Advice & Education for Those with Shoulder Pain

This article arises from information gained via a recent literature review that was published in the Journal of Orthopedic & Sports Physical Therapy dealing with shoulder pain. Shoulder pain is the third most common musculoskeletal disorder seen in primary care physical therapy. Pain focal to the top of the shoulder is commonplace with a number of different underlying injuries subsequently affecting quality of life. 82 patient-focused studies regarding shoulder injury were included in this review. The goal was to summarize patient directed advice and proactive education which were gleaned from the various articles.

The author of this article has practiced physical therapy for over 35 years, treating adult surgical and non-surgical cases currently numbering around 10,000. The goal of this article is to convey these major themes and expand upon them as appropriate with the appreciation that educated and empowered patients are able to make better decisions regarding the management of their shoulder condition thus leading to improvements in their well-being and quality of life, while minimizing health care costs.

Key Themes for Advice and Education for Those with Superiorly (top of shoulder) Located Shoulder Pain.

• Exercise Intensity and Pain Response
  • JOSPT Literature Review
    • Pain during exercise should not exceed the numeric pain rating scale of 3/10
    • Pain should not last longer than 30 seconds following exercise.
  • Buisman addendum:
    • If the patient is experiencing pain about the shoulder for the first time and the situation is not of chronic origin, these parameters are good ones to follow. As well there should not be a change in one’s sleep quality following exercise earlier in the day noting that other daily activities may have been the origin for the night pain and need to be modified as well. Pain of a 3/10 or less is permissible as long as it is good pain; similar to what one experiences getting a deeper massage, it hurts but it feels good and this correlates to challenging musculature in a positive fashion. Pain, like that experienced with a brick falling on one’s foot, needs to be avoided because joint or tendinous structure is most likely being irritated.
    • For those with chronic pain, raising the level of existing pain (which may be greater than 3) by 1 on a 1-10 pain scale, again with a return to prior pain levels immediately following exercise is permissible.
• Activity Modification
  • JOSPT Literature Review
    • Avoid painful movements and repetitive overhead movements ie sport or work related.
  • Buisman addendum:
    • Easier said than done but crucial. Pain tells you that something is being injured and this information needs to be respected and addressed which is difficult with our Midwestern/sport societal mores.  The “pay me now or pay me later” truism rings clear in this situation and though it seems to be a hassle to modify activity for an extended period to allow inherently poorly vascularized tissue to heal, it is a much easier road to take than surgical intervention or potentially greater long term impairment in the future.
• Posture Advice
  • JOSPT Literature Review
    • Keeping the arms at your side, use assistive equipment to minimize overhead work.
    • Protect the shoulder at night via positioning
  • Buisman Addendum:
    •  Repetitive overuse i.e. spending the day at a keyboard can be just as problematic over the long run as for those whose arm and shoulder use was much more aggressive i.e. a carpenter or plumber. Use of a standing desk is beneficial in many respects including the well-being of one’s shoulder. And though it can be time consuming, utilization of adaptive equipment available in all professions is wise with respect to minimizing long term trauma to the shoulder noting that approximately 50% of 65 year olds have a rotator cuff tear. Most are asymptomatic but none the less can be a debilitating issue at a time in life when one now has the time to recreate without hindering professional/home responsibilities.
    • Positioning of one’s thorax and shoulder blade play a crucial role in the long term health of the ball and socket joint and rotator cuff musculature. Poor slumping posture greatly affects the mechanical function of the shoulder girdle leading to enhanced patterns of wear and tear as well as limited motion of the arm overhead.
    • Sleep is often a major problem for those having shoulder pain. A “30/30/30 rule” can be followed which places the shoulder joint in a position where soft tissues are most lax providing maximal spacing in the joint. These are degree increments beginning with the elbow at the side and forearm positioned straight ahead. Use pillows to move the elbow 30 degrees to the side,30 degrees forward with 30 degrees of rotation of the forearm toward the stomach. This can be adopted for sleeping on the back or the uninvolved side.
    • Some unfortunately have to take refuge in a recliner using the same positioning concept with the addition of the downward pull of gravity to gain further spacing in the joint.
• Pain Self-management
  • JOSPT Literature Review
    • The studies note a number of options including: over the counter anti-inflammatories and analgesics (pain killers), heat, ice, taping.
    • Lifestyle changes are important as well; stay out of pain.
  • Buisman Addendum:
    • Recall first and foremost that pain is telling you something and the utilization of medicine can give one the false sense of security to go beyond safe levels of activity.
    • Analgesics such as Tylenol, basically just tell your brain that everything is OK. Again, a concern with those experiencing a new case of shoulder pain with the desire of overmedicating to allow continuance of prior daily activity intensity.
    • For those with chronic non-surgical shoulder pain, this may be the correct option if one is fully aware of their limitations.
    • Analgesics are best utilized at night appreciating that getting a good night’s sleep is crucial to many aspects of life. Other than falling out of bed, you can’t really hurt yourself, the only concern is subsequently spending too much time lying on the injured shoulder.
    • Over the counter non-steroidal  drugs (OTCNSD) actually help reduce the amount of inflammation in the joint thus enhancing the healing process. By ridding inflammation, which creates pain via a chemical process (think of gas on a cut), pain symptoms are also reduced which is an added bonus, Unfortunately, many people are gut intolerant or have contraindications to use OTCNSD due to other medications that they are taking.
    • There are now many over the counter options that combine the two, even adding a mild sleep agent; again and excellent option for some at night.
    • Taping has become a recent option, decreasing the stress placed on regional injured muscles and ligaments as well as neurologic structure. If it is going to work; you will know it right away.
    • Heat and ice are classic options. Be careful that they are not applied for too long; usually 10-15 minutes will do. Both enhance vascularization to the shoulder moving blood in and inflammatory fluids out, thus enhancing one’s ability to heal while diminishing local pain at times as well. I like heat in the morning if just stiff, common place in a joint with long standing arthritic change, and ice at the end of the day to stabilize pain and inflammation following a day of overuse/irritation. Applying either just before bed is a good option as well to enhance sleep quality.
    • Eliminating pain during the day is crucial. Ongoing insults to the joint only lead to further irritation and potentially irreversible tissue change as well as the propensity for the joint to stiffen which is only another issue to deal with .
• Pathoanatomical and Diagnosis Information
  •  JOSPT Literature Review
    • Anatomic and biomechanical information about the cause of the shoulder injury as well as education with regard to specific tissues injured, their recovery rates and potential short and long term lifestyle ramifications should be discussed with the patient.
  • Buisman Addendum:
    • The shoulder has been defined as the most complicated joint structure in the body. As well many of the tissues that are injured have been subject to a lifetime of overuse and abuse. These structures are poorly vascularized and thus once injured require extended periods of time and lifestyle modification to resolve the issue.
    • A thorough discussion in this regard and including underlying information regarding the injury and tissues involved is crucial in creating a compliant patient that is willing to be a team player in this often drawn out process.
• Behavioral Approaches
  • JOSPT Literature Review
    • Goal setting, positive reinforcement and ongoing clinician induced motivation and reassurance play a crucial role in the shoulder rehabilitation process.
  • Buisman Addendum: 
    • We take for granted the complexity and functionality of the shoulder girdle until something goes wrong. For most, there has been a lifetime of overuse and abuse leading to slowly progressive symptoms and dysfunction.
    • Unfortunately, the structures involved have restricted vascular supplies and thus healing capacities are much slower. These factors often lead to frustration during the rehabilitation process. If therapy protocols and healing parameters are not followed, the long term outcome may be less than desired once again leading to more frustration.
    • It is imperative that the treating therapist is verbally supportive, sets appropriate patient goals including regular discussions regarding time and healing parameters as well as expected functional progressions and necessary patient involvement in the process.
    • 80-90% of patients with shoulder pain will have their issue resolved in a non-surgical fashion. If the issue is of chronic nature, a multi month effort will classically be required. This will include an initial course of formal physical therapy care transitioning into a home program once the patient is at a point where remaining issues can be resolved independently.
    • When necessary, surgical intervention is highly successful when the appropriate patient with the correct diagnosis under the care of a competent surgeon followed by an encompassing rehab program, requiring many months effort is undertaken. This is the equation for success.
• Pain Physiology Education
  • JOSPT Literature Review
    • Education regarding the neuroscience of pain about the shoulder girdle is of benefit to the patient.
  • Buisman Addendum:
    • There are two components to one’s shoulder pain
      • Chemical pain can in part be appreciated much like auto exhaust; a byproduct of burning fuel, in this case fuel expended in the healing process. Nerves react to this “exhaust” and become hypersensitive. This is the “achy pain” that one experiences in the morning.
      • Mechanical pain is due to impact or compression against neurologic structure embedded in bone cartilage and tendon.
      • In either of the cases above, the more it occurs, the more hypersensitive the nerves get. Many will thus describe that even and easy jarring of the shoulder created significant pain.
      • Again, the compromised vascular system of the shoulder only further complicates the healing process.
    • Response to pain can also occur on a systemic level. A case in point is those suffering from a frozen shoulder. Stopping the brain’s appreciation of shoulder pain via the modification of activity is required to stop the body’s attempt to shrink wrap and thus preserve the joint.
• CONCLUSIONS
  • Unless there is a mod/massive rotator cuff/ligamentous/labral tear or fracture/significant instability, conservative care is warranted with a trial of 2-6 months to determine whether a conservative program will resolve the impairment. The majority of shoulder injuries are resolved in a conservative fashion.
  • A protocol is a general guideline and needs to be further defined/refined for each patient, on a continuum as well as appreciated with ongoing assessment. This needs to be communicated with the referring physician.
  • Generally pain is a guide with respect to manual intervention intensity and exercise progressions especially when ligamentous structure and the joint capsule is more reactive. Ongoing pain symptoms, regardless of the origin, only further entrench long standing compensatory dysfunction.
  • Restoration of function about the shoulder girdle is commonly a prolonged process due to the complexity of the structure. Patient education is crucial with respect to basic mechanical function, time frames of the healing process as well as individualized short and long term goals. The patient needs to be made compliant in the process or outcomes will be compromised.
  • If surgical intervention is necessary, there needs to be the following components to ensure success: The right patient with the right diagnosis in the hands of a capable surgeon followed by an extensive individualized rehab program with appropriate short and long term goals that are consistently assessed and reviewed with all parties involved.