Shoulder rehabilitation

Training with knee pain

Physiotherapy after shoulder surgery

Shoulder complaints are generally treated conservatively. This means the complaints will not be treated surgically but with the help of physiotherapy, adjustments in daily activities and pain medication. Sometimes a local injection of corticosteroids can be chosen. An exception is a complex bone fracture that needs to be stabilized by surgery. In a small part of the people with persistent shoulder pain, surgery can possibly still offer a solution. This is often preceded by a conservative policy. When the different treatment options do not bring about the desired result, the decision to operate is made together with the orthopaedic surgeon.



Cruciate ligament injury

Anatomy and function of the shoulder joint

The shoulder joint consists of the humerus(upper arm bone), scapula(shoulder blade) and clavicle(collarbone). The joint between the upper arm and the shoulder blade is called the glenohumeral joint. The clavicle with the scapula is the acromioclavicular joint. Another joint of the shoulder area is the scapulothoracic joint. This is the joint between the scapula and the ribs. These joints allow the shoulder to move in many different directions. The shoulder contains many different muscles and tendons. The function of these muscles is to move and stabilize the shoulder during different daily movements. There are smaller muscles that are closer to the joint but also larger muscles that have a more powerful function. These small muscles are called the rotator cuff, these muscles sit like a corset around the head of the shoulder. Anatomically, a distinction is made between a local muscle system and a global muscle system. Functionally, however, they have largely the same function. In an unrestrained shoulder, the glenohumeral capsule, the capsule surrounding the glenohumeral joint is stretchy, long and does not restrict the normal range of motion of the shoulder. The function of this capsule is to provide firmness in the shoulder. Around the capsule is the labrum. In every joint so also in the shoulder there is synovial fluid, also called joint fluid. Synovium ensures that joint surfaces can move smoothly in relation to each other by minimizing friction.

Shoulder instability

The shoulder joint has the greatest range of motion in our body. This is because anatomically, the socket is very small and shallow compared to the relatively large shoulder head. To compensate, at the edge of the shoulder socket is the labrum (cartilage ring). The labrum creates, as it were, a larger socket and is attached to the head of the shoulder like a kind of sucker. Furthermore, the joint is strongly enveloped with joint capsule, ligaments and various muscles. Normally, this provides sufficient stability to the shoulder during daily activities and sports.

Instability at the shoulder joint is almost always the result of an accident or as a consequence of long-term overloading, such as in various sports where a lot of work is done in the end position of the joint. In an accident, depending on the force and direction of the trauma, damage can occur to, for example, the labrum, ligaments and possibly muscles. Since, together, these must provide stability for the shoulder, the reduced functioning of one or more of these structures can cause problems. 

People who suffer from instability are dealing with a shoulder that dislocates (luxates) or tends to dislocate (sub-luxation). In many cases this is due to the labrum. Overloading or trauma can cause a tear in the labrum, which reduces the stability of the shoulder. Unfortunately, the labrum does not have the ability to repair itself. With surgery, the labrum can be sutured so that stability can be restored. In the medical world this is called a labrum repair.

Rotator cuff rupture

The rotator cuff consists of 4 muscles; teres minor, supraspinatus, subscapularis and infraspinatus. It is a group of muscles that have their main function in rotating the shoulder and stabilizing the shoulder head in the socket. In most cases, a rotator cuff tear involves the supraspinatus muscle. After that it is more often the infraspinatus. Ruptures in the other two muscles are rare. 

Often the tearing of muscles or tendons is due to an accident. With the rotator cuff, this is often the case as well. Here too, too great an impact from, for example, a fall can cause the muscles to tear. Even more often it is the case with the rotator cuff as a result of aging. The tendons are then of lesser quality and are less strong. Various scientific studies show that half of all people over the age of 60 have at least a partial rupture in one of the rotator cuff muscles. So it is also partly a normal phenomenon just like gray hair and wrinkles. These people were also pain free. When the symptoms correspond to an image on an ultrasound scan, for example, the cause of the pain may well be a rotator cuff tear. Surgery for a cuff rupture depends on several factors such as age and daily load. Also, the tendon tissue must be of good quality, otherwise a re-rupture is quite likely. As we get older, we can generally cope reasonably well with missing one or more shoulder tendons. At a younger age, this is different. If an operative policy is chosen, the goal is to place the tendon back in its original position. If this does not work, we can also choose to anchor the tendon in a different place. 

Physical testing if a (partial) rotator cuff tear is suspected
When a cuff rupture is suspected, the physical therapy examination comes in handy. Often, with such a rupture, not much can be seen abnormally from the outside. Sometimes blue discoloration is visible if the symptoms have arisen after a trauma. In the physiotherapeutic examination, reduction of strength will be noticed in directions that have to do with rotations and/or lifting of the arm.

Internal rotation lag sign
This test is used to test the m. subscapularis. The patient is asked to sit upright with the elbow at 90 degrees. The examiner brings the arm fully to endorotation (turning inward) and asks the patient to maintain this position. At the time the subscapularis is ruptured this will not be possible.

External rotation lag sign
This test tests the supraspinatus and infraspinatus muscles. The starting position is the same as the previous test. This time, however, the therapist turns the arm completely to exorotation (outward) and asks again to maintain this position. Again, inability to maintain this position gives a positive test result.

Empty can test
The empty can test involves testing the supraspinatus muscle. This test is performed with the arms 90 degrees abduction and fully rotated inward. With the arms in the scapular plane, the examiner applies force to the arms in a downward direction. Inability to resist this resistance (and especially a difference between the two arms) gives a positive test result.

In addition to these specific tests, in many cases an inability to perform certain movements or an abnormal movement pattern can be seen in a general movement test. When in doubt, additional examination can be requested to get clarity. 

Biceps repair

The biceps runs from the shoulder region to the forearm. It is a muscle consisting of two heads (long head and short head) whose main function is to bend the elbow. The long head of the biceps has its attachment over the shoulder and in it also supports movements in the shoulder joint.

With a muscle injury, we use different degrees. It is possible that there is only muscle pain or a slight strain. But it may also be that there is a muscle tear or even a complete tear. 

Like any muscle in the body, the biceps can be damaged. A rupture in the biceps usually occurs with heavy lifting or after trauma such as a fall on the extended arm. In many cases, the long head of the biceps is affected. In the case of a biceps tendon rupture, there has been a clear moment when the symptoms started. Discoloration in the affected area may also be visible and the popeye phenomenon may occur. Here, a bulge in the upper arm can be seen because the muscle belly retracts into the arm. This does not always have to be present. The tendon can tear off at the top or at the bottom. 

In many cases, surgery is not necessary for a biceps rupture. Especially in older age, the choice to operate is almost not made. Exceptions to this are people who play sports at a high level or have heavy physical work. The tendon can then be put back in its original place, in the case of a distal rupture this is at the tuberositas radii. See here a video about the operation technique. 

Knee Osteoarthritis
Arjan Naaijkens

Shoulder & rehabilitation specialist Arjan Naaykens

SLAP leasie

At the top, the biceps attaches to the top of the socket of the shoulder. More specifically, to the glenoid which is part of the labrum. When the attachment loosens on this side, there can also be some damage to the labrum. A lot of force is needed for this. In some cases, you can hear something snapping during the accident. Moving the arm overhead is often very painful or even impossible. The pain is often situated at the front and the top of the shoulder head. A SLAP lesion is not very common. The diagnosis is often missed because only a keyhole surgery can give a definitive answer. In general, we distinguish between 4 different types:

  • Type 1 is a partial tear, so the tendon is still adhering to
  • Type 2 is a complete tear at the top of the labrum
  • Type 3 is a buckethandle tear, a piece of the labrum may become lodged in the joint space causing entrapment and irritation
  • Type 4 is a buckethandle tear that continues in the tendon of the biceps

If surgery is necessary, the biceps tendon can be reattached by means of an anchor, often at a higher location in the shoulder. After surgery you will not be allowed to do much, if any, physical activity for 6 weeks in order for the anchor to grow back properly. Your movements must also be severely restricted and you will often spend large parts of the day in a sling. 2 weeks after surgery some careful movement is allowed under the supervision of a physiotherapist. After 6 weeks you can gradually build up the strength and load capacity of the shoulder region again. 

Rehabilitation at Fysio Fitaal

Rehabilitation after shoulder surgery takes a lot of effort and is quite intensive. It can take up to 12 months before you are back on a level that allows you to fully participate in your sport again. This takes a lot of willpower but also time. During the rehabilitation, there will always be small and sometimes big setbacks. Especially in certain phases, it will go slower than you had thought. Patience is necessary. Our specialists will guide you through this process as best as they can and motivate you where necessary. Fysio Fitaal works with specialists in the field of shoulder rehabilitation. Because of this combination of expertise, extensive facilities and passion for physical therapy you have come to the right place.

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