Frequently Asked Questions
Joint Conditions In The Upper Body
The AC joint is the pointy protrusion near the top outer edge of the shoulder at the meeting point of the outer edge of the collarbone (clavicle) and the bony projection (acromion) on the top of the shoulder blade (scapula). The AC joint allows you to lift your arm up above your head. AC injuries are common in younger active individuals and can range from acromioclavicular (AC) and coracoclavicular (CC) ligament sprains, to a complete dislocation of the AC joint.
The two types of AC joint injuries are Type I and Type II where the ligament tears are incomplete and the joint is still intact and these are treated conservatively. Type III injuries involve rupture of the AC and CC ligaments as well as the joint capsule, resulting in an elevated clavicle. The damage to the AC joint may injure the cartilage within the joint and can later cause arthritis of the joint.
The mechanism of injury to the AC joint can be either direct or indirect. Direct impact can be caused by a collision or fall onto the shoulder with the arm next to the body (adducted position). Indirect injuries are less common but can occur after a fall onto an outstretched arm. In most indirect injuries, the AC ligament is more commonly affected than the CC ligament. Type III AC joint injuries are often seen after falling off a bicycle or colliding with another bicycle, in contact sports and in car accidents.
Your physio will perform a physical assessment, looking for a “step deformity” of the joint, swelling or bruising, and feel for any tenderness over the AC joint and outer edge of the collarbone. Range of motion of the shoulder will be limited because of pain.
To test for an AC joint injury, your physiotherapist will lift your arm up to 90 degrees and take it passively across your chest with the elbow bent (flexed), which will cause pain if your AC joint is injured. You may be sent for an X-ray to determine the severity of the injury.
In the early phase post-injury, ice can help to reduce swelling and bruising, and your physio may tape your AC joint and/or apply a sling so your forearm is supported. You may need to use a sling for up to 3-4 weeks, particularly if your daily activities require your arm to hang for long periods of time but this will depend on your symptoms. For example, if your pain has significantly decreased and your function has improved, you may only need a sling for a week, particularly if you have a type I AC joint sprain. Your physio will also advise you on how to support your arm while you sleep.
1-2 weeks after the injury, your physio may suggest you do gentle swinging exercises for your shoulder and after 4-6 weeks they may begin to gently mobilise your shoulder joint to prevent excessive scarring and improve joint mobility. Once full range is achieved within a pain-free state, you will be given progressive resistive exercises to restore function.
Frozen shoulder, also known as adhesive capsulitis, is an inability to lift your arm up above your head or move your arm in different directions, initially because of pain and later because of stiffness. It has four phases: pain, stiffening, frozen and thawing. The natural course of recovery for a frozen shoulder (if you do nothing) from initial pain to thawing and resolution of symptoms, is typically 2-3 years.
This condition can occur after a shoulder or arm injury, particularly if the arm has been immobilised in a sling. It can also occur after shoulder surgery, open-heart surgery or breast cancer treatment (either after the surgery or with radiotherapy treatment) but sometimes there is no obvious cause.
The first signs of frozen shoulder vary between women and men, with women having difficulty doing up their bra, and men having trouble getting their wallet out of their back pocket. Both may have pain on reaching up to put on a seatbelt.
In the initial stages as the shoulder joint is painful, your physio will advise you on:
- how to support your arm while sleeping
- discuss strategies to minimise driving as this will make you symptoms worse
- forearm support on your office chair to decrease the gravitational loading of your arm
- taping support of the shoulder may help minimise shoulder pain and assist with sleep
- heat, cold or acupuncture to assist with pain management
- gentle exercises, perhaps including a home pulley device
In the stiffness and thawing phases of this condition, you may find that physio treatment including mobilisation, massage, trigger point therapy and dry needling, will help improve mobility of your shoulder.
If you have injured your shoulder, the pain is acute and comes on quickly, otherwise onset may be gradual secondary to repeated or sustained hand-over-head activities. If you have this condition it will be painful to lift your arm, especially out to the side, with pain being worse between 60-120 degrees of movement, or it may limit your ability to lift the arm at all, or use it with any force in that position as in throwing a ball or writing on a whiteboard.
The pain can be worse at night and affect your sleep, especially if you lie on your affected shoulder. You may also feel or hear a popping or grinding sensation when you move your shoulder but these in themselves are not problematic.
After performing a series of tests to confirm the diagnosis, your physiotherapist will devise a treatment program to manage your condition in a number of ways:
- pain reduction will be the initial aim along with reducing inflammation and preventing further impingement and tissue damage – likely to include rest, ice and modified activities and your physio may massage your muscles or mobilise your joints to loosen your shoulder, neck or thoracic spine (the area of spine between your shoulder blades)
- taping can be useful to change your shoulder posture, allowing more space for the inflamed tendon and/or bursa – simple strategies to change your posture so that your shoulder does not hurt so much, allowing your shoulder blade (scapular) muscles to work better and assist in improving inflammation
- strengthening exercises will form part of your rehabilitation program – using an elasticised band to encourage strengthening of the shoulder blade and rotator cuff muscles
- as your symptoms improve, your physio will progress and increase the range of exercises to make them more functional
- core stability and gluteal (buttock) muscle strengthening may also be introduced if you play sport involving overhead activities (eg tennis or volleyball).
Golfer’s elbow is a descriptive term for pain on the inside of the elbow that occurs when gripping or lifting with the palm facing upwards, or when hitting a golf ball. The muscles that bend the wrist forwards attach onto a bony point on the inside of the elbow (medial epicondyle) via a common tendon. One of the most common diagnoses for golfer’s elbow is tendinopathy of the common flexor tendons of the wrist which is typically an overuse injury.
Another common cause is direct impact to the inside of the elbow, but golfer’s elbow is usually caused by increased activities that load the tendon, such as hitting a hundred or so balls in preparation for a golfing trip. The tendon becomes painful in response to increased activities involving gripping and pushing. The tendon also tends to become swollen which in some people results in increased pain. If untreated this can result in increased symptoms and weakness which impacts on activities of daily living.
Your physio will make the diagnosis based on your combination of signs and symptoms, differentiating between other conditions that cause pain in this area, such as ulnar nerve entrapment and referral from your neck or upper back.
Accurate diagnosis is important in determining the best treatment for this condition. Once your physio has established the source of your pain, they will discuss with you the best management of your condition. Over a period of 12 weeks this may include some hands-on treatment and possibly ultrasound or ice, along with an elbow brace or strapping in the short term. Exercises will be prescribed to assist with pain relief and to enhance the tendon’s ability to cope with load.
This is a term given to pain on the outside of the elbow, which is typically aggravated by gripping or lifting when the palm is facing downwards. One of the most common diagnoses for tennis elbow is tendinopathy of the common extensor tendons of the wrist which is the result of overuse.
This condition is most commonly caused by an increase in activities that load the tendon, usually gripping activities such as pruning, playing tennis and handyman activities such as using a screwdriver. The tendon responds to this increased activity by becoming swollen and begins a process of trying to make itself stronger in order to better perform the task in the future. In some people the tendon actually becomes more painful and if left untreated can become debilitating, limiting activities of daily living.
Your physio will differentiate between radial nerve entrapment and referred pain from your neck which can also cause pain in this area. Accurate diagnosis is important so that your physio can prescribe the best management programme for your condition to return you to your desired activities, which may include:
- being fitted with a brace or strapping in the short term
hands-on treatment such as mobilisation with movement (MWM)
- education in self-management techniques
- exercises with weights to help reduce pain and improve forearm muscle strength
- progression of these exercises over a period of 12 weeks
The carpal tunnel is a narrow passageway on the palm side of the wrist, the floor of which is formed by the bones of the wrist and a strong ligament that creates the roof of the tunnel. The median nerve runs through the carpal tunnel and gives feeling to the skin of the thumb, index finger, middle finger and half of the ring finger. It also gives movement to some of the muscles around the thumb.
Carpal tunnel syndrome occurs when there is pressure on the median nerve from a variety of causes including:
- pregnancy (fluid retention)
- wrist arthritis
- wrist fracture
- thickened tendons
- tendon inflammation
- hand trauma causing swelling
The diagnosis is based on signs and symptoms, including:
- pins and needles around the thumb, index and middle fingers, seeming worse at night
- associated wrist discomfort
- weakness of the hand and thumb
difficulty grasping objects
- pain radiating up into the arm
These signs and symptoms, together with a clinical assessment involving simple tests, help your physiotherapist or GP arrive after a diagnosis. Occasionally a nerve conduction test may be recommended.
Physiotherapy management may involve any combination of the following :
- splinting to maintain the wrist in a neutral or slight forward-bent position to maximise the space in the tunnel to relieve pressure on the median nerve
- ergonomic advice aimed at avoiding aggravating wrist positions and activities
- exercises such as gentle tendon gliding movements to reduce swelling and limit adhesions
nerve stretches involving gentle movements of your arm and neck to improve movement of the nerve and to increase blood flow to the nerve to assist with healing
strengthening of the hand may be required once symptoms have settled
- surgery is indicated in a small percentage of people suffering a loss of sensation or inability to contract the muscles supplied by the median nerve
- post-operatively, physios can assist with scar management, desensitising and special exercises
Ganglions are cysts (collections of fluid) that vary in size and firmness. They may be soft and “squishy” but sometimes feel hard like a bone. Very small ganglions that are difficult to see can be the most painful because of the level of fluid pressure inside the cyst. Some ganglions, even very large ones, can be completely pain-free.
Ganglions involve the joint fluid in the wrist bulging from inside the wrist (out-pouching) or sometimes from the sheath around a tendon. Although they are completely safe and harmless the pain can be distressing and may limit activity.
There are a few different theories about what causes ganglions to form but usually it is after an injury or trauma to a joint or ligament in your hand or due to repetitive use of your hand, fingers or wrists, but they may also form due to a bulging out (herniation) of the joint capsule that surrounds the joints in your hand.
Ganglions may appear suddenly or they may develop gradually over time. They usually look like a lump on the back of your wrist. Ganglions tend to fluctuate up and down in size over time and may also change depending on activity. In the wrist the lump will become more prominent when your wrist is flexed forward. As the ganglion gets squashed when the wrist is bent up, it may be difficult to fully lean on your wrist such as when doing a push-up.
You can confirm the diagnosis of a wrist ganglion by getting an ultrasound, although this is rarely necessary, as your physio will be able to diagnose the condition.
In many cases ganglions do not require any treatment and approximately half will resolve over time without intervention. If a ganglion is not causing pain or limiting the use of your hand, then no treatment is required. However, if it is causing pain, limiting the use of your wrist or hand or pressing on a nearby nerve causing altered sensation, numbness or tingling, then treatment is indicated and may include:
splinting to reduce the pain
strapping with tape to enable higher level of loading activity such as at the gym
advice on how to modify your activities and what activities to avoid
gentle exercises to maintain the range of movement and function in your hand
A small percentage of people will require treatment with steroid injection, drainage via needle aspiration, or surgery. Physiotherapy will usually be required if the ganglion has been surgically removed.