Shoulder Pain | Pain Treatment Recomendations & Info | IMPACT Physical Therapy

Shoulder Pain

Osteoarthritis

“Arthritis” is a term used to describe inflammation of the joints. Osteoarthritis (OA) is the most common form of arthritis and usually is caused by the deterioration of a joint. Typically, the weight-bearing joints are affected, with the knee and the hip being the most common.

An estimated 27 million Americans have some form of OA. According to the Centers for Disease Control and Prevention, 1 in 2 people in the United States (US) may develop knee OA by age 85, and 1 in 4 may develop hip OA in their lifetime. Until age 50, men and women are equally affected by OA; after age 50, women are affected more than men. Over their lifetimes, 21% of overweight and 31% of obese adults are diagnosed with arthritis.

OA affects daily activity and is the most common cause of disability in the US adult population. Although OA does not always require surgery, such as a joint replacement, it has been estimated that the use of total joint replacement in the US will increase 174% for hips and 673% for knees by the year 2030.

Physical therapists help patients understand OA and its complications, provide treatments to lessen pain and improve movement, and offer education about obesity and healthy lifestyle choices. Research has shown that light to moderate activities such as walking, biking, and swimming can provide more benefits than harm to your joints, and promote weight loss. One study showed that just an 11-pound weight loss reduced the risk of OA in the women studied.

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What is Osteoarthritis?

Your bones are connected at joints such as the hip and knee. A rubbery substance called cartilage coats the bones at these joints and helps reduce friction when you move. A protective oily substance called synovial fluid is also contained within the joint, helping to ease movement. When these protective coverings break down, the bones begin to rub together during movement. This can cause pain, and the process itself can lead to more damage in the remaining cartilage and the bones themselves.

The cause of OA is unknown. Current research points to aging as the main cause. Factors that may increase your risk for OA include:

  • Age. Growing older increases your risk for developing OA because degeneration and aging of the cartilage and synovial fluid increases over time.
  • Genetics. Research indicates that some people’s bodies have difficulty forming cartilage. Individuals can pass this problem on to their children.
  • Past injury. Individuals with prior injury to a specific joint, especially a weight-bearing joint (such as the hip or knee), are at increased risk for developing OA.
  • Occupation. Jobs that require repetitive squatting, bending, and twisting (eg, construction, landscaping, childcare) are risk factors for OA. People who perform jobs that require prolonged kneeling (eg, miners, flooring specialists) also are at high risk.
  • Sports. Athletes who repeatedly use a specific joint in extreme ways (eg, pitchers, football linemen, ballet dancers, runners) and those who engage in high-impact joint loading done in a repetitive manner (eg, running, jumping, landing on hard surfaces) may increase their risk for developing OA later in life.
  • Obesity. Being overweight causes increased stress to the weight-bearing joints (such as knees), increasing the risk for development of OA.

How Does it Feel?

Typically, OA causes pain and stiffness in the affected joint. Common symptoms include:

  • Stiffness in the joint, especially in the morning, which eases in less than 30 minutes
  • Stiffness in the joint after sitting or lying down for long periods
  • Pain during activity that is relieved by rest
  • Cracking, creaking, crunching, or other types of joint noise
  • Pain when you press on the joint
  • Increased bone growth around the joint that you may be able to feel

Caution: Swelling and warmth around the joint is not usually seen with OA and may indicate a different condition or signs of inflammation. Please consult a doctor if you have swelling, redness, and warmth in or around a joint.

How Is It Diagnosed?

Osteoarthritis is typically diagnosed by your doctor using an X-ray, but there are signs that may lead your physical therapist to suspect you have OA. Joint stiffness; difficulty moving; joint cracking, creaking, or crunching; and pain that is relieved with rest are typical symptoms. Physical therapists often use the American Academy of Rheumatology criteria for diagnosing knee OA, which lists the presence of pain, plus at least 3 of the following 5 criteria:

  • Age >50 years
  • Stiffness <30 minutes
  • Crepitus (a grinding/crunching sound emitted from the joint with movement)
  • Bone tenderness
  • Bony enlargement

How Can a Physical Therapist Help?

Physical therapist treatment has proven to be an effective treatment for OA, and may help you avoid surgery and use of prescription painkillers. Although the symptoms and progression of OA are different for each person, starting an individualized exercise program and addressing risk factors can help relieve your symptoms and slow the condition’s advance.

Your physical therapist may:

  • Perform a thorough examination to determine your symptoms.
  • Observe what activities are difficult for you.
  • Design an individualized exercise program to address your specific needs and improve your movement.
  • Use manual (hands-on) physical therapy to improve movement of the affected joint.
  • Offer suggestions for adjusting your work area to lessen the strain on your joints.
  • Teach you aerobic and strengthening exercises to improve your movement and overall health.
  • Design and teach you a home-exercise program to improve your strength and movement.
  • Teach you an exercise program for safe weight loss, if you need to lose weight to ease pressure on your joints.
  • Recommend simple lifestyle changes that will help keep the weight off.

In cases of severe OA that are not helped by physical therapy alone, surgery, such as a knee or hip replacement, may be necessary. Your physical therapist will refer you to an orthopedic surgeon to discuss the possibility of surgery.

Frozen Shoulder (Adhesive Capsulitis)

Often called a stiff or “frozen shoulder,” adhesive capsulitis occurs in about 2% to 5% of the American population. It affects women more than men and is typically diagnosed in people over the age of 45. Of the people who have had adhesive capsulitis in 1 shoulder, it is estimated that 20% to 30% will get it in the other shoulder as well. Physical therapists help people with adhesive capsulitis address pain and stiffness, and restore shoulder movement in the safest and most effective way possible.


What is Frozen Shoulder (Adhesive Capsulitis)?

Adhesive capsulitis is the stiffening of the shoulder due to scar tissue, which results in painful movement and loss of motion. The actual cause of adhesive capsulitis is a matter for debate. Some believe it is caused by inflammation, such as when the lining of a joint becomes inflamed (synovitis), or by autoimmune reactions, where the body launches an “attack” against its own substances and tissues. Other possible causes include:

  • Reactions after an injury or surgery
  • Pain from other conditions, such as arthritis, a rotator cuff tear, bursitis, or tendinitis, that has caused a person to stop moving the shoulder
  • Immobilization of the arm, such as in a sling, after surgery or fracture

Often, however, there is no clear reason why adhesive capsulitis develops.

Frozen Shoulder: See More Detail

How Does it Feel?

Most people with adhesive capsulitis have worsening pain and a loss of movement. Adhesive capsulitis can be broken down into 4 stages; your physical therapist can help determine what stage you are in.

Stage 1: “Prefreezing”

During stage 1 of its development, it may be difficult to identify your problem as adhesive capsulitis. You’ve had symptoms for 1 to 3 months, and they’re getting worse. Movement of the shoulder causes pain. It usually aches when you’re not using it, but the pain increases and becomes “sharp” with movement. You’ll begin to limit shoulder motion during this period and protect the shoulder by using it less. The movement loss is most noticeable in “external rotation” (this is when you rotate your arm away from your body), but you might start to lose motion when you raise your arm or reach behind your back. Pain is the hallmark feature of this stage; you may experience pain during the day and at night.

Stage 2: “Freezing”

By this stage, you’ve had symptoms for 3 to 9 months, most likely with a progressive loss of shoulder movement and an increase in pain (especially at night). The shoulder still has some range of movement, but it is limited by both pain and stiffness.

Stage 3: “Frozen”

Your symptoms have persisted for 9 to 14 months, and you have a greatly decreased range of shoulder movement. During the early part of this stage, there is still a substantial amount of pain. Toward the end of this stage, however, pain decreases, with the pain usually occurring only when you move your shoulder as far you can move it.

Stage 4: “Thawing”

You’ve had symptoms for 12 to 15 months, and there is a big decrease in pain, especially at night. You still have a limited range of movement, but your ability to complete your daily activities involving overhead motion is improving at a rapid rate.

How Is It Diagnosed?

Often, physical therapists don’t see patients with adhesive capsulitis until well into the freezing phase or early in the frozen phase. Sometimes, people are being treated for other shoulder conditions when their physical therapist notices the signs and symptoms of adhesive capsulitis. Your physical therapist will perform a thorough evaluation, including an extensive health history, to rule out other diagnoses. Your physical therapist will look for a specific pattern in your decreased range of motion called a “capsular pattern” that is typical with adhesive capsulitis. In addition, your physical therapist will consider other conditions you might have, such as diabetes, thyroid disorders, and autoimmune disorders, that are associated with adhesive capsulitis.

How Can a Physical Therapist Help?

Your physical therapist’s overall goal is to restore your movement, so you can perform your daily activities. Once the evaluation process has identified the stage of your condition, your physical therapist will create an individualized exercise program tailored to your specific needs. Exercise has been found to be most effective for those who are in stage 2 or higher. Your treatment may include:

Stages 1 and 2

Exercises and manual therapy. Your physical therapist will help you maintain as much range of motion as possible and will help reduce your pain. Your therapist may use a combination of range-of-motion exercises and manual therapy (hands-on) techniques to maintain shoulder movement.

Modalities. Your physical therapist may use heat and ice treatments (modalities) to help relax the muscles prior to other forms of treatment.

Home-exercise program. Your physical therapist will give you a gentle home-exercise program designed to help reduce your loss of motion. Your therapist will warn you that being overly aggressive with stretching in this stage may make your shoulder pain worse.

Your physical therapist will match your treatment activities and intensity to your symptoms, and educate you on appropriate use of the affected arm. Your therapist will carefully monitor your progress to ensure a safe healing procedure is followed. 

Pain medication. Sometimes, conservative care cannot reduce the pain of adhesive capsulitis. In that case, your physical therapist may refer you for an injection of a safe anti-inflammatory and pain-relieving medication. Research has shown that although these injections don’t provide longer-term benefits for range of motion and don’t shorten the duration of the condition, they do offer short-term pain reduction.

Stage 3

The focus of treatment during phase 3 is on the return of motion. Treatment may include:

Stretching techniques. Your physical therapist may introduce more intense stretching techniques to encourage greater movement and flexibility.

Manual therapy. Your physical therapist may take your manual therapy to a higher level, encouraging the muscles and tissues to loosen up.

Strengthening exercises. You may begin strengthening exercises targeting the shoulder area as well as your core muscles. Your home-exercise program will change to include these exercises.

Stage 4

In the final stage, your physical therapist will focus on the return of “normal” shoulder body mechanics and your return to normal, everyday, pain-free activities. Your treatment may include:

Stretching techniques. The stretching techniques in this stage will be similar to previous ones you’ve learned, but will focus on the specific directions and positions that are limited for you. 

Manual therapy. Your physical therapist may perform manual therapy techniques in very specific positions and ranges that are problematic for you. They will focus on eliminating the last of your limitations.

Strength training. Your physical therapist will prescribe specific strengthening exercises related to any weakness that you may have to help you perform your work or recreational tasks. 

Return to work or sport. Your physical therapist will address movements and tasks that are required in your daily and recreational life.

Rotator Cuff Tear

The “rotator cuff” is the group of 4 muscles and their tendons responsible for keeping the shoulder joint stable. Injuries to the rotator cuff are common—either from accident or trauma, or with repeated overuse of the shoulder. Risk of injury can vary, but generally increases as a person ages. Rotator cuff tears are more common later in life, but also can occur in younger people. Athletes and heavy laborers are often affected; older adults can injure the rotator cuff when they fall on or strain the shoulder. When left untreated, a rotator cuff tear can cause severe pain and a decrease in the ability to use the arm. Physical therapists help people with rotator cuff tears address pain and stiffness, restore movement to the shoulder and arm, and improve their activities of daily living.


What is a Rotator Cuff Tear?

The “rotator cuff” is a group of 4 muscles and their tendons (tissues that attach muscles to bones), which connects the upper arm bone, or humerus, to the shoulder blade. The important job of the rotator cuff is to keep the shoulder joint stable. Sometimes, the rotator cuff becomes inflamed or irritated due to heavy lifting, repetitive arm movements, or trauma such as a fall. A rotator cuff tear occurs when injuries to the muscles or tendons cause tissue damage or disruption.

Rotator cuff tears are called either “full thickness” or partial thickness,” depending on how severe they are.

  • Full-thickness tears extend from the top to the bottom of a rotator cuff muscle/tendon.
  • Partial-thickness tears affect at least some portion of a rotator cuff muscle/tendon, but do not extend all the way through.

Tears often develop as a result of either a traumatic event or long-term overuse of the shoulder. These conditions are commonly called “acute” or “chronic.”

  • Acute rotator cuff tears are those that occur suddenly, often due to traumas, such as a fall or lifting of a heavy object.
  • Chronic rotator cuff tears are much slower to develop. These tears are often the result of repeated actions with the arms working above shoulder level, such as with ball-throwing sports or certain work activities.

People with chronic rotator cuff injuries often have a history of rotator cuff tendon irritation that causes shoulder pain with movement. This condition is known as shoulder impingement syndrome.

Rotator cuff tears also may occur in combination with injuries or irritation of the biceps tendon at the shoulder, or with labral tears (to the ring of cartilage at the shoulder joint). Your physical therapist will explain the particular details of your rotator cuff tear.

Rotator Cuff Tear: See More Detail

How Does it Feel?

People with rotator cuff tears can experience:

  • Pain over the top of the shoulder or down the outside of the arm
  • Shoulder weakness
  • Loss of shoulder motion
  • A feeling of weakness or heaviness in the arm
  • Inability to lift the arm to reach up, or reach behind the back
  • Inability to perform common daily activities due to pain and limited motion

How Is It Diagnosed?

To help pinpoint the cause of your shoulder pain, your physical therapist will complete a thorough examination that will include learning details of your symptoms, assessing your ability to move your arm, identifying weakness, and performing special tests that may indicate a rotator cuff tear. For instance, your physical therapist may raise your arm, move your arm out to the side, or raise your arm and ask you to resist a force, all at specific angles of elevation.

In some cases, the results of these tests might indicate the need for a referral to an orthopedist or other professional for imaging tests, such as ultrasound imaging, magnetic resonance imaging (MRI), or a computed tomography (CT) scan.

How Can a Physical Therapist Help?

Once a rotator cuff tear has been diagnosed, you will work with your orthopedist and physical therapist to decide if you should have surgery or if you can try to manage your recovery without surgery.

If you don’t need surgery, your physical therapist will work with you to restore your range of motion, muscle strength, and coordination, so that you can return to your regular activities. In some cases, you may learn to modify your physical activity so that you put less stress on your shoulder.

If you decide to have surgery, your physical therapist can help you both before and after the procedure.

Regardless of which treatment you have—physical therapy only, or surgery and physical therapy—early treatment can help you speed the healing process and avoid permanent damage.

If You Have an Acute Injury

If a rotator cuff tear is suspected following a trauma, seek the attention of a physical therapist or other health care provider to rule out the possibility of serious life- or limb-threatening conditions. Once serious injury is ruled out, your physical therapist will help you manage your pain and will prepare you for the best course of treatment.

If You Have a Chronic Injury

A physical therapist can help manage the symptoms of chronic rotator cuff tears as well as improve how your shoulder works. For large rotator cuff tears that can’t be fully repaired, physical therapists can teach special strategies to improve shoulder movement. However, if physical therapy and conservative treatment alone do not improve your function, surgical options may exist.

If You Have Surgery

If your condition is severe, you may require surgery to restore use of the shoulder; physical therapy will be an important part of your recovery process. The repaired rotator cuff is vulnerable to reinjury following shoulder surgery; working with a physical therapist is crucial to safely regaining full use of the injured arm. After the surgical repair, you will need to wear a sling to keep your shoulder and arm protected as the repair heals. Your physical therapist will apply treatments during this phase of your recovery to reduce pain and gently begin to restore movement. Once you are able to remove the sling for exercise, your physical therapist will begin your full rehabilitation program.

Your physical therapist will design a treatment program based on both the findings of the evaluation and your personal goals. Your physical therapist will guide you through your postsurgical rehabilitation, which will progress from gentle range-of-motion and strengthening exercises to activity- or sport-specific exercises.

Your treatment program most likely will include a combination of exercises to strengthen the rotator cuff and other muscles that support the shoulder joint. The time line for your recovery will vary depending on the surgical procedure and your general state of health, but return to sports, heavy lifting, and other strenuous activities might not begin until 4 months after surgery and full return may not occur until 9 months to 1 year after surgery. Following surgery, your shoulder will be susceptible to reinjury. It is extremely important to follow the postoperative instructions provided by your surgeon and physical therapist.

Your rehabilitation will typically be divided into 4 phases:

  • Phase I (maximal protection). Phase 1 of treatment lasts for the first few weeks after your surgery, when your shoulder is at the greatest risk of reinjury. During this phase, your arm will be in a sling. You will likely need assistance or need strategies to accomplish everyday tasks, such as bathing and dressing. Your physical therapist will teach you gentle range-of-motion and isometric strengthening exercises, provide hands-on treatments (manual therapy), such as gentle massage, offer advice on reducing your pain, and may use techniques such as cold compression and electrical stimulation to relieve pain.
  • Phase II (moderate protection). This next phase has the goal of restoring mobility to the shoulder. You will reduce the use of your sling, and your range-of-motion and strengthening exercises will become more challenging. Exercises will be added to strengthen the “core” muscles of your trunk and shoulder blade (scapula), and the rotator-cuff muscles that provide additional support and stability to your shoulder. You will be able to begin using your arm for daily activities, but will still avoid heavy lifting. Your physical therapist may use special hands-on mobilization techniques during this phase to help restore your shoulder’s range of motion.
  • Phase III (return to activity). This phase has the goal of restoring your strength and joint awareness to equal that of your other shoulder. At this point, you should have full use of your arm for daily activities, but you will still be unable to participate in activities such as sports, yard work, or physically strenuous work-related tasks. Your physical therapist will advance the difficulty of your exercises by adding weight or by having you use more challenging movement patterns. A modified weight-lifting/gym-based program may also be started during this phase.
  • Phase IV (return to occupation/sport). This phase will help you return to work, sports, and other higher-level activities. During this phase, your physical therapist will instruct you in activity-specific exercises to meet your needs. For certain athletes, this may include throwing and catching drills. For others, it may include practice in lifting heavier items onto shelves, or instruction in proper positioning for everyday tasks such as raking, shoveling, or doing housework.

Rotator Cuff Tendinitis

Disorders of the rotator cuff and the tissues around it are the most common causes of shoulder pain in people over 40 years of age. Rotator cuff tendinopathy occurs when a shoulder tendon (a bundle of fibers connecting muscle to bone) is irritated and becomes sore. With continued irritation, the tendon can begin to break down, causing tendinosis—a more chronic condition. People who perform repetitive or overhead arm movements, such as weight lifters, athletes, and manual laborers, are most at risk for developing rotator cuff tendinopathy. Poor posture can also contribute to its development. A physical therapist can help you identify and correct risk factors for rotator cuff tendinopathy, and help you decrease your pain while improving your shoulder motion and strength.


What is Rotator Cuff Tendinitis?

The rotator cuff muscles are a group of 4 muscles that attach the humerus (upper arm bone) to the scapula (shoulder blade). The rotator cuff muscles help raise, rotate, and stabilize the upper arm. A tendon is a bundle of fibers that connects the muscles to the bone. Rotator cuff tendinitis occurs when the tendon connected to the rotator cuff muscles becomes inflamed and irritated. The condition can be caused by:

  • Repetitive arm movements, such as those performed by a hair stylist or house painter
  • Overhead shoulder motions, such as those performed by baseball pitchers or swimmers
  • Weakness and muscle imbalances in the shoulder blades and shoulder muscles
  • Tight muscles and tissues around the shoulder joint
  • Bony abnormalities of the shoulder region that cause the tendons to become pinched
  • Poor posture, such as rounded shoulders caused by leaning over a computer for long periods (shoulder impingement syndrome)

How Does it Feel?

Rotator cuff tendinopathy is characterized by shoulder pain that can occur gradually over time or start quite suddenly. The pain occurs in the shoulder region and sometimes radiates into the upper arm. It does not usually radiate past the elbow region, although it can. You may be symptom free at rest or experience a mild, dull ache; however, pain can be moderate to severe with certain shoulder movements and can be easily provoked. Reaching behind the body to perform a motion, as in fastening a seat belt, can be very painful. So can overhead activities, such as throwing, swimming, reaching into a cupboard, or combing your hair. The pain can worsen at night, especially when rolling over or attempting to sleep on the painful side. You may notice weakness when lifting and reaching for household items. Holding a heavy platter or taking a pan off the stove may become difficult. If the condition is left untreated, it is possible to begin to experience pain in other areas, such as the neck. 

How Is It Diagnosed?

A physical therapist will perform an evaluation and ask you questions about the pain and other symptoms you are feeling. Your physical therapist may perform strength and motion tests on your shoulder, ask about your job duties and hobbies, evaluate your posture, and check for any muscle imbalances and weakness that can occur between the shoulder and the scapular muscles. Your physical therapist will gently touch your shoulder in specific areas to determine which tendon or tendons are inflamed, and may perform other special tests to detect rotator cuff tendinopathy. Generally, a physical examination is all that is needed to diagnose rotator cuff tendinopathy. If the symptoms do not resolve with physical therapy, imaging (eg, MRI) may be considered, to help determine any possible underlying condition that could be affecting the shoulder.

How Can a Physical Therapist Help?

It is important to get proper treatment for tendinitis as soon as it occurs. Over time, a degenerated tendon that is not treated can begin to tear, causing a more serious condition. Physical therapy can be very successful in treating rotator cuff tendinitis, tendinosis, and shoulder impingement syndrome. You will work with your physical therapist to devise a treatment plan that is specific to your condition and goals. Your individual treatment program may include:

Pain management. Your physical therapist will help you identify and avoid painful movements to allow the inflamed tendon to heal. Ice, massage, or moist heat may be applied for pain management. Therapeutic modalities, such as iontophoresis (medication delivered through an electrically-charged patch) and electrical stimulation (TENS) may be applied.

Patient education. Posture education is an important part of rehabilitation. For example, when your shoulders roll forward as you lean over a computer, the tendons in the front of the shoulder can become pinched. Your physical therapist may suggest adjustments to your workstation and work habits. Your physical therapist will also instruct you in ideal sitting, standing, and sleeping positions to help alleviate symptoms. Your therapist may suggest different ways to perform currently painful activities and show you movements to avoid while the shoulder is painful.

Manual therapy. Your physical therapist may use manual techniques, such as gentle joint movements, soft-tissue massage, and shoulder stretches, to get your shoulder moving again in harmony with your shoulder blade.

Range-of-motion exercises. You will learn exercises and stretches to help your shoulder and shoulder blade move properly, so you can return to reaching and lifting without pain.

Strengthening exercises. Your physical therapist will determine which strengthening exercises are right for you, depending on your specific condition. You may use weights, medicine balls, resistance bands, and other types of resistance training to challenge your weaker muscles. You will receive a home-exercise program, so you can continue rotator-cuff and shoulder-blade strengthening long after you have completed your formal physical therapy.

Functional training. As your symptoms improve, your physical therapist will help you return to your previous level of function, which may include household chores, job duties, and sports- related activities. Functional training can include working on lifting a glass into a cupboard or throwing a ball using proper shoulder mechanics. You and your physical therapist will decide what your goals are, and get you back to your prior level of functioning as soon as possible.

Acromioclavicular Joint (AC Joint) Injuries

Acromioclavicular (AC) joint injury is a term used to describe an injury to the top of the shoulder, where the front of the shoulder blade (acromion) attaches to the collarbone (clavicle). It can be caused by a traumatic event, such as a fall directly on the outside of the shoulder, or by repetitive overuse. AC joint injuries are most common in individuals younger than 35 years of age, with males sustaining 5 times more traumatic AC joint injuries than females. Because younger athletes are most likely to participate in high-risk and collision activities, such as football, biking, snow sports, hockey, and rugby traumatic AC joint injuries occur most often in this population. AC joint injuries can be identified and effectively treated by a physical therapist, often avoiding the need for surgery.


What Are Acromicioclavicular (AC) Joint Injuries?

There are 4 ligaments holding the 2 bones of the AC joint (the acromion and the clavicle) together. When an AC joint injury occurs, these ligaments are stressed, resulting in some degree of joint separation. There are 2 types of injuries that can occur at the AC joint: traumatic and overuse injuries.

traumatic AC joint injury occurs when there is a disruption of the joint due to damaged ligaments holding the 2 bones of the joint together. This injury is called a shoulder separation (in contrast to a shoulder dislocation, it involves the ball-and-socket joint of the shoulder).

Traumatic AC joint injuries are most common in individuals who sustain a fall and land on the outside of the shoulder or onto a hand (eg, a football player who is tackled, a bicyclist who crashes, or a manual laborer who falls off a ladder.

Traumatic AC joint injuries are graded from mild to severe based on the amount of separation of the joint. Treatment of mild cases likely will be provided by a physical therapist; more severe cases may require surgery followed by physical therapy.

An overuse AC joint injury occurs over time as repeated, excessive stress is placed on the joint. Cartilage at the ends of the acromion and clavicle bones protects the joint from daily wear and tear. Over time, the demand placed on this cartilage may be more than it is capable of enduring, resulting in an overuse injury. Significant wearing of the cartilage is known as arthritis. Overuse AC joint injury is most common in individuals who perform tasks, such as heavy weight lifting (bench and military presses), or jobs that require physical labor with the arms stretched over the head.

How Does it Feel?

With an AC joint injury, you may experience:

  • General shoulder pain and swelling
  • Swelling and tenderness over the AC joint
  • Loss of shoulder strength
  • A visible bump above the shoulder
  • Pain when lying on the involved side
  • Loss of shoulder motion
  • A popping sound or catching sensation with movement of the shoulder
  • Discomfort with daily activities that stress the AC joint, like lifting objects overhead, reaching across your body, or carrying heavy objects at your side

How Is It Diagnosed?

Diagnosis of an AC joint injury starts with a thorough review of the patient’s medical history, including specific questions regarding when the pain began, and what aggravates and relieves the pain.

Your physical therapist will examine your shoulder and assess different measures, such as sensation, motion, strength, flexibility, tenderness, and swelling. Your physical therapist will perform several tests specific to the shoulder joint to examine the structures located there. The therapist may also ask you to briefly demonstrate the activities or positions that cause your pain. Other nearby areas, such as your neck and upper back will also be examined to determine whether they, too, might be contributing to your shoulder condition.

While an AC joint injury can usually be identified through a shoulder examination, diagnostic imaging, such as ultrasound, x-ray, or MRI is often used to confirm the diagnosis and determine the severity of the injury.

How Can a Physical Therapist Help?

Once other conditions have been ruled out and an injury to the AC joint is diagnosed, your physical therapist will work with you to develop an individualized plan tailored to your specific shoulder condition and your goals. There are many physical therapy treatments that have been shown to be effective in treating this condition. Your physical therapist may focus on:

Range of Motion. An injury to the AC joint, whether traumatic or overuse, causes the joint to be irritated, often resulting in swelling and stiffness, causing loss of normal motion. Motions that are usually most difficult after an AC joint injury are reaching across your body and lifting your arm directly overhead. While it is important to regain your normal shoulder motion, it is also important to allow your injury to heal without placing excessive stress on the healing joint. Your physical therapist will assess your motion and the degree of your injury, and establish a plan that will balance joint protection and motion restoration.

Strength Training. After an injury, the surrounding muscles demonstrate weakness. All of the muscles near the shoulder and elbow as well as those of the upper back, work together to allow for normal, coordinated upper-body motion. Therefore, balancing the strength of all the upper-body muscles is crucial to making sure the shoulder joint is protected and moves efficiently. Your physical therapist will design an individualized exercise program to strengthen the muscles at and around the shoulder, so that each muscle is able to properly perform its job.

Manual Therapy.Physical therapists are trained in manual (hands-on) therapy. If needed, your physical therapist will gently move and mobilize your shoulder joint and surrounding muscles as needed to improve their motion, flexibility, and strength. These techniques can target areas that are difficult to treat on your own.

Pain Management.Your physical therapist may recommend therapeutic modalities, such as ice and heat to aid in pain management.

Functional Training. The AC joint is a relatively small joint that is often asked to bear a significant load. In order to successfully meet this demand, there is a need for functional training, teaching your entire shoulder to work best in different positions. For example, when lifting overhead, poor coordination places undue stress on the shoulder. Physical therapists are experts in assessing movement quality. Your physical therapist will be able to point out and correct your movements to help you maintain a pain-free shoulder.

Education. The first step to addressing your shoulder pain is rest. The amount of rest required varies, and largely depends on the degree of your injury. Your physical therapist will create a personalized plan for your rehabilitation, so you can safely return to your desired daily and recreational activities.

Biceps Tendinitis

Biceps tendinitis is a common cause of shoulder pain and impingement (compression of tissue with movement), often developing in people who perform repetitive, overhead movements. Biceps tendinitis develops over time, with pain located at the front of the shoulder, and usually worsens with continued aggravating activity. When treating biceps tendinitis, physical therapists work to determine the exact source of the pain by assessing the entire shoulder, and typically prescribe a program of activity modification, stretching, and strengthening to resolve pain and return individuals to their desired activities.


What is Biceps Tendinitis?

Tendinitis is a condition in which inflammation accumulates at a tendon, causing pain. The biceps tendon, the tendon associated with the biceps muscle, is made up of 2 parts: the long head and the short head. The long head of the biceps is most commonly affected by tendinitis, as the tendon from the muscle runs up the length of the arm and attaches to the labrum (a rim of cartilage) and the shoulder blade in the shoulder joint.

Biceps tendinitis results when excessive, abnormal forces are applied across the tendon, including tension (a pulling of the muscle and tendon), compression (pushing or pinching), or shearing (rubbing). When the tendon is subjected to repetitive stresses, it can become irritated, swollen, and painful. 

There are many factors that may lead to biceps tendinitis, including:

  • Activities requiring repetitive overhead movement of the arms, such as placing dishes in a high cupboard or lifting boxes above the head.
  • Rotator cuff tears
  • Weakness in the rotator cuff and muscles of the upper back
  • Shoulder joint hypermobility (looseness)
  • Shoulder joint and/or muscle tightness
  • Poor body mechanics (how a person controls their body when moving)
  • An abrupt increase in an exercise routine
  • Age-related body changes
  • Other pathology within the shoulder joint
Biceps Tendinitis See More Detail

How Does it Feel?

If you are experiencing biceps tendinitis, you may feel:

  • Sharp pain in the front of your shoulder when you reach overhead, behind your back, or across your body
  • Tenderness to touch at the front of your shoulder
  • Pain that may radiate toward the neck or down the front of the arm
  • Dull, achy pain at the front of the shoulder, especially following activity
  • Weakness felt around the shoulder joint, usually experienced when lifting or carrying objects or reaching overhead
  • A sensation of “catching” or “clicking” in the front of the shoulder with movement
  • Pain when throwing a ball
  • Difficulty with daily activities, such as reaching behind your back to tuck in your shirt, or putting dishes away in an overhead cabinet
  • Pain when resting that may become worse at night

How Is It Diagnosed?

When you first go to see your physical therapist, the therapist will review your medical history, ask you to describe your shoulder condition, and perform a comprehensive physical exam of your shoulder and upper trunk. Your physical therapist will assess different measures, such as sensation, motion, strength, and flexibility, and may ask you to briefly perform the activities that cause your pain.

Your physical therapist will likely touch various areas on your shoulder to see which seem to be most consistently painful. Other nearby areas, such as your neck and upper back, also will be examined to determine whether they might be contributing to your shoulder pain.

Imaging techniques, such as an X-ray or MRI, are typically not needed to diagnose biceps tendinitis. However, in the event that your physical therapist suspects there are other conditions present in your shoulder, you may be referred to an orthopedist for further investigation.

How Can a Physical Therapist Help?

Once biceps tendinitis has been diagnosed, your physical therapist will work with you to develop an individualized plan tailored to your specific shoulder condition and your goals. There are many physical therapy treatments that have been shown to be very effective in treating this condition. Your treatment may include:

Range-of-motion exercises. Often, abnormal motion of the shoulder joint may contribute to biceps tendinitis. Your physical therapist will assess your shoulder motion compared to the expected normal motion and to the motion of your other shoulder. Your physical therapist will guide you through exercises to improve your shoulder’s range of motion.

Muscle strengthening exercises. The muscles of the shoulder and upper back work together to allow for normal, coordinated upper-body motion. Based on the way the shoulder joint is designed (a ball-and-socket joint, like a golf ball on a golf tee), there are many directions in which the shoulder may move. Therefore, balanced strength of all the upper-body muscles is crucial to make sure the shoulder joint is protected and is moving efficiently. Your physical therapist will choose exercises to safely strengthen the muscles around your shoulder without causing more pain.

Manual therapy. Physical therapists are trained in manual (hands-on) therapy. Your physical therapist will gently move and mobilize your shoulder joint and surrounding muscles as needed to improve their motion, flexibility, and strength. These techniques can target areas that are difficult to treat on your own.  

Pain management. Your physical therapist may recommend therapeutic modalities, such as ice and heat, to aid in pain management, and reduce the need for medication, including opioids.

Functional training. Improper movements can, over time, cause pain in the body. Physical therapists are experts in assessing movement quality and in training people to function at their best. Your physical therapist will point out and correct any movements that could be causing you trouble, so you can maintain a pain-free shoulder throughout your daily activities. Often, the strategies learned through specific education from your physical therapist will allow you to avoid reversing the positive effects of your physical therapy, and help make sure that your improvements last.

Shoulder Labral Tear

An unstable shoulder joint can be the cause or the result of a labral tear. “Labral” refers to the ring of cartilage (glenoid labrum) that surrounds the base of the shoulder joint. Injuries to the labrum are common, can cause a great deal of pain, and may make it hard to move your arm. A labral tear can occur from a fall or from repetitive work activities or sports that require you to use your arms raised above your head. Some labral tears can be managed with physical therapy; in severe cases, surgery may be required to repair the torn labrum.


What is a Shoulder Labral Tear?

The ring of cartilage called the glenoid labrum provides extra support for the shoulder joint, helping to keep it in place. A shoulder labral tear occurs when part of this ring is disrupted, frayed, or torn. Tears may lead to shoulder pain, an unstable shoulder joint, and, in severe cases, dislocation of the shoulder. Likewise, a shoulder dislocation can result in labral tears.

When you think of the shoulder joint, picture a golf ball (the head of the upper-arm bone, or humerus) resting on a golf tee (the glenoid fossa, a shallow cavity or socket located on the shoulder blade, or scapula). The labrum provides a rim for the socket (golf tee) so that the humerus (golf ball) does not easily fall off. If the labrum is torn, it is harder for the humerus to stay in the socket. The end result is that the shoulder joint becomes unstable and prone to injury.

Because the biceps tendon attaches to the shoulder blade through the labrum, labral tears can occur when you put extra strain on the biceps muscle, such as when you throw a ball. Tears also can result from pinching or compressing the shoulder joint, when the arm is raised overhead.

There are 2 types of labral tears:

  • Traumatic labral tears usually occur because of a single incident, such as a shoulder dislocation or an injury from heavy lifting. People who use their arms raised over their heads—such as weight lifters, gymnasts, and construction workers—are more likely to experience traumatic labral tears. Activities where the force occurs at a distance from the shoulder, such as striking a hammer or swinging a racquet, can cause a traumatic labral tear. Falling on an outstretched arm also can cause this type of tear.
  • Nontraumatic labral tears most often occur because of muscle weakness or shoulder joint instability. When the muscles that stabilize the shoulder joint are weak, more stress is put on the labrum, leading to a tear. People with nontraumatic tears tend to have more “looseness” or greater mobility throughout all their joints, which might be a factor in the development of a tear.
Labral Tear: See More Detail

How Does it Feel?

A shoulder labral tear may cause you to feel:

  • Pain over the top of your shoulder
  • “Popping,” “clunking,” or “catching” with shoulder movement, because the torn labrum has “loose ends” that are flipped or rolled within the shoulder joint during arm movement, and may even become trapped between the upper arm and shoulder blade
  • Shoulder weakness, often on one side
  • A sensation that your shoulder joint will pop out of place

How Is It Diagnosed?

Not all shoulder labral tears cause symptoms. In fact, when tears are small, many people function without any symptoms. However, healing may be difficult due to the lack of blood supply available to a torn labrum. The shoulder with a labral tear may pop or click without being painful, but if the tear progresses, it is likely to lead to pain and weakness.

If your physical therapist suspects that you have a labral tear, your physical therapist will review your health history and perform an examination that is designed to test the condition of the glenoid labrum. The tests will place your shoulder in positions that may recreate some of your symptoms, such as “popping,” “clicking,” or mild pain, to help your physical therapist determine whether your shoulder joint is unstable. Magnetic resonance imaging (MRI) also may be used to complete the diagnosis. Some labral tears may be difficult to diagnose with certainty without arthroscopic surgery. Your physical therapist may consult with an orthopedic surgeon if necessary.

How Can a Physical Therapist Help?

When shoulder labral tears cause minor symptoms but don’t cause shoulder instability, they usually are treated with physical therapy. Your physical therapist will educate you about positions and activities to avoid, and tailor a treatment plan for your recovery. Your treatment may include:

Manual therapy. Your physical therapist may provide gentle manual (hands-on) therapy to decrease your pain and begin to restore movement in the shoulder area.

Strengthening exercises. Improving the strength of the muscles of the shoulder will help you decrease the stresses placed on the torn labrum and allow for better healing. Your physical therapist may design rotation exercises that target the muscles of the shoulder joint, and shoulder-blade (scapular) exercises to provide stability to the shoulder joint itself.

Stretching exercises. An imbalance in the muscles or a decrease in flexibility can result in poor posture or excessive stress within the shoulder joint. Your physical therapist may prescribe stretching exercises—such as gentle stretches of the chest (pectoralis) muscles—to improve the function of the muscles surrounding the shoulder. Your physical therapist also may introduce middle-back (thoracic) stretches to allow your body to rotate or twist to the side, so the shoulder joint doesn’t have to stretch further to perform tasks, such as swinging a racquet or golf club.

Postural exercises. Your physical therapist will assess your posture, and teach you specific exercises to ensure your shoulders are positioned properly for daily tasks. A forward-head and rounded-shoulder posture puts the shoulders at risk for injury.

Education. Education is an important part of any physical therapy treatment plan. Your physical therapist will help you understand your injury, the reasons for modifying your activities, and the importance of doing your exercises to decrease your risk of future injury.

Home-exercise program. A home-exercise program is an important companion to treatment in the physical therapy clinic. Your physical therapist will identify the stretching and strengthening exercises that will help you steadily improve your shoulder function and meet your work, home, and activity goals.

Following Surgery

In more severe cases, when conservative treatments are unable to completely relieve the symptoms of a labral tear, surgery may be required to reattach the torn labrum. Following surgery, your physical therapist will design a treatment program based on your specific needs and goals, and work with you to help you safely return to your daily activities.

A surgically repaired labrum takes 9 to 12 months to completely heal. Immediately following surgery, your physical therapist will teach you ways to avoid putting excessive stress or strain on the repaired labrum.

As the labrum heals, your physical therapist will introduce resistance and strengthening exercises, such as those listed above, to your treatment plan, to address your specific needs, and help you slowly and safely return to performing daily tasks that require force or lifting. Your physical therapist is trained to gradually introduce movements in a safe manner to allow you to return to your usual activities without reinjuring the repaired tissues.


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