Physiotherapy for the Shoulder

The gleno-humeral joint, known in lay terms as the shoulder, is a vital part of the links in the upper limb and responsible for our ability to place our hands where we can see them to perform activities. Because flexibility is a prime requirement the shoulder is a less stable joint with moderate muscle power and a large range of motion. It is described as a “soft tissue joint”, implying that the joint’s functional ability is dependent on its soft and not its hard components. Physiotherapists are closely involved in treating and rehabilitating the shoulder, dealing with the muscles, ligaments and tendons.

The shoulder joint is constructed from the socket of the scapula and the humeral head, the ball at the top of the upper arm bone. The head of the upper arm is a large ball and important tendons insert onto it to move and stabilise the shoulder, but the shoulder socket, the glenoid, is small in comparison and very shallow. A cartilage rim, the labrum of the glenoid, deepens the socket and adds to stability. The acromio-clavicular joint lies above the shoulder joint proper and provides dynamic stability during arm movements, being made up from part of the scapula and the outer end of the clavicle.

The major stability and flexibility joints of the upper limb shoulder girdle are the scapulothoracic and glenohumeral joints and these joints are held steady and moved by large and powerful muscles. The pectoralis major and latissimus dorsi muscles stabilise and perform strong movements, the serratus anterior stabilises the scapula on the thorax, the rotator cuff stabilises the humeral head on the socket and the deltoid and other muscles perform movements. The shoulder blade and thorax need to be kept in a stable relationship for the glenohumeral joint to perform precise and controlled movements.

Around the shoulder all the muscles narrow down into flat, fibrous tendons, some larger and stronger, some thinner and weaker. All these tendons are anchoring themselves to the humeral head, allowing their muscles to act on the shoulder. The rotator cuff includes a group of relatively small shoulder muscles, the subscapularis, the supraspinatus, the infraspinatus and the teres minor. The tendons form a wide sheet over the ball, allowing muscle forces to act on it. The rotator cuff, despite its name, acts to hold the humeral head down on the socket and allow the more powerful muscles to perform shoulder movements.

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

The shoulder joint is not typically affected by OA (osteoarthritis) but when it is physiotherapists treat arthritic shoulders by joint mobilisations, muscle strengthening and ranges of motion. Once physio has nothing else to offer, total shoulder replacement is one of the further options, with various surgical techniques involving replacing the humeral ball and the scapular socket either anatomically or in reverse. The shoulder is often called a “soft-tissue joint” as the soft tissues, their strength and balance, are vital to the function of the joint. Post-operative physio management is essential as the correct protocol must be closely followed to ensure success.

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