How to manage shoulder injuries

A shoulder injury is the most common musculoskeletal injury with which patients present to their GP. The sooner the patient presents, the better their chances of recovery. But with early intervention and the right treatment, even chronic, progressive biomechanical injuries can regain near-normal function.

Classifying shoulder injuries

Shoulder injuries are termed as 'acute' or 'chronic' depending on the time of presentation. For example, if the patient presents immediately after injury, it is classified as acute. If the patient presents after a couple of weeks, it is classified as chronic.

Clinically, shoulder injuries are classified into two broad categories: Articular Classification and Stabiliser Classification.

Articular Classification

Extra articular lesions
•    Rotator cuff injuries
•    Adhesive capsulitis
•    Shoulder impingement injuries (anatomical / functional)

Intra articular lesions
•    Labral tear leading to joint instability
•    Osteoarthritis

Stabiliser Classification

Injury of static stabilisers of shoulder — affecting joint stability
•    Adhesive capsulitis
•    Labral tear - joint instability

Injuries to dynamic stabiliser of shoulder — affecting joint control and altering joint anatomy
•    Rotator cuff injuries
•    Shoulder impingement injuries
•    Injury to scapulothoracic joint stabilisers

Causes

Shoulder injuries are most commonly caused by contact sports, natural wear and tear with age, or other comorbidities. Causes of shoulder pain include:
•    Shoulder sprain
•    Rotator cuff tears
•    Shoulder dislocation/subluxation
•    Adhesive capsulitis/frozen shoulder
•    Shoulder bursitis
•    Shoulder arthritis
•    Shoulder tendinitis

Presentation

The patient often presents with diffuse shoulder pain, poorly localised region, difficulty in performing across-body movements and overhead movements, and sometimes disturbed sleep due to pain. They may also experience neck pain or referred pain indicating a red flag condition including gall stones, angina, or pneumonia.

Shoulder pain management

Prescription medications

Low dosage NSAIDs, opioids sparing agents and paracetamol are first line agents prescribed to reduce pain, improve sleep, and restore movement. In many cases, long-term chronic/persistent pain is treated with corticosteroid injections or hydro-dilation, depending on the stage of the condition.

Physiotherapy

Physiotherapy is the first treatment approach for soft tissue / musculoskeletal and soft tissue injuries. The physiotherapy treatment protocol helps treat the condition, reduce symptoms, and improve strength and endurance. With regular physiotherapy sessions, patients can gain near-normal function, participate in everyday activities, and prevent further injury.

Surgery

Surgery is required in severe cases when conservative treatment fails to provide promising results.

Although the majority of shoulder conditions improve with non-surgical management over time, there are a few cases that require surgery, including fractures, dislocations, acute or chronic rotator cuff tear, and chronic arthritic wearing of shoulder joint cartilage. 

Preventing shoulder injuries

• Ask the patient to observe what activities trigger the shoulder pain. The patient can work with a physiotherapist to modify that activity.
• Encourage the patient to act quickly when they suffer a shoulder injury so a treatment plan can be commenced quickly. Early intervention leads to faster healing and prevention of further biomechanical deterioration.
• Stress management is a core factor in shoulder pain. Anxiety and stress lead to chronic muscle spasms and severe pain. It is the most common triggering agent in pathological shoulder pain.
• Screen patients for underlying pathological conditions that might be causing their shoulder pain.

Recovery

Returning back to normal functionality depends on the type of shoulder injury, whether it was due to trauma, pathological changes, secondary comorbid conditions, and clinical presentation. Typically patients recover within three months. However, in chronic cases the recovery time can stretch from six months up to three years. 

- Dr Humda, Physiotherapist

Learn more about this topic in the HealthCert Professional Diploma program in Musculoskeletal & Sports Medicine - fully online or with optional practical workshops.

References

• https://academic.oup.com/ptj/article/101/3/pzaa229/6054190
• https://link.springer.com/article/10.1007/s40674-021-00184-z
• https://link.springer.com/article/10.1186/s12905-022-01773-3
• https://www.sciencedirect.com/science/article/pii/S1058274622005523
• https://journals.sagepub.com/doi/abs/10.1177/02692155221083496
• https://www.sciencedirect.com/science/article/pii/S1058274621005450
• https://onlinelibrary.wiley.com/doi/full/10.1155/2021/7211201