'Ouch! Shoulder Pain'

Periathropathis humeroscapularis (PHS)

PHS is broad term used to describe a variety of degenerative and inflammatory conditions that affect the shoulder. The term in itself cannot justify any specific therapeutic intervention. Therefore, an accurate diagnosis is necessary.



· Trauma/ injury

· Degenerative changes of the shoulder joint (capule, perosteum, ligaments, tendons or bursae)


Conditions associated with PHS:

· Degenerative rotator cuff syndrome- with or without rupture

· Shoulder impingement

· Arthrosis of the acomio-clavicular joint (AC joint)

· Hyer-mobility with frequent dislocation

· Frozen shoulder



The painful arc test allows the therapist to make distinctions for a number of conditions which are normally indicated at different degrees of the test (Fig 2.). If pain is present between 60-120° that suggests impingement syndrome; if pain is worse between 120-180° acromio-clavicular joint involvement. Complete rotator cuff tear can be indicated by the empty beer can test. This test is most reliable in the over 50s’ and there is high rates of false positives results in younger athletes. This tests measure the integrity of the supra-spinatus: the most common site of rotator-cuff tears. The patient is asked to abduct the arm to 90° and then horizontally rotate the arm to 30° and then tip their hand as if they were empty a can. This test can also be performed with added resistance which is applied by the therapist’s hand. 

Fig 2: Painful arc test to assess shoulder impingement

Degenerative rotator cuff syndrome

The rotator cuffs include:

· Infraspinatus

· Supraspinatus

· Subscapularis

· Teres minor


These muscles stabilise the shoulder joint and articulate the head of the humerus to glenoid fossa (cavity of the scapula). Primarily these muscles allow the arm to perform inward and outward rotation and lateral abduction.

Tears of the rotator cuff mainly occur at the tendons of the supraspinatus and intrspinatus. Furthermore degenerative and chronic inflammation may accompany rotator cuff syndromes and visa-versa. 



· Pain which radiate to the upper arm

· Reduced range of motion resulting from pain by lifting the arm above horizontal and lateral

· Avoidance of movement

· Long term inactivity can cause shrinking of the joint capsule and may be often mistaken for Frozen shoulder

· Chronic degeneration will weaken the muscle tendon laminae which may lead a partial or full rupture


Training recommendations:

Training should not begin until insertions have fully healed. Therefore it’s important to first get an accurate assessment of joint architecture (e.g. MRI, CT and X-ray) before prescribing any exercise for the patient.



Strengthening of the shoulder should be a long term programme beginning with low intensity training for at least 6 months to 1 year. Specifically the patient should perform internal and external rotation of the shoulder using therabands or at pulley machines. Medium intensity to high intensity training can follow on after this period. However, isolation movements may not be necessary if the patient engages in proper upper body compound movement because the rotator cuffs could become overtrained.

Shoulder Impingement

Shoulder impingement syndrome is a common overuse injury caused by continued forceful overhead movements. Swimmers who engage in front crawl are most susceptible as are sports that involve frequent overhead mechanics such as tennis and volleyball.


This is caused by the narrowing of the gap between the head of the humerous and the top of the acromium which puts pressue on the tendons of both the long head of the bicep and the rotator cuffs (supraspinatus). Constant friction causes inflammation and bone spurs may also develop underneath the acromium process.



· Gradual onset of pain

· Tenderness exacerbated by rotary movement of the shoulder

· Pain is present between 60-120° that suggests impingement syndrome; pain is worse between 120-180° may suggest athrosis of the acromio-clavicular joint.


Training recommendations:

Compound movements such as bench press and overhead press should be avoided during the early stages of rehabilitation. Overhead and horizontal pulling exercises with hand supinated will increases the gap between the humeral head and aromium process and will help activate the shoulder depressors. The patient should be encouraged to avoid hunching and keep their shoulders down during these movements. In addition, internal and external rotation of the shoulder using therabands or at pulley machines will help strengthen rotator cuff muscles.

Assess exercise tolerance; determine mobility through pain-free ROM; base level strength.

Schedule training through systematic phases:


Strength building/pain reducing


Tendinopathy at the insertion (inflammation of the tendon)

Tendinopathy is characterised by painful inflammation at the muscle tendon unit and is nearly always caused by abnormal mechanical loading. Examples typically include: impingement of the shoulder; epicondylitis (tennis elbow), medial-condylitis (golfers elbow), tendinopathy of the ilio-tibia-band (ITB); Achilles tendinitis. 


Overtraining; poor recovery; muscular imbalances, and; muscular weakness.



Painful under pressure; pain at the muscle insertion; vigorous movement exacerbates the pain; swelling (oedema) and fatty deposits accrue. Fibres at the end of tendons become rough and bone spurs may develop in adjacent bones.


Consequently, movement is restricted leading to atrophy. In serious cases lack of movement results in sclerosis and chronification.


Training recommendations:

If symptoms are minor both antagonist and agonist muscles can be worked. For more serious tendinopathy, working the antagonist muscles will help stretch the injured tendon and stretch the fibres of the agonist muscles.

Exercise interventions recommended:

In the case of tendinopathy of the ITB the main training outcomes are (1) to relieve pressure of the lateral tibial condyle, (2) activating the main knee extensors (rectus femoris, vastas lateralis, vastas intermedialis, vastas medialis).


The patient will perform extension movements with a solid focus on peak contraction (4 second hold) at full extension either through an isolation movement such as the leg extension or a compound movement like the leg press.  

Unilateral movements can be done, but there are limitations on how much contribution the patient can get from the vastus group of muscle especially the vastas medialis. Single leg press, lunges, glute extension demand greater contribution from the gluteal muscles and so reduce the amount contribution from the extensors muscles. Plus, the main focus for the patient is not necessarily to perform a movement, but more importantly to relieve painful symptoms and make it easier for them to maximize muscle activation.


Strength Training Used in Therapy

Balanced Musculature

If we over use muscles or continually adopt poor posture, eventually a greater counter tension will occur between antagonist-agonist pairs. In time, this will negatively impact the supporting bones and joints and often results in pain (e.g.: medial or lateral epicondylitis; calcifications at the elbow etc.).

In worst cases, muscular imbalances can be managed and corrected through proper remedial strength therapy (RST). More good news is that weaker muscles respond positively and very quickly to both PST and RST, which will inevitably help to reduce musculoskeletal pain.

At Vis-Therapeia many clients come to us for various musculoskeletal conditions. We try to address their needs by prescribing appropriate and adapted exercise regimes.

Muscular imbalances can be managed and corrected through proper remedial strength therapy”


Remedial Strength Therapy

Postural problems, muscular pain and injuries can come about as a result of muscular imbalances within the body. Muscular imbalances can also be congenital, such as spinal scoliosis, lordosis and kyphosis, knocked knees, bowed legs, etc. Yet counter tensions occur naturally during everyday movement and physical activity.

In order to move any part of our body we need at least two muscles to do the work. We refer to these as antagnostic- agonistic pairs. For example, when we bend the elbow, this movement is instigated by the bicep muscles (agonist/tension) and opposed by the tricep muscles (antagonist/counter-tension).

It’s really important to identify the precursors of injuries; assess exercise tolerance; determine mobility through pain-free ROM; base level strength.  

On our RST programmes patients train through systematic phases: Activation Strength building/pain reducing, and Functional  

 Activation: Will allow you determine what the patient can cope with; establish exercise tolerance, and; establish effective pain-free activity. 4 session (4 week) phase; give the patient time to recover from each individual session, i.e.: one week.  

Strength: The main training outcome is to inverse the relationship between STRENGH and PAIN. Therefore, it’s important that you make it clear to the client that painful symptoms may take some time to reduce. Low-intensity slow measurable resistance exercise for spinal muscles can be extremely effective for treating various musculoskeletal conditions. 4 session (4 week) phase; give the patient time to recover from each individual session, i.e.: one week.  

Functional: We start to prescribe medium intensity training to high intensity training for the patient. Patients will most likely be free of painful symptoms. However, critical to reducing spinal deconditioning involves maximizing muscle tissue strength and neuromuscular activity. Again, 4 session (4 week) phase; give the patient time to recover from each individual session, i.e.: one week.