Description/ Introduction

Upper Crossed Syndrome aka “proximal or shoulder girdle crossed syndrome” involves a delicate imbalance of muscles. It is characterized by tightness in some muscles (the upper trapezius and levator scapula) on the dorsal side crosses paths with tightness in others (the pectoralis major and minor) along with a weakness of the deep cervical flexors (ventrally) crosses with weakness of the middle and lower trapezius. This intricate pattern of imbalance creates joint dysfunction that causes postural changes as well as pain/discomfort and stiffness in the neck and shoulder. The Physios at our clinics aim to combat Upper Crossed Syndrome and its symptoms by using a variety of treatment techniques and modalities to provide lasting long-term relief.

Clinical Signs and Symptoms

UCS manifests as:

• Headaches
• Neck pain or strain
• Chest tightness
• Upper back pain, especially in the shoulders
• Restricted neck or shoulder range of motion
• Numbness, tingling, and pain in the upper arms
• Posture changes (Rounded Back and Forward Head)

Physical Therapy for Upper Crossed Syndrome

Physical Therapy helps patients with Upper Crossed Syndrome by helping address the issue at its root cause. A combination of manual techniques, modalities, strengthening exercise, postural retraining, as well as patient education will help treat the symptoms of the condition as well as prevent its reoccurrence.

Services Offered by Us:

Physical therapy can help manage Upper Crossed Syndrome and aid in returning to normal everyday function without difficulty/discomfort. Our PTs are trained to provide relief by doing the following:

• Laser Therapy and Ultrasound Therapy: Used for heating and promotes tissue healing.
• Interferential Therapy: Stimulates the muscle and nerve fibers.
• Shockwave Therapy: to relieve pain.
• Exercise Therapy: Muscle Strengthening and Stretching and training to improve overall function.
• Postural Training: for the best positions for weight bearing to reduce stress on the muscles and joints.
• Education: Learning different techniques to perform daily activities even while being limited
• Manual Therapy: Manual techniques such as trigger point release is beneficial in improving mobility and reduce pain.

Description/Introduction

The Shoulder is one of only two ball and socket joints of the body, this allows it a greater degree of freedom when it comes to movement, at the cost of stability. A painful shoulder can cause hindrances to daily activities such as difficulties is reaching and lifting objects as well as difficulty with tasks such as bathing and dressing/ undressing. Physio Asia Therapy Centre aims to target shoulder pain at the root and build a strong foundation of strength and mobility to prevent secondary injuries.

Clinical Signs and Symptoms

Pain in the shoulder may also present with:

• Muscle tension around the area of the neck and arm
• Pain that can be felt radiating down the arm.
• Swelling and Stiffness around the joint
• Pain/ Stiffness during reaching for objects and picking up objects from the ground.
• Difficulty in daily activities such as bathing, eating, and dressing/undressing.
• Numbness on the joint and even down the arm
• Muscle Spasm

Causes

Shoulder Pain may be caused by one of the following underlying conditions.

• Rotator Cuff Injuries:
  • Rotator Cuff Tears: Partial or full tears of the tendons connected to the arm bone. These can result from trauma or repetitive motion.
  • Tendinitis: Inflammation of the rotator cuff tendons due to overuse.
• Arthritis:
  • Osteoarthritis: Wear and tear of the joint cartilage.
  • Rheumatoid Arthritis: An autoimmune condition affecting the shoulder joint.
• Bursitis:
  • Inflammation of the fluid-filled sacs (bursae) that cushion the bones, tendons, and muscles near the shoulder joint.
• Adhesive Capsulitis (Frozen Shoulder):
  • A condition characterized by stiffness and reduced range of motion in the shoulder joint.
• Fractures:
  • Bone fractures in the shoulder due to direct injury or osteoporosis.
• Referred Pain:
  • Pain originating from other areas (e.g., neck arthritis, liver or lung diseases) but felt in the shoulder.
• Muscle Strains:
  • Injury or inflammation of shoulder or upper arm muscles.
• Labral Tears:
  • Cartilage injuries within the shoulder joint.
• Nerve Compression or Injury:
  • Conditions affecting the brachial plexus or other nerves in the shoulder region.
• Shoulder Instability:
  • Dislocation or subluxation of the shoulder joint.

How Can Physiotherapy Help with Shoulder Pain:

Physical therapy can help manage shoulder pain and aid in returning to normal everyday function. Our PTs are trained to provide relief by doing the following:

• Laser Therapy and Ultrasound Therapy: Used for heating and promotes tissue healing.
• Interferential Therapy: Stimulates the muscle and nerve fibers.
• Shockwave Therapy: to relieve pain.
• Exercise Therapy: Muscle Strengthening and Stretching and training to improve overall function.
• Postural Training: for the best positions for weight bearing to reduce stress on the muscles and joints.
• Education: Learning different techniques to perform daily activities even while being limited
• Manual Therapy: Manual techniques such as trigger point release is beneficial in improving mobility and reduce pain.

Description/ Introduction

Adhesive Capsulitis aka “Frozen Shoulder” is a condition that is caused by the thickening of the shoulder capsule –a sheath that encases the joint of the shoulder, thus restricting movement. The main symptoms of frozen shoulder are joint pain and stiffness that worsen over time. The Physios at our clinics aim to combat Adhesive Capsulitis and its symptoms by using a variety of treatment techniques and modalities to provide lasting long-term relief.

Clinical Signs and Symptoms

Frozen Shoulder often presents with symptoms such as:

• Sharp pull or pain in the middle of upper arm on sudden movements, like a flash of lightening 
• Difficulty raising your arm sideways or forwards or carrying objects.
• Difficulty putting the arm behind your back. 
• Pain in mid-range of shoulder movement 
• Pain in shoulder lasting for more than a few days.
• Swelling or significant bruising around the shoulder or arm
• Shoulder pain that occurs at night or at rest, also disrupting normal sleep patterns

1. Freezing Stage

• Duration: Lasts approximately 2 to 9 months.
• Characteristics:
  • Pain takes center stage.
  • Any shoulder movement triggers discomfort.
  • Gradual loss of shoulder mobility.
  • Simple tasks such as fastening a seatbelt or reaching for a cup becomes difficult.

2. Frozen Stage

• Duration: Persists for about 4 to 12 months.
• Characteristics:
  • Pain may ease, but stiffness intensifies.
  • The shoulder resembles a rusted hinge, resisting movement.
  • Everyday activities like putting on a coat, combing hair become impossibly difficult.
  • Nocturnal discomfort/pain that disrupts sleep.

3. Thawing Stage

• Duration: Gradual improvement over 5 to 24 months.
• Characteristics:
  • The shoulder cautiously thaws, like a winter morning yielding to the sun.
  • Movement becomes less painful.
  • Range of motion gradually returns.
  • Patients regain the ability to reach overhead and perform daily tasks.

How Can Physiotherapy Help Frozen Shoulder Patients

Physical Therapy for Frozen Shoulder focuses on the management of symptoms present and reduction of pain and increasing available range of motion. Physiotherapy can help patients achieve decrease in pain/discomfort, improvement in muscle strength, return to activities of daily living, etc.

Services provided by Us:

Our physiotherapists will assess the painful area and treat the symptoms with a combination of techniques, some are as follows:

Physical therapy can help manage shoulder pain and aid in returning to normal everyday function. Our PTs are trained to provide relief by doing the following:

• Laser Therapy and Ultrasound Therapy: Used for heating and promotes tissue healing.
• Interferential Therapy: Stimulates the muscle and nerve fibers.
• Shockwave Therapy: to relieve pain.
• Exercise Therapy: Muscle Strengthening and Stretching and training to improve overall function.
• Postural Training: for the best positions for weight bearing to reduce stress on the muscles and joints.
• Education: Learning different techniques to perform daily activities even while being limited
• Manual Therapy: Manual techniques such as trigger point release is beneficial in improving mobility and reduce pain.

DO YOU HAVE ANY OF THESE SHOULDER PAIN SYMPTOMS?

• Sharp pull or pain in the middle of upper arm on sudden movements, like a flash of lightening
• Difficulty raising your arm sideways or forwards or carrying objects
• Putting the arm behind your back
• Pain in mid-range of shoulder movement
• Pain in shoulderlasting for more than a few days
• Swelling or significant bruising around the shoulder or arm
• Shoulder painthat occurs at night or at rest, also disrupting normal sleep patterns

Frozen shoulder and Rotator Cuff tendinits are common conditions treated by Physiotherapists in Singapore. Our team of highly qualified and experienced Singapore physiotherapists can assess your shoulder and use specialised methods of physiotherapy treatment to reduce the pain and improve shoulder movement.

COMMON SHOULDER PROBLEMS

• Frozen shoulder– It is characterized by pain with significant loss of its range of motion in all directions progressively worsening over a period of time. The capsule around the shoulder joint becomes thickened and inflamed almost causing the shoulder joint to be stuck causing severe stiffness and shoulder pain. It’s common in diabetics and females over 50.

• Acromial spur– Deposits of calcium may appear in the tendon which may cause swelling and tension in the tendon. This can cause a sharp pain.
• Rotator cuff tendonitis, ThePainful Arc Syndrome or Supraspinatus Impingement:  Rotator cuff muscles have tendons to attach to the arm bone, but these tendons travel between bones of the shoulder joint and therefore commonly get pinched or injured and then inflamed, especially the Supraspinatus tendon is one of the most injured.
• Arthritis – Rheumatoid arthritiscommonly affects the shoulder joint and also the neck
• Shoulder and collar bone fracture
• Shoulder instabilityor Weakness- occurs when the shoulder joint capsule or ligament and muscles that surround the shoulder joint do not maintain the ball within its socket. It may cause the joint to be loose and slip out of its position on movement and capsule pain and instability

COMMON CAUSES OF SHOULDER PAIN

• Rotator Cuff Tendon inflammation
• Biceps Tendon inflammation
• Fall onto an outstretched arm or directly onto the shoulder
• Fracture or shoulder labral tear
• Repetitive use and wear and tear
• Bursitis- The sac of fluid that cushions the tendon can also be damaged
• Exercises with overhead weight lifts done with wrong techniques
• Shoulder dislocation or subluxation
• Poor posture
• Poor Breathing patterns

PHYSIOTHERAPY TREATMENT FOR SHOULDER PAIN

It is important in the early stages to prevent the condition from becoming more complex with rapid loss of muscle strength and stability around the shoulder blade and shoulder. If prolonged it may lead to Frozen shoulder, Neck Pain, headaches.

Physiotherapy for shoulder depends entirely on the cause of the problem. Hence, it is important to understand the cause of your symptoms before starting a treatment program which may include:

• Shoulder Joint Mobilisationand Muscle Releases
• Radial Shock Wave therapy
• Electrotherapy including Short –Wave Diathermy and Laser therapy
• Shoulder blades/ Rotator Cuff Stabilisation exercise
• Specific physiotherapymobility and strengthening exercises for shoulder pain
• Trunk and neck mobilisation
• Posture correction and advise on techniques of movement in sports to prevent stress on the shoulder tendons to reduce the risk of future injury and improve efficiency of movement.
• Shoulder taping

Are you suffering from Shoulder pain? Have you had a prior shoulder injury or rotator cuff injury? Have you recently recovered from a frozen shoulder but can’t achieve the last few degrees of range? OR are you just looking at improving your shoulder movements and range?
If so, then read on for some exercises to assist with increasing your shoulder mobility.

The shoulder joint also known as the glenohumeral joint is a ball and socket joint.  This complex joint is one of the most mobile joints in the body. The movements that occur in this joint are:

1. Flexion – Arm moving forwards and up towards the head
2. Extension – Arm moving straight backwards, away from the body
3. Adduction – Arm moving towards the midline/ across the body
4. Internal Rotation – Rotating the shoulder inwards so that the thumb is pointing towards the midline
5. External Rotation – Rotating the shoulder outwards so that the thumb is pointing away from the midline.

Mobility V/S Flexibility?

Mobility refers to the ability of a joint to move actively through a range of motion.
Mobility requires both flexibility and strength. Whilst people mistakenly use these terms interchangeably and flexibility is a component of mobility, they are in fact not the same thing.

Flexibility refers to the ability of a muscle to temporarily lengthen. Flexibility is passive.

Why is it important to work on shoulder mobility?

Mobility is important to maintain joint health. Our ability to move without pain or restrictions means we can easily perform our daily activities and strength train. If you have limited mobility, it may lead to compensatory patterns which further predisposes your body to injuries.  As most movements of the upper limb involve the shoulder joint, it is important to ensure shoulder mobility is not compromised.

What influences shoulder mobility?

• Scapula movements
• Glenohumeral joint movement (Shoulder joint movement)
• Thoracic spine (mid-back) mobility

A compromise of either of these along with their surrounding musculature will have an impact on the mobility of the shoulder joint.  Here are some exercises you can try to work on the mobility of your shoulder joint:

Please note, all exercises should be pain free. If you are suffering from pain with movements or are unsure about the exercises, please consult your Physiotherapist before attempting them. Please perform all movements SLOWLY. Sudden entry/ exit of certain positions can result in muscle spasms. Suggestions by our Physiotherapist in Singapore centre:

1) Thoracic Rotations against the wall

1. Start in a half kneeling position next to a wall, with your left hip and knee bent at 90 degrees, out in front of you.
2. Place a block or cushion between your left knee and the wall
3. Have your Left arm extended out resting on the wall at 90 degrees
4. Have your Right hand touch your left palm
5. Ensuring the hips stay pointing forward, rotate through the midback to bring your right arm across, aiming for the wall behind you
6. Return back slowly to have your palms touching again

7. Repeat x10 on each side
* Ensure your back IS NOT arching
* Ensure the movement comes from the mid-back, NOT the lower back or hips
* Ensure you ARE NOT leaning back
* Move into and out of each rotation SLOWLY. Sudden movements can result in muscle spasms.
* Move across as far towards wall as your mid-back will allow you – DO NOT push into pain.

2) Wall slides

1. Place your forearms and hands along a wall so that your elbows are bent and your arms point towards the ceiling.
2. Push your elbows into the wall to pull your shoulder blades away from each other as you slide your hands up the wall.
3. Feel an effort in the Serratus Anterior muscle – along the sides of your ribcage.
4. Return to the original position
5. Repeat x10.

6. Do make this more challenging, you can loop a resistance band around your forearm and follow the steps above.

* Ensure back stays flat and neutral throughout the exercise – Do NOT arch the back
* Ensure forearms stay parallel throughout. AVOID flaring out the elbows as you move up
* Ensure shoulders are relaxed. DO NOT shrug the shoulders to lift the elbows.

3) Sleeper stretch – For the back of the shoulder joint

1. Start by lying on your side with the left arm on the bottom.
2. Your bottom arm should be bent at the shoulder, elbow and forearm at 90 degrees – pointing up to the ceiling
3. Use your top arm to gently draw your left forearm towards the bed for an inward stretch.
4. Hold for 15 seconds, repeat on opposite side
*Ensure there is no pinching pain with this
* DO NOT push into discomfort or pain.

4) Shoulder rotation stretch

1. Start by standing straight with a band or belt in your arms at approximately shoulder’s width apart (or slightly wider)
2. Keeping the back flat, bring the band overhead, as far back as your shoulder allows
3. Hold this position for 5 seconds
4. Return band SLOWLY back to the front
5. Repeat x10

* DO NOT bend your elbows
* DO NOT shrug your shoulders
* DO NOT arch your back when elevating yours arms

5 ) Shoulder joint mobility (CARs)

1. Standing up tall, with the back flat raise your left arm up keeping the elbow straight
2. SLOWLY ROTATE the arm moving up towards the ceiling and then backwards into extension.
3. Try to keep the arm pressed as close to the head as possible
4. Finish by bending the elbow and resting the back of your hand on your back.
5. Repeat x 10 on each side.
6. The GOAL is to move the shoulder through its maximum range of movement.

* DO NOT arch the back
* KEEP elbow straight when moving the arm overhead and into extension
* DO NOT push into a painful range.

Frozen shoulder is a condition that leads to stiffness of the shoulder joint, therefore causing restriction in movement. Simple activities such as reaching overhead, sideward, and behind the back can become very difficult and painful.

Although the cause of FS is still unknown, some risk factors identified were diabetes, stroke, sedentary lifestyle, thyroid disease, and a previous history of shoulder injury.

Studies also found that frozen shoulder is two to four times more common in women between 40-60 years of age and with the nondominant shoulder being more affected.

Frozen shoulder, if not secondary to any shoulder injury or preexisting condition such as diabetes, is primarily a diagnosis of exclusion, based on thorough history taking, physical examination and appropriate imaging.Common clinical findings include: stiff and painful shoulder for at least 4 weeks, severe shoulder pain affecting work and daily activities, pain at night, and restriction of both active and passive shoulder motions. 

Although frozen shoulder can be painful, it is important to move the affected shoulder in all directions to maintain and increase available range. Stretching and mobilization exercises should also be done daily to prevent progressive stiffening of the shoulder joint.

Physical therapy has been shown to be beneficial in conservative management of frozen shoulder. Typical program will include mobilization, stretching, and strengthening exercises. Home exercises and self-management techniques are also vital parts of a comprehensive physical therapy program to promote patient independence.

Before initiating any exercise, the affected shoulder should be warmed up first either by taking a warm shower or placing a hot compress on the affected area for 10-15 minutes. Pain can be present when performing exercise but as long as the pain is tolerable it is safe to continue.

1. Pendulum stretch/Codman`s exercise

Goal: Stretch the shoulder joint

Procedure:

a.) Stand and lean slightly over a table using the good arm as a support and letting the affected arm to hang down

b.) Swing the arm in small circles in clockwise, and then counterclockwise directions for 10 revolutions each

c.) Do this once daily and as symptoms improve, progress to bigger swing diameter

d.). If comfortable and pain-free, you can hold a light weight (3-5 lbs) on the affected arm to gently increase the stretch on shoulder.

2. Self-mobilization Technique

Goal: Mobilize the shoulder

Procedure:

 a.) Lie on your stomach, propped up on both elbows

 b.) Shift your body weight downward between the fixed arms

 c.) Return to previous position, and repeat

 d.) Do this or 10-20 times at least twice daily

4. Cross-body stretch

Goal: Stretch the back of your shoulder

Procedure:

a.) In sitting or standing position, use good arm to lift the affected arm at the elbow

b.) Bring the affected arm up and across your body, gently stretching the back of the affected shoulder

c.) Hold the stretch or 10-15 seconds and repeat three times

d.) Do this twice DAILY!

Goal: Increase shoulder flexion

5. Towel stretch

Procedure:

a.) Hold a towel behind your back

b.) Good arm holds the one end above, while the affected arm holds the other end below

• Using your good arm, then slowly pull the affected arm upward to stretch it
• Hold the position for 10-15 seconds and repeat three times; do this twice daily

Goal: Increase shoulder inward rotation

If you are suffering from frozen shoulder you can consult one of our Singapore Physiotherapist or Manila Physiotherapist.

Call us for an appointment or send your queries to: info@physioasia.com

REFERENCES:

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Donatelli, R. (2012). Physical Therapy of the Shoulder (5th ed.). St. Louis, MO: Elsevier/Churchill Livingstone.

Dutton, M. (2012). Dutton’s Orthopaedic Examination, Evaluation, and Intervention (3rd ed.). New York: McGraw-Hill Medical.

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Sueki, D., & Brechter, J. (2010). Orthopedic Rehabilitation Clinical Advisor (1st ed.). Maryland Heights, MO: Mosby Elsevier.

Wyss, J., & Patel, A. (2013). Therapeutic Programs for Musculoskeletal Disorders (1st ed.). New York: Demos Medical Publishing