with one foot forward and grab the band with the opposite hand.
      • Pull the band up and back diagonally, rotating your torso and mimicking the motion of starting a lawn mower.
      • Slowly return to the starting position and repeat before switching sides.

    6. Isometric Internal Rotation

    • Purpose: Strengthen the subscapularis muscle of the rotator cuff without moving the shoulder, which is helpful when active movement is painful.
    • How to Perform:
      • Stand next to a wall with your elbow bent at 90 degrees, holding a small towel or cushion between your forearm and the wall.
      • Press your forearm into the wall, engaging the internal rotators of the shoulder.
      • Hold the tension for 10-15 seconds, then relax and repeat.

    7. Isometric External Rotation

    • Purpose: Strengthen the external rotators (infraspinatus and teres minor) of the rotator cuff without movement, useful for stabilising the shoulder.
    • How to Perform:
      • Stand next to a wall with your elbow bent at 90 degrees, this time with the back of your hand pressing against the wall.
      • Push your hand outward into the wall, engaging the external rotators.
      • Hold the tension for 10-15 seconds, then relax and repeat.