Shoulder Injuries & Disorders

Frozen shoulder is a common disorder seen in patients generally between 40-70 years of age. Symptoms are typically high pain with quick movements and over reaching, sometimes with prolonged pain after these events. Several conditions can imitate this condition. If left untreated, the disorder is estimated at 15-18 months duration, with aggressive therapy counterproductive. Commonly prescribed rotator cuff exercises, chest stretching and PNF exercise patterns can aggravate the disorder.

Biologically, it is an aggressive, but self-limiting, mono-articular inflammatory disorder with dominant features of synovitis, capsular fibrosis and early SASD bursitis findings. The condition does not image well, and the diagnosis is made via a comprehensive clinical examination. 

We have developed a progressive 8 week exercise program to regain 90% of pre injury movement in most patients.

Specific concepts of sub threshold positioning, creep, pain latency and symptom spread are important to learn at the beginning of a frozen shoulder recovery program. These concepts guide the pace of recovery and home exercise methods.

Intra articular steroid (+/- hydrodilation) can be used in treatment resistant cases, typically reserved for high pain or severe motion loss, however the same motion / stretch techniques are required to regain range of motion within the 8 week cycle. The need for steroid can normally be assessed within two-three weeks of beginning the recovery program and a therapeutic window does exist for regaining movement during a post injection period. 

Surgical options should generally be avoided (MUA or capsular releases) in almost all cases due to possible complications, post operative rebound and a full recovery in almost all patients with physiotherapy and safe injection work. 

*A lack of sound classification in medicine has led to many incorrect diagnoses in general practice and we are also aware of some institutions in Canada and abroad exploiting this fact and making incorrect statements about the pathology and the treatment of adhesive capsulitis.

Cases treated ~ 2,000+ 

Pain felt at the front of the shoulder, may indicate biceps pathology and they can be difficult to treat. Biceps tendinopathy is a collective term for bicep pathology including tendinitis (inflammatory), tenosynovitis (swelling / fluid accumulation) and tendinosis (degenerative effects). It may also include biceps instability or stenosis. Patient complaints often involve anterior shoulder pain, restrictions in rotation and positive special tests related to the subacromial space. Bicep pathology in isolation is difficult to determine from subacromial and ACJ changes. Some pathology may be seen on ultrasound or MRI, seen as splits or swelling (tenosynovitis in most cases). Anatomical variants can be confused for pathology. Biceps pathology is typically difficult to visualize on imaging and also presents challenges under surgical inspection.

Biceps tenosynovitis may be a precursor to adhesive capsulitis and acutely present as adhesive capsulitis in rare cases with similar pain and restriction.  

Specific exercise, manual therapy and non-steroidal / steroidal medications are used in various combinations to improve and manage suspected bicep pathology. Injection options include sleeve and intra-articular steroid. Surgical options include removing the long head from inside the shoulder and creating an attachment at a lower position (biceps tenodesis) to avoid entrapment or synovitic responses. There are several variations for surgery, including inlay and onlay techniques for tenodesis, or alternatively tenotomy for some patients. Diagnostic arthroscopy may be valuable prior to tenodesis to evaluate the effect of subacromial and ACJ decompression on shoulder function and pain. 

Cases treated ~ 500+

Calcific tendinopathy is a relatively common finding estimated in 3-15% of the population and may be asymptomatic despite a sizeable calcification. Calcific tendinopathy can exist over a 10 year life cycle, with specific treatments reducing the disorder to 3-9 months of symptoms. 

Clinical cases are highly variable and patients can present with catching and clicking, restrictions in movement, localized or broad arm pain. Some are acutely painful without much warning and others can be less intense, but with stubborn pains lasting more than 10 years. The most debilitating have strong features of pain, poor cuff strength and restricted movement.

It can be confused for adhesive capsulitis or biceps / SASD pathology, and in rare cases  may co-exist with adhesive capsulitis. Confirmation of calcific deposits (now identified as calcium carbonate) can be made through x-ray and ultrasound. MRI will often miss this disorder. Calcium size, location and typing are important in determining the correct clinical therapy. 

Treatment requires significant experience and delicacy in determining when and how much to progress in physiotherapy. There are many clinical pitfalls when treating symptomatic and persistent calcific tendinopathy. Regular clinical testing, progressive treatment strategies and long term followup are all important aspects of care, along with understanding how to apply  treatments including shockwave and barbotage (also known as needling & lavage or UGPL) procedures.

Cases treated ~500+

Clavicle fractures are divided into several subtypes depending on the location of fracture and severity of deformity or displacement.

Undisplaced fractures are normally managed through general physician or surgical consultation, with short to medium term sling use and physiotherapy to reduce shoulder stiffness and promote early healing through progressive exercise.

Displaced fractures are normally managed by an orthopedic surgeon and sometimes fixed with an anatomically shaped plate and screws depending on the location of the fracture. 

Delayed union, fibrosis union and non-union can occur at times and methods have been devised to promote healing.

Physiotherapy is often necessary for regaining full shoulder movement and reviewing any neck or AC joint trauma that may have occurred at the time of the fracture. Return to contact sport should be delayed until full healing is achieved on plain film.

Cases treated ~ 75-100

The shoulder (glenohumeral and acromioclavicular joints) have five or six individual bursa  with the subacromial subdeltoid (SASD) bursa considered the source of most bursal complaints in the shoulder. 'Impingement signs' are often observed during overhead and behind back movements. Catching or hitching of the shoulder is common and pain is often noted at the tip of the shoulder or midway down the upper arm.

Bursitis may or may not be combined with cuff tears, biceps tendinopathy, calcific tendinopathy or frozen shoulder. Isolated bursitis appears to be relatively common based on clinical testing, speed of recovery and imaging findings (high false negative rate is likely on imaging). Bursitis is common in the athletic and non-athletic individual.

Bursitis may respond rapidly to anti inflammatory measures, but should be supported with improvements to posture, shoulder motion, strengthening exercise and awareness of potential triggering event including contributions from the neck and thoracic spine.

Physiotherapy treatment is necessary to assess movement, strength and exercise choices (to reduce the risk of recurrence once recovery is achieved). Significant controversy exists as to the best anti inflammatory measure and broad versus targeted methods. 

Pain referred from the cervical spine together with SASD bursitis is a common dual presentation requiring both mechanical and anti inflammatory remedies to achieve full recovery.

Cases treated ~ 1,000+

Shoulder pain generated from the spine (cervical more commonly than thoracic) is a common observation in many chronic shoulder complaints. Manual spinal therapy is typically very effective in reducing or eliminating these symptoms. Mobilization is preferred due to the broader treatment effects and low risk relative to manipulative techniques.  Massage has been observed to be much less effective in these cases.

Separating shoulder pathology from spinal referral is one of the early diagnostic challenges in treating the upper extremity successfully. Complete and long term recovery from shoulder pain often involves treating any shoulder pathology with careful progressions of spinal therapy.

Referred pain to the shoulder can be classed as radicular or non-radicular pain (somatic). Most pain complaints are non-radicular (i.e. non nerve root pathology) and can be effectively treated with a combination of spinal manual therapy, careful cervical stretching and cervical stabilization methods. There are likely patho-mechanical changes in the spine based on the recovery pace noted in a large group of patients as these treatments are progressed. Soft tissue imaging is rarely required and has low utility in these cases, unless recurrent with progressive symptoms or consistent neurovascular signs.

For example, a patient presenting with localized biceps pain, may test negative on a variety of provocative shoulder tests, including stressful maneuvers for bicep and cuff pathology. Depending on the history of the problem and when the complaint arises (during bench press for example), the source of the pain may be a referral from the spine and projecting (referring) pain to the shoulder. 

Identifying and separating shoulder pathology from spinal referral requires the therapist to have significant experience in pattern recognition, comprehensive examination skills and regular review of patient symptoms and physical tests. Changes within a physiotherapy session may be due to pain modulation via other inputs (i.e. manual therapy to the neck) and may not represent true effects. Irregular findings during shoulder testing (contradictory combined tests) will increase the suspicion of a spinal referral component.

Cases treated ~ 1,000+ spinal / bursal combinations

Post traumatic / surgical stiffness is believed to be a fibrotic reaction of the shoulder joint, without the strong inflammatory component characteristic of adhesive capsulitis. It is not a muscle spasm or the effect of 'muscles shortening'. Shorter self recovery times are expected compared to 'frozen shoulder', however stretch programs are considered important to ensure timely recovery.  Common after fracture and surgical procedures, occasional after traumatic dislocation and across all age groups.

Physiotherapy guidance and management is important for determining correct exercise and manual therapy options, progressing workloads and avoiding the pitfalls (such as traditional athletic stretches)  to regain movement. 

Cases treated ~ 300-400 as the primary complaint

A variety of classifications exist for injuries to the upper arm involving fractures of the shaft, anatomical or surgical neck, tuberosities or head of the humerus. 

These fractures display common stiffness complications, delayed fracture healing and impeded shoulder movement sometimes due to angulation, or tuberosity / humeral head displacement. Unstable multi part fractures can be stabilized but sometimes are better managed with shoulder replacements due to the low chances of satisfactory healing and movement after severe fracture.

Key movements should be taught early on in the healing phase and progressed within the comfortable limits of the fracture healing. Excessive force or movement can delay healing and prolonged sling time appears to a factor in greater stiffness levels. 

Medium to long term restrictions in movement require significant problem solving by the surgeon and physiotherapist as many of these restrictions can be due to bony changes and other soft tissue injuries overlooked at the time of fracture.

Cases treated ~ 200-300 

The rotator cuff is an important structure for supporting rotational movements of the shoulder and generating overhead force. Rotator cuff injuries commonly affect individuals over the age of 40, with increasing frequency in each additional decade of life. Rotator cuff tears in under 40 year olds are generally rare. Cuff injuries can be painful and are often diagnosed clinically through multiple special tests, however determining the extent of injury requires significant experience and imaging is preferred (high resolution ultrasound or MRI).

Tear width is normally the most important factor, followed by thickness and the portion of the cuff tissue (surface and location). Some small tears may have healing potential, however full thickness tears are very unlikely to heal and should they heal, will do so with   low tensile strength. Rotator cable integrity, joint geometry and supporting intact cuff play a role in how well the shoulder can compensate for a rotator cuff tear. Tear progression over time and surgical windows add to the need for an early discussion with an experienced physiotherapist.

Additionally, age, exercise history and the extent of the tear need to be considered when deciding on a surgical or non-surgical recovery. Small (1cm or less) through to large cuff tears (up to 3cm) require significant physical testing to determine whether surgery is the best option and what recovery is expected from rehabilitation. Post surgical care with physiotherapy is critical in reducing the risks of re-tear and therapy should continue for a minimum of 1 year for best outcomes. 

Post surgical protocols are variable and current evidence and consensus suggest careful progressions under physiotherapy guidance are likely to produce the best outcomes.

Cases treated ~ 1,000+

Shoulder dislocations normally occur due to high trauma directly to the shoulder joint or via to outstretched arm position, creating leverage at the shoulder joint. Other mechanisms may include rapid forward stretch with single and double shoulder dislocations observed.

Choice of management and rehabilitation versus surgery depends on how many dislocations you have had, under what circumstances and your age. Recurrence is high in younger populations and permanent bony damage is not uncommon with recurrent dislocations. 

Dislocations in the younger age group often cause damage to the labrum (lining) of the shoulder, commonly affecting the lower front corner (Bankart lesion). Approximately 95% of dislocations are anterior (forward). During a shoulder dislocation, injuries may occur to both sides of the glenohumeral joint and within the capsule. The most common injuries are Bankart tears and Hill-Sachs impaction fractures. Both of these injuries usually do not heal and the severity often determines the overall stability of the shoulder for later activity. Early support and consultation with an experienced physiotherapist are important at this stage. Recurrent dislocations are a major concern leading to further joint pain, cartilage effects and reduced confidence in arm motion.

Subluxations are not true dislocations and describe excess unwanted movement at the shoulder joint without full dislocation. Bony and soft tissue injuries are still possible with recurrent subluxations.

A thorough rehabilitation program can be successful in preventing further dislocations and reducing subluxations. An eight to twelve week program is an ideal test and training period to progress through the rehabilitation stages. Evaluation of stability and comfort is performed both passively and dynamically, with negative apprehension testing the ideal outcome.

If you require surgery, choosing your surgeon and understanding the different surgeries are an important step before making any decision. Protecting the surgical site post operatively while minimizing shoulder stiffness is key. You should be monitored for any post surgical complications, taught recovery techniques for movement and strength, and support for early pain management. 

Return to exercise and sport can sometimes be rapid in non-surgical cases for the in-season athlete, wtih sufficient monitoring and after season care. In post surgical cases, full recovery  can be achieved in 6-9 months. Return to moderate general exercise often within 10-12 weeks and return to sport at 3-9 months depending on the contact levels and pace of recovery post operatively.

Cases treated ~ 500+

Since the 1970s, it has slowly morphed into a term used to describe an array of symptoms noted during shoulder movement, with different interpretations by academics, therapists, radiologists and surgeons.  Several sub types have been proposed including outlet, primary and internal impingement along with other compartments of the shoulder such as subcoracoid impingement. Shoulder 'impingement' is therefore a very broad description and is akin to saying 'shoulder pain'. Movement disorders of the shoulder can normally be traced back to a specific diagnosis of the shoulder and the term impingement should be avoided where possible.

The term 'impingement' is now an unfortunate and common reference by professionals and patient alike, usually to describe uncomfortable sensations in the shoulder, commonly during mid points of movement, or at end range movements of the shoulder. Most shoulder disorders create some form of pain during arcs of movement or at end range. 

More than 10 common diagnoses can generate these mid range symptoms, some soft tissue, some bony and some movement based or referred. Each one will require a different treatment for a successful outcome.

Unfortunate attempts by the academic world to investigate and solve shoulder 'impingement'  have also contributed to this clinical misunderstanding, with a mixture of pathologies having overall poor outcomes to any one intervention. 

If you have received a final diagnosis of 'shoulder impingement', you should seek a more experienced opinion. Further discussion can be found under the 'ghost diagnoses' section on this page.

Shoulder separations refer to the disruption of the acromioclavicular (AC) ligament and suspensory (coracoclavicular) ligaments that support the AC joint. Injuries are normally graded on level of disruption from mild (grade I) to complete (grade III). More unusual disruptions and clavicle displacement receive higher grades and may require surgery (grades IV-VI).

Unusual variants have also been noted in the past decade, namely a suggested grade III(B) that results in secondary scapular dyskinesis and restriction of overhead movement. Pediatric separations are also very uncommon (under 15 years of age) with periosteal or growth plate disruptions noted at the clavicular or coracoid attachments.

Recovery is normally within a 4-8 week period for the grades I-III. The higher grades may require surgical evaluation and are defined with multi-plane x-rays. An arm sling or tape support can be used for short term pain relief, however we have had more success with early exercise approaches.

Physiotherapy protocols exist for staged return to sport based on the grade of injury, cervical spine effects and how well the patient manages the exercise process.

Long term pain due to untreated ACJ separations can be solved through appropriate therapy and do not require surgical support in most cases. Improvements in shoulder girdle and neck function are also necessary for some patients to gain full relief.

Operative support is typically last resort due to a high surgical complication rate in all but the most expert surgical hands. Grade V injuries can be successfully managed non-operatively in about half of the cases seen.

Cases treated ~ 200-300 including III A/B, IV, V and paediatric classifications

Disorders leading to AC joint (ACJ) pain include ACJ synovitis, osteoarthrosis(itis), supra-acromial bursitis and osteolysis. Combinations of inflammatory and mechanical signs are commonly noted, including referral from the cervical spine. Some scapular dyskinesis may play a role in these conditions and common triggers are resistance training such as excessive bench press or pushups.

Pain from the acromioclavicular joint (ACJ) is sometimes difficult to separate from  glenohumeral joint pain and a thorough examination is required to define the source.  Disorders of the ACJ can mimic 'impingement' findings or contracture and can produce referred pain. Special imaging views in stress positions can be helpful.

Treatment is a combination of physiotherapy (managing activity levels, making the right exercise choices and specific scapular control) and sometimes sports medicine support. Some AC disorders may require surgery for full recovery. 

Cases treated ~ 100-200 non-traumatic cases including all sub types noted above.

Acute Inflammatory Bursitis (AIB) is a rapid onset, severe bursitis affecting the subacromial subdeltoid (SASD) bursa. It can be triggered by an innocuous event in the preceding 12-24 hours. Pain is typically very severe and arm movement difficult. Palpation at the tip of the shoulder should be exquisitely sensitive in almost all cases.

Early pain management is important and a variety of options are available. Recovery is normally within several days, however some shoulders will continue to show mild - moderate symptoms beyond six weeks. Delayed management and uncontrolled inflammation may increase the risk of longer term symptoms.

After an acute inflammatory bursitis, the shoulder should be examined for signs of calcific tendinopathy, prominent scapular dyskinesis or other mechanical problems to reduce the risk of recurrence.

Cases treated ~ 50+

There are several  inflammatory diseases that may involve the shoulder joint, the most common being rheumatoid arthritis, a condition affecting the synovial layers and joint capsule leading to joint deformity, pain and cartilage changes.

These conditions are normally managed with medication, physiotherapy guidance for activity and exercise together with occupational therapy for hand function and assistive devices.

Periods of inflammatory flare are often reduced with specific medications and exercise methods are matched to the patients' status, with more activity possible during periods of remission / stable symptoms.

Polymyalgia Rheumatica (PMR) is a somewhat rare inflammatory condition that typically affects both shoulders and may present similar to bilateral adhesive capsulitis. See PMR in the rare section for more details.

The articular surfaces of the shoulder (GHJ) create an unstable configuration with the humeral head having approximately 3 times the surface area of the glenoid. The labrum of the shoulder has been likened somewhat to the meniscus of the knee but more accurately is similar to the  labrum of the hip, providing additional stability through 'suction and bumper' effects. 

Disruptions at the top of the shoulder joint are often referred to as SLAP (Superior Labrum, Anterior to Posterior) tears and are usually identified on MRI or MRA (magnetic resonance arthrogram). There are many classifications of SLAP tears with the most common thought to be type II (includes minor disruption of the bicep anchor). Some radiologists and surgeons continue to use SLAP classifications, while most describe any tear based on a clock overlay (SLAP tears are within 10 o'clock to 2 o'clock positions). These tears may or may not be symptomatic and are commonly seen in specific sporting populations, particularly overhead throwing, climbing and ball sports. 

Diagnosing SLAP tears and confirming them as the source of patient symptoms requires exclusion of almost all other pathologies and using select positive tests biased towards the superior labrum. Imaging can produce false negatives and positives.  Arthroscopic evaluation is the gold standard to determine the severity of these lesions. Treatment commonly involves cutting  the biceps tendon and reattaching (tendonesis) to remove the tensile and torsional loads away from the labrum.

SLAP tears often co-exist with other injuries including biceps tendinopathy and cuff injury, making separation of the sources of pain more difficult under clinical examination.

Treatment should begin with non-surgical methods (cuff conditioning, scapular positioning, improved sports mechanics and medication / injection procedures) and continued for some time. Surgical options exist for cases resistant to these measures.

Cases treated - 100+ based on surgical outcomes, high clinical suspicion

Biceps ruptures at the shoulder joint lead to what is commonly known as Popeye's arm. The outer portion (long head) of the biceps muscle shortens towards its remaining attachment at the elbow, resulting in a larger muscle bulge above the elbow. Some residual pain is commonly experienced in the shoulder or arm for a period of weeks to months and strength loss is typically mild.

Biceps ruptures at the shoulder are not surgically repairable in most cases. Partial, full and complete tears of the biceps at the elbow are more significant and may require early surgical assessment. Mild to moderate grade tears can be managed in physiotherapy and without surgery.

A biceps rupture at the shoulder tends to increase the suspicion for adverse cuff changes and it is important to have a full shoulder assessment after this injury. Increasing the strength of supporting tissues, particularly careful selection of rotator cuff training, is highly recommended.

Cases treated ~ 50-75 LHB ruptures including proximal and distal tears

Several key peripheral nerves support the function of the shoulder, that include movement and placement of the scapula and muscle force via the rotator cuff. The most common nerve injuries leading to decreased shoulder movement or pain, are the long thoracic nerve (LTN), suprascapular nerve, axillary nerve and accessory nerve in that order of frequency (from highest to lowest). Peripheral nerve injuries may have a specific mechanism or be part of a brachial neuritis.

The long thoracic nerve supplies the serratus anterior muscle. It is a key component in upward rotation, protraction and lateral slide of the scapula. Injury to the nerve and resulting loss of function to the muscle, often results in a 'winging scapula'.  It may be injured through compression or stretch, to both the neural and potentially vascular structures (subscapular artery) supporting the nerve. Injuries may occur due to trauma, arm positioning during general anaesthesia, prolonged compression in sleep, viral reaction and as a post operative complication of thoracic surgery.

No other motor nerves supply the serratus anterior and mild cases of injury typically show subtle effects during arm motion and are usually more pronounced during descent of the arm or weighted arm movements. More severe nerve loss can result in difficulty raising the arm above shoulder height due to loss of upward scapular rotation (the scapular sling). Substitution options can be taught in physiotherapy to regain overhead motion, even with significant LTN loss.

The supra scapular nerve supplies two important portions of the cuff, namely supraspinatus and infraspinatus muscles. The nerve may be injured due to trauma, cystic compression (via SLAP injury), infection or other pathology. Common locations of disturbance are at the supra scapular notch (loss to both muscles) and the spinoglenoid notch (loss to infraspinatus only) of the scapula.

No other motor nerves supply these muscle bellies, with loss of external rotation and overhead lifting strength. Functional loss / severity can be defined by weighted testing of the arm. Full recovery from suprascapular nerve injuries is thought to be more common than for LTN injuries.

Axillary nerve loss (deltoid) often leads to profound losses of arm movement and squaring off of the shoulder, whereas accessory nerve loss to the upper trapezius results in 'drooping' of the shoulder girdle. 

Physiotherapy involvement is very important to guide recovery activities and correct compensations while the nerve(s) recover. There are no known methods for accelerating nerve recovery. Recovery is normally within a 6-12 month period which includes nerve and subsequent muscle recovery.

Exercises to support normal arm function are important, along with avoiding secondary complications such as subacromial bursitis and spinal related pains. Recovery can be complete or incomplete and in our clinical experience, nerve or muscle transfers should be delayed / avoided due to sufficient natural recovery in most patients.  If no function is regained, a surgical consult is required to discuss the various options.

Cases treated ~ 40-50

Osteoarthritis (OA) of the shoulder can be seen on x-ray, with severe grades normally  required for the condition to be the primary source of shoulder pain. The severity of osteoarthritis is normally graded as mild, moderate or severe  and agreement between radiologists is unfortunately low.  We estimate reporting to be under / over graded in 25% of cases due to incorrect measurements and that can be increased by lack of patient presentation. Joint space loss (axillary view most accurate), subchondral sclerosis, osteophytes, erosions and joint deformity are characteristic signs of OA and graded subjectively. 

Direct visualization of the films is very important when determining the significance and severity of symptomatic osteoarthritis(osis). Osteoarthritis is commonly referred to as a 'wear and tear' phenomenon due to increasing prevalence as we age and a low occurrence in the younger age groups. 

Mild to moderate osteoarthritis can be observed on x-ray without symptomatic shoulder pain, including rare patients exhibiting severe x-ray changes with near full shoulder motion and minimal pain. Early external rotation loss and overhead movement may be the first signs of symptomatic osteoarthritis. The shoulder has some capacity to adapt to these restrictions using increased scapula motion. 

There are  several classification methods depending on the history one attributes to the osteoarthritic signs with examples including dislocation arthropathy, cuff arthropathy or crystalline arthropathy. Glenoid changes are normally first and can be difficult to detect, followed by humeral head signs. Significant deterioration results in greater range loss, and commonly joint crepitus (cracking, grinding or sometimes clunking) that can be induced during physical testing.

Many treatment options exist from general exercise and care, to specific physiotherapy exercise protocols, injection therapy and finally surgical options ranging from CAM (comprehensive arthroscopic management) type procedures through to full arthroplasty (joint replacement). A comprehensive discussion with your physiotherapist is the recommended starting point, with assistance from sports medicine and surgery in the more severe cases. Your age will be a factor in your surgical options, including CAM procedures, interposition, semi, TSA (total shoulder arthroplasty) and reverse TSA procedures.

Regular physiotherapy is important for post surgical recovery with stiffness and weakness being the key issues to solve.  Recovery of full movement and strength is possible for TSA and moderate to full movement with some strength loss in rTSA procedures. Reverse joint replacements are unique to the shoulder and allow for moderate to good recovery in the absence of rotator cuff function. 

Progressive medium to long term physiotherapy is strongly recommended to achieve the highest function after joint surgery. Specific post surgical protocols exist for TSA and rTSA procedures and are normally provided by your surgeon for immediate post operative restrictions. Middle and late stages of rehabilitation and recovery are normally determined by your treating therapist and gains can be made beyond the first year of recovery.

Cases treated ~100 non-surgical, 100+ surgical across ages 25-85, from interposition surgeries through to rTSA.

A very controversial shoulder topic, with different methods of assessment and treatment  throughout the world. Assessment is subjective and based on visual inspection or reaction to corrective movements. Several suggested methods of objective measurement have been disproved based on asymptomatic dyskinesis or poor prediction rates of shoulder dysfunction.  

Any arrhythmic movement of the scapula, significant displacement away from the thoracic wall or mal-adaptive movement (scapula flip) can be considered a scapular dyskinesis. Scapular dyskinesis refers to the abnormal placement or movement of the scapula relative to the thoracic wall or in relation to accepted normals of scapulohumeral rhythm. It is often termed scapula winging, scapula tilt or poor scapula rhythm (coordination). Scapula movement disorders may only be observed during specific movements, speeds, directions or under certain loads. 

Dyskinesis can be divided into primary (motor nerve disruptions / direct disorders of the scapula or supporting thoracic cage) and secondary (adaptations or mal-adaptations to other shoulder disorders such as cuff tears, spinal pain, ACJ IIIB injuries, calcific tendinopathy, adhesive capsultis, etc). 

Dyskinesis can also include movement disorders due to surrounding muscle weakness, incoordination or hypermobility, often resulting in scapula flip during bracing of the arm. Due to the difficulty in assessing scapula placement objectively in 3D, visual inspection remains the gold standard of determing thresolds for a dyskinesis diagnosis. Significant clinical experience is required to determine whether scapula movement is within normal limits or is abnormal.

Symptoms of dyskinesis generally do not manifest as scapula pain, but rather neck, ACJ and lateral arm pain (likely subacromial effects). Pathology at the scapula is uncommon (such as true scapular bursitis) or crepitus on movement (see snapping scapula syndrome). 

Despite some current academic advice, altering scapula movement to enhance or work around an adjacent joint disorder is ill advised and caution is required in using scapular repositioning / assistance tests.

An experienced clinician must identify any glenohumeral or surrounding pathology before determining the importance or severity of a scapula dyskinesis.

Many methods of treatment exist and vary from isolation strategies to facilitation strategies, with an experienced clinician blending or switching between these depending on the patient need and reaction to treatment.

Cases treated - primary neurological 50-100, secondary ~ 200-300

The scapula provides the socket of the shoulder (glenoid) that blends with a large flat blade for attachment of the four rotator cuff muscles and attachments for ligament support to the clavicle. 

Scapula fractures of the blade (body) are generally non-surgical. Neck fractures and two or three part fractures are more serious and may need surgical stabilization. Fractures that involve the glenoid surface can be managed without surgery provided displacement is minimal. Most fractures will be managed by an orthopedic / shoulder surgeon and broad pain patterns are possible into the arm until sufficient healing occurs.

Physiotherapy interventions  are recommended during the healing phases to maintain surrounding joint function and to maximize mobility in the shoulder joint.

Cases treated ~ 25-50

Snapping scapula syndrome relates to cracking, grinding or crepitus at the shoulder blade (scapula) during shoulder blade movement or upper arm motion. The 'snapping' is likely due to muscular banding, fibrotic changes and rarely scapular bursitis. Most cases can be improved significantly with correction of scapular movement into a better position (generally avoiding downward corrections), massage therapy and postural / exercise corrections. 

The condition may be aggravated by the patient rolling their shoulders and forcing the shoulder into low positions. Some patients will have a single click or snap while others may experience through range, continuous snapping.

Physiotherapy is the mainstay of treatment, and injection therapy is rarely required.  Surgical options such as superior angle osteotomies are not recommended.

Cases treated - 50+ as a primary concern

Radicular pain refers to irritation of typically a single spinal nerve root with characteristic pain patterns following a dermatomal / myotomal distribution of symptoms. Spinal nerve roots supplying the shoulder and arm exist from C4 to T1 with common nerve roots being affected at C6 and C7.

Pain may be the overriding feature without significant sensory or motor loss. Nerve root disorders of the cervical spine are typically sensitive to end range cervical motion or prolonged flexion / extension positioning. Provocative maneuvers such as Spurlings test or quadrant tests may be unremarkable. 

Identifying mild - moderate radicular pain in the early stages can be difficult due to similar symptoms and signs from non-radicular pathology.  

An experienced physiotherapist can provisionally diagnose the disorder with improvements through select shoulder and neck exercises. Avoiding pain triggers and careful use of manual therapy is important. Spinal manipulation is generally contraindicated. Specific shoulder and neck exercises can be very helpful in reducing pain and preventing further injury or aggravation. 

Various medications may also be necessary to help manage strong pain, with recovery typical over a 6-12 week period provided the patient is compliant to restrictions in activity and regular physiotherapy guidance. 

In the later stages of recovery, cervical manual therapy and cervical stabilization routines (a 6-8 week program) are highly recommended to minimize the risks of recurrence or progression of cervical changes.

Cases treated ~ 75-100