Conditions & Injuries: Arms & Shoulders

Wrist fracture

With a fractured wrist, you may have broken either your radius or your ulna at the ends near your wrist, or have fractured one of the carpal bones, which are the two lines of bones in your wrist area. The most common carpal bone to fracture is your scaphoid, which is just under your thumb.

Common causes

Wrist fractures are typically the result of a fall where you land on your hand with your arm outstretched.

Rehabilitation after a wrist fracture

If the parts of the fractured bones are still aligned, you will be put in a plaster cast for 6 weeks. Your wrist will then be X-rayed before the cast comes off to check there is good bone union. If the bone is displaced and the doctor is unable to manipulate it back into alignment, you will need surgery. A pin and plate will be used to maintain alignment before you are put in a plaster cast. The carpal bones don’t typically displace and will be treated conservatively in a cast, but if there is a non-union, surgery may be required to stabilise your wrist.

Physiotherapy-wise, treatment won't start until you've come out the cast. At this stage the wrist will normally be really stiff and the muscles in your hand and wrist will be weak as you won’t have used them for 6 weeks. Therefore your physiotherapy will start with movements to mobilise your wrist and improve range of movement, as well as strengthening exercises for the wrist and the hand. Initially, after you come out of the cast you won't be able to fully weight-bear through your arm. You should only start to do that around 3 months after your injury to ensure that you've got good bone union and you don’t refracture it.

Average recovery time

Due to being immobilised for 6 weeks there'll be a lot of deconditioning in your wrist and hand muscles, and it can take up to a year to make a full recovery. Typically you'll make an 80 percent recovery by 6 months.

Tennis elbow

With tennis elbow you feel pain on the outside of the elbow, which is known as the lateral side of the elbow. The pain is a very localised to that area, and with rest it usually settles, but as soon as you start using the muscles that attach to this area the pain returns.

Common causes

Tennis elbow usually happens with people who are office workers and play racket sports. Your wrist is likely to extend too far backwards when you hit the ball which puts strain on the muscles. This could be due to poor grip strength or the result of using a mouse or keyboard where the wrist is lower than where the fingers, meaning the fingers are often extended and the muscles are weakened.

The point where the tendons for the extensor muscles for your wrist and fingers attach is mainly on the lateral side of your elbow where you’ll experience the pain with tennis elbow. When we test whether you have tennis elbow, we’ll ask you to resist wrist extension or lifting your middle finger to see if we can reproduce your pain.

How we treat tennis elbow

Tennis elbow typically doesn’t require surgery. Physiotherapy will include a graduated strengthening programme starting with eccentric loading exercises, where you load the muscles as you lengthen them, and then concentric loading exercises, where you shorten the muscles (i.e. contract them) as you load them. For short-term relief we may perform soft tissue release of your wrist and finger extensor muscles, and acupuncture.

Average recovery time

The average recovery time is about 6 weeks, but it does depend on how long you've had the symptoms for. It may take as long as six months.

Fractured arm or shoulder

A fractured arm or shoulder involves your humerus, which is the bone at the top of your arm between your shoulder your elbow. You could fracture either the main shaft or the neck of the humerus or the greater tubercle, which is part of the shoulder joint.

Common causes

Most fractures in the arm happen when you fall or when you dislocate your elbow or shoulder.

Rehabilitation after a fractured arm

Your fracture could be displaced (where the broken ends of the bone are not aligned) or non-displaced. If it is displaced or you have a fracture to the greater tubercle then the fractured parts of the bones will need to be realigned or reattached in surgery. If it’s non-displaced, it will typically be treated conservatively, and you’ll be advised to keep it in a sling and start physiotherapy within a couple of weeks. Your consultant will review you at 6 weeks to make sure that bone formation has started between the two fractured halves.

As physios, we will help you with regaining full range of movement in the shoulder and elbow, as these can become stiff whilst being in a sling. We’ll also provide you with an exercise programme to regain full range of movement and muscle strength so that you can move your arm actively, first without and then with a load as your recovery progresses.

Average recovery time

Typically, you’ll be able to see a union of the bone on X-ray within 3 to 6 months. If you don’t have surgery, it may take slightly longer to make a full recovery as consultants are more cautious about using and loading your arm, whereas if it's been surgically repaired and shows good bone formation, you are likely to be able to use it fully slightly earlier. Either way, it will take you a year to make a full recovery.

Read our article on Preparing for your surgery

Frozen shoulder

If you have a frozen shoulder, you will experience a gradual reduction in how you can move your shoulder, typically starting with putting your arm behind your back. Women usually notice they are having difficulty putting on and taking off a bra, while men often won't notice until later when they can't get their hand into their back pocket. As it progresses, you’ll notice difficulties taking your arm out to the side and then lifting it forward above your head. A frozen shoulder usually starts with just a feeling of stiffness, but you may feel pain around the shoulder and this pain may radiate down into the elbow. It is most typical in middle-aged women.

Common causes

The cause of frozen shoulder is still not fully understood. For some reason, the capsule around the shoulder reduces in size, restricting the movement in the shoulder. This results in muscular weakness within the range that is restricted.

How we treat a frozen shoulder

Physiotherapy can help you to regain your range of movement with manual therapy and passive stretching, and maintain muscle strength. You physio will provide you with exercises as your symptoms improve to increase your strength and range. We can also help you to make sure that you don't overload the other shoulder and cause damage and pain.

Average recovery time

Normally with the guidance of a physio, a frozen shoulder can resolve within a year or two without any surgical intervention. Research has shown that if you have surgical intervention to stretch the capsule around the shoulder joint, you may reduce the recovery time by a couple of months.

Shoulder stiffness

With shoulder stiffness, you may have reduced movement of your arm in certain directions, and pain throughout the movement or at the end of your range. Sometimes stiffness can be without pain.

Common causes

Shoulder stiffness could be caused by a rotator cuff tear caused by the degeneration of your soft tissue, or trauma due to falling or overloading the arm which causes a muscular strain.

How we treat stiff shoulders

Physiotherapy depends on the cause of the stiffness and is likely to include manual therapy to release muscle tightness and enable you to perform a programme of stretching and strengthening, targeting the activities that you're finding difficult so that you can return to performing them with confidence and without compensatory mechanisms that could lead to other problems.

Average recovery time

Depending on the longevity of the shoulder stiffness it can take 6 weeks to 2 years to recover.

Read our article on Preparing for your operation

Rotator cuff tear repair

If you have a rotator cuff tear, you usually experience pain when moving your shoulder and may have difficulty performing certain movements actively, but you have full range of movement when someone else moves your arm. The pain is normally very localised to the area of the rotator cuff that has been torn. The tear could be to any one or to several of the 4 muscles that make up the rotator cuff: supraspinatus, subscapularis, infraspinatus and teres minor. Typically a rotator cuff tear will be repaired surgically only if you are under 50 and the injury was caused by trauma. If you’re older and the tear is due to degeneration of your soft tissues, surgery is unlikely to be successful.

Common causes

A rotator cuff tear can be caused by a fall or a dislocation, but in older people it could result from the natural degeneration of soft tissues.

Rehabilitation after a rotator cuff repair

A tear to a rotator cuff muscle isnormally in the tendon rather than the muscle belly and surgery will involve suturing and anchoring the tendon back into its normal position. After the surgery, you will be in a sling for 4 to 6 weeks, depending on your surgeon with restrictions to certain movements, depending on the muscle that has been repaired to ensure you don't put too much strain on that tendon while it is forming a strong attachment to the bone. Physiotherapy will include manual therapy to help regain full range of movement and a progressive strengthening programme to regain the ability to load the arm with weight of your own body so that you can get back to your daily activities and sporting endeavours.

Average recovery time

It will take you about a year to make a full recovery, but you should be able to move the arm throughout range within 6 weeks to 3 months.

Shoulder pain

You may experience pain around the front or side of the shoulder, which could also radiate down to the elbow. The pain could be either a constant ache or a sharp pain when you move the arm. If you have pain when you move your arm, it could be within what we call the painful arc, which is at between 45 and 100 degrees, or it could be at the end of your range. You are likely to feel weakness and have reduced control over your shoulder movement as you will be using your shoulder less. There may also be a change in the position of your shoulder blade, which puts the muscle in a suboptimal position to activate certain muscle groups efficiently.

Common causes

There are a number of causes for shoulder pain. One common causes of shoulder pain is a rotator cuff tear, which is either been sustained by a sudden load applied to the arm, as a tackle or a sectione in rugby might do, or it could be a gradual onset, which is known as a degenerative rotator cuff tear and is typically found in older people.

Pain at the front of the shoulder could be due to injury, tightness or weakness in the biceps, the pectoral muscles or the front of your deltoid muscle, whereas pain on the side your shoulder could be due to your supraspinatus, infraspinatus, the mid-portion of your deltoid or bursitis, which is irritation of the sac of fluid between the tendon and the bone.

How we treat shoulder pain

First, we’ll assess your shoulder, arm and upper back to pinpoint the cause.This will include an assessment of your movement patterns and your muscle strength. Your physio will then give you a progressive exercise programme to improve your strength and your shoulder positioning when moving the arm. We may use manual therapy to help with short-term pain relief and muscle tightness, and to help facilitate changes in shoulder movement patterns.

Average recovery time

With physiotherapy, shoulder pain can take about 6 weeks to resolve, but addressing muscular weakness can take up to 3 to 6 months, depending on how long you’ve had the shoulder pain and how coping your mechanisms for the pain have impacted on the rest of your body.

Shoulder dislocation

With a dislocated shoulder, the head of your humerus (upper-arm bone) is forced out of your shoulder socket. It is extremely painful and you won’t be able to move the arm until it’s put back into the socket. If you can, get this done immediately after the injury, otherwise it will have to be done in hospital under general anaesthetic because your arm and shoulder muscles will do into spasm, which will make it difficult to move the arm. Your arm should be relocated by a physio that has been trained to do it, or by a trauma doctor, such as an orthopaedic consultant or a doctor that works in A&E.

Common causes

You can dislocate your shoulder by landing on an open arm, your body moving at speed while your arm is fixed, or by a direct blow to the shoulder. Your shoulder can dislocate in any direction, but most commonly it’s either forwards or backwards.

Rehabilitation after a shoulder dislocation

When the shoulder dislocates it can cause secondary injuries such as a fracture, stretching of the shoulder capsule, a labral tear, and muscle and ligament tears that will also need to be treated and investigated by MRI and X-ray after your joint shoulder has been relocated. Most dislocations are treated conservatively initially with rest, ice and a slow return to activity, but if you keep dislocating your shoulder, you may need surgery to improve the stability of the joint. After a dislocation it’s advisable to have physiotherapy to improve the strength in the muscles around the shoulder to help improve stability and help you regain full range of movement in your shoulder. This could include manual therapy to help release tight muscles, and exercises based in the pool and in the gym.

Average recovery time

Depending on whether it’s a simple dislocation or recurrent dislocations that require surgery, recovery could take 6 weeks of strengthening or 6 to 12 months of physiotherapy rehabilitation.

Read our article on Preparing for your surgery

Shoulder arthroscopy

A shoulder arthroscopy is a surgical procedure that is performed as keyhole surgery. It is usually performed if you have ongoing shoulder pain that appropriate physiotherapy has not been able to improve. It may be a diagnostic procedure to understand where the pain is coming from or be done to remove or repair any soft tissue damage.

Rehabilitation after shoulder arthroscopy

After the arthroscopy, you can usually move your arm normally unless the surgeon has had to perform a more extensive procedure. If a sling is required, you’ll be informed by the physiotherapist after the surgery. Even with a simple shoulder arthroscopy, you’ll need physiotherapy afterwards to regain full function of the problematic shoulder.

Your physiotherapy treatment will be based on what was learnt from the arthroscopy. It will typically include an exercise programme to regain full range of movement and muscle strength around the shoulder and some manual therapy to assist with regaining full range and give you confidence in moving the arm normally. These could be performed on land, but some people find it beneficial to start physiotherapy-based exercises in the pool as it provides support to the arm as well as gentle resistance.

Average recovery time

The recovery time will vary from 6 weeks to 6 months.

SLAP repair

SLAP repair surgery is required when you tear your labrum, which is a thickened ring of cartilage in your shoulder joint. SLAP stands for superior labral anterior posterior and refers to the position of the tear to the labrum.

Common causes

A SLAP tear typically happens when you dislocate your shoulder, which can happen during a fall, from a direct impact to the shoulder, or when the arm is fixed and the rest of your body keeps moving. If you have a feeling of instability in the shoulder on raising your arm above your head or when a physio or consultant performs the apprehension test you may have torn your labrum.

Rehabilitation after a SLAP repair

An orthopaedic surgeon specialising in shoulders will advise you if a SLAP repair is necessary. To repair the labrum, the surgeon will use sutures to anchor it back onto the acetabulum, which is part of your shoulder joint. After the surgery, most surgeons will want you to stay in a sling for 6 to 8 weeks and restrict rotational movements of the shoulder during this time. You will require physiotherapy after the surgery to regain full range of movement of your shoulder and regain your muscle strength, as this will have diminished due to inactivity of that arm.

Physiotherapy will include manual therapy to release tightness in the muscles surrounding the shoulder, and assistance with moving the shoulder through its range.

You will progress through an exercise programme designed according to the recovery period and restrictions set by the surgeon. This will typically start with assisted movement and progress to exercises that put load through the shoulder using body weight and/or weights in the gym.

Average recovery time

It will typically take you about 6 months to be able to perform daily tasks without any restrictions. If you want to go back to sports that require weight-bearing through the arm or using your shoulder, it will take a full year to 18 months to make a full recovery where you have the same use of your shoulder as you had prior to the injury.

Read our article on Preparing for your surgery

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