A Patient's Guide to Self-Assessment and Treatment of The Shoulder

If Only Our Bodies Came With User Manuals!

It's tough to know when its okay to push through pain or stiffness, or to know if the recent shoulder tweak that happened last week is of any importance. Over the last number of years I've picked up a number of strategies from research and experts in the sports medicine and orthopaedic world - I hope this can serve as a general guide! (NB - this is a blue print for simple shoulder injuries, and will not fit every situation.  Use the following information as the guide that it is, and seek additional advice if you need further guidance!)

Did You Hurt Your Shoulder Within The Last 7 Days?

To start it off, if you've hurt your shoulder in the last 7 days, read through the following flow chart, and then the corresponding text below:

Grade 2-3 muscle, tendon, ligament, labral or joint capsule tear
If you experience significant pain, possibly with swelling or bruising, it is likely that you have significantly injured your soft tissues.  While outliers exist (bone fracture or nerve involvement), it is most likely an issue related to a tear of a muscle, tendon, ligament, or the joint structure,  If the pain in significant, a trip to the ER or family doctor may be the best first option.  

In terms of rehabilitation, it is probably best to let the shoulder heal for at least 7 days from the initial injury date before starting active rehab exercises.  During this time you should see your local physiotherapist or sports medicine physician for an accurate diagnosis and to develop a treatment plan. 

During the first 7 days, you can support the shoulder with tape or a sling, apply ice (if you need to numb the pain), and perform pain-free range of motion.  You should continue to exercise your lower body during this time.  You can reasonably expect that there will be a range of motion limitation and/or strength reduction for at least 3 weeks from the date of the injury.  It would be advisable to avoid loading the injured tissues with exercise for at least 3 weeks as the injury heals.  As per standard tissue healing timelines, the injured tissues will not reach their full strength for up to 9-12 months in a healthy adult… so it is important that you do not re-injure it in the first 3-6 months (to be conservative).

Muscle spasm, acute tendonitis, grade 1 muscle, tendon or ligament tear.
If you've come to the conclusion that it's likely a muscle spasm, or minor muscle strain / ligament sprain, start immediately with soft tissue release, foam rolling, and gentle stretching into the areas of tightness.  Within the first 3-7 days, start to do some light and pain-free resistance exercises to the surrounding muscles (e.g. easy rotator cuff exercises with a theraband). By the end of week 2 you should have loosened up most of the muscle tightness around the shoulder, and should be starting to gradually increase load/exercise for the shoulder.  If your discomfort and limited range of motion is not gone within the first 2 weeks, get it assessed and treated. These small nagging injuries have a way of accumulating over the years and may predispose you to a more severe problem in the future.

Have You Had Shoulder Pain For More Than 7 Days?

This becomes more complicated as we have to discern between a number of different potential concerns.

Acromioclavicular (AC) joint dysfunction - There are a few differed reasons that you may develop AC joint dysfunction.
First, and most simple, is a direct hit to your shoulder.  You will remember this happening, so in this case, its not too complicated. You will likely experience pain and joint laxity when you press on the AC joint, and in severe cases you may experience a 'separated shoulder' that looks like this:

Visual of a Grade 3 Separation

Anatomical Visualization

The good news about separated shoulders is that physiotherapy (as opposed to surgery) is often enough to help athletes and recreationalists return to their sports and daily activities pain free. 

If you do not remember a direct trauma, the following may apply to you:
The AC joint is often the site of arthritis and come on from overuse or impact (most often seen in athletes (hockey, football, baseball, weight lifters, or overhead work).  Pain and dysfunction from the AC joint often can cause impingement of the rotator cuff, and as such may present with muscle weakness, pain down the arm as far as the elbow, and a painful arc of motion.  The symptoms that you experience during the arc of motion can help differentiate if it is just the joint that is irritable, or if there may be a rotator cuff impingement; If you have pain between 45-120 degrees abduction, but no pain before or after this range, then it is likely that you have an impingement of supraspinatus muscle (with or without an inflamed bursa).  If you only have pain at the very top of this range of motion, it is likely that your AC joint is irritable.

Assessment-informed treatment is often the key if it is a chronic pain:
1) You may benefit from other tests that can be done by a physiotherapist to assess joint integrity. 
2) An X-ray may be of benefit to ensure there is no bone spur or congenital abnormality of the acromion,
3) A diagnostic ultrasound may be helpful to discern whether the supraspinatus tendon or subacromial bursa are irritated.

Conservative treatment is the first-line treatment, as you will almost certainly have tightness and weakness of the surrounding shoulder musculature which may be causing secondary pain.  A good assessment is usually needed to assess and treat the neck, thoracic spine, scapulothoracic rhythm, sternoclavicular joint mobility, scapulohumeral rhythm, and the AC joint.  Most importantly, returning to a quality, pain-free exercise program will quicken the recovery.

Differentiating Reasons for a Stiff Shoulder Joint

One of the easiest ways to assess a stiff joint, is to look at passive range of motion, and try to assess the end-feel of the motion.  If you are lacking 45 degrees of passive shoulder external rotation, and it feels like there is a capsular or joint restriction (hard end-feel), you likely fit into this category.  Often, these cases require a medical approach to rule out other pathologies - be prepared to seek a referral to your family doctor or sports medicine physician for some imaging (to rule out sinister pathology or rule in arthritis), or blood work.

To assess passive shoulder external rotation, lay down on your back, and with you painful arm completely relaxed, use a broomstick or cane to gentle push the painful arm outwards (rotating the shoulder out). Keep your elbow relaxed and next to your ribcage. Remember... you are trying to assess the stiffness of the joint, so all muscles in the painful arm must remain relaxed!

Glenohumeral Osteoarthritis
If you have had a previous shoulder trauma, are 50+ years old or have a family history of arthritis, the most likely problem is that of glenohumeral osteoarthritis (could be from previous instability, or because of normal wear and tear associated with age).
Manual therapy that focuses on improving joint capsule mobility is often required to make progress.  Various joint injections exist that may help with lubrication of the joint, or inflammation within the joint.  At home, patients can start with rolling tight muscles on the back of the shoulder joint to loosen any tissues that may be restricting the joint mobility. Ultimately, most progress will be made with the help of physiotherapy or medical intervention.

Adhesive Capsulitis (Frozen Shoulder)
The most likely alternative reason for a stiff shoulder is adhesive capsulitis.  The strongest risk factor for developing adhesive capsulitis is being a peri-menopausal female. Other risk factors include thyroid disorders, diabetes, cervical disc issues, post-op mastectomies, a recent fall/trauma, and having a previous frozen shoulder.  The shoulder seems to stiffen and become painful without a usual cause, and keeps patients awake at night.  We see patterns of limited external rotation, internal rotation and flexion.

If the diagnosis of adhesive capsulitis is reached, patients may find a cortisone injection helpful in the early stages.  There has also been some clinical evidence showing that manipulation of the fibrotic joint under a nerve block may be of benefit..  Otherwise, regular physiotherapy that includes stretching, shockwave therapy, and manual therapy (soft tissue release, IMS, and joint mobilizations) will provide the greatest benefit.  

Shoulder Pain with Limited Active Range of Motion but Without Joint Stiffness

If you do not have a stiff glenohumeral joint (more than 45 degrees passive external rotation), yet there is shoulder pain and limited active range of motion, a skilled practitioner will take you through a number of tests to help determine whether the pain is coming from a rotator cuff tear, labral tear or ligamentous tear (this is usually preceded by a dislocation / subluxation).  The diagnosis of a tear must be ascertained by the clinic history, movement exam, special tests, response to treatment, and possibly ultrasound/MRI/other imaging. 
For the purposes of this article I am going to avoid the discussion of which special tests may be useful for diagnosing tears; This is a contentious issue as most special tests are... not that special; they are not very specific toward testing just one tissue and often lead to false positives.  This topic is beyond the scope of this article.

Shoulder Pain Without a Clear Pattern

Very few patients fit into this category, so if you think that you do, its likely that you've missed something during your self-assessment.  Excluding this caveat, I write this last section for completion.
1. Referred Pain - A painful shoulder that has no pattern of painful movement may be experiencing referred symptoms from the neck, diaphragm or the heart.
2. Cancer/Metastases - A number of different viscera can create pain into the shoulder region. Most likely include the lung, liver, and gallbladder.  Typically you will experience unrelenting pain (nothing can make the symptoms change), difficulty sleeping at night, excessive fatigue, weight loss, a fever, or any number of other changes in your normal health.  See the following link for more information:
https://www.cancer.org/cancer/cancer-basics/signs-and-symptoms-of-cancer.html
3. Pain Syndromes - Widespread hypersensitivity/hyperalgesia may also affect the shoulder.  Various non-specific pain syndromes may create shoulder pain and include: Chronic Regional Pain Syndrome, Myofascial Pain Syndrome & Fibromyalgia.

A Final Note

In most cases of shoulder pain, an exercise program is the key component necessary to return to full function without pain.  In cases of partial thicken tendon tears, full thickness tendon tears or subacromial impingement, a  specific and progressive exercise program often provides improved function, reduced pain and reduced need of surgery when compared with a general exercise program (1, 2, 3).
My typical progression in the clinic is:
1) Determine if patient has any red flags that indicate immediate medical  assessment / intervention.
2) Assess full body movement to determine how one area of the body may be affecting another.
3) Assess the shoulder for joint integrity, ligament and tendon damage, flexibility and strength.
4) Perform manual therapy, IMS and shockwave (if needed) to reduce pain and improve joint position/posture.
5) Provide patient with a specific, graduated exercise program.
6) Assess progress of the shoulder and repeat 2-6 as indicated until full function is .recovered, or a referral is indicated to see a sports medicine specialist.

References

(1) Björnsson Hallgren, H. C., Adolfsson, L. E., Johansson, K., Öberg, B., Peterson, A., & Holmgren, T. M. (2017). Specific exercises for subacromial pain: Good results maintained for 5 years. Acta Orthopaedica, 1-6.

(2) Holmgren, T., Hallgren, H. B., Öberg, B., Adolfsson, L., & Johansson, K. (2012). Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study. Bmj, 344, e787.

(3) Kukkonen, J., Joukainen, A., Lehtinen, J., Mattila, K. T., Tuominen, E. K. J., Kauko, T., & Äärimaa, V. (2014). Treatment of non-traumatic rotator cuff tears. Bone Joint J, 96(1), 75-81.