Ann’s story – how physiotherapy helped her shoulder pain

Read how a course of rehabilitation helped Ann return to playing tennis after a shoulder pain due to a rotator cuff injury

Ann is a 60 year old keen tennis player recently retired from her job as a midwife. She had been looking forward to spending her extra free time playing more tennis but had suddenly developed severe shoulder pain when serving and doing overhead smash shots. She was otherwise healthy.

When I first assessed Ann, she was quite frustrated at not being able to play tennis because of her shoulder pain. However it was also affecting her ability to do everyday activities that require her to lift her arm above the level of her shoulder. She was occasionally waking up in the night because of the pain – particularly if she rolled onto the painful shoulder. Her GP had suggested that a steroid injection might be helpful for the shoulder pain but she was keen to avoid this as she had already had 2 steroid injections for tennis elbow in the past and they had only provided temporary relief.

One of the key parts of the physical examination was to test the strength of the rotator cuff to try to determine if there might be a tear. The rotator cuff is a sling of tendons that envelope the ball component of the ball and socket joint of the shoulder. Their primary role is to help keep the ball centred in the socket when we move our arm. Tears of the rotator cuff are very common in the over 50s as these tendons tend to become worn and vulnerable over the years. In fact by the age of 80 most people will have a tear of at least one of these tendons.

When I examined Ann, one part of the rotator cuff tested as slightly weak and very painful. This meant that there was probably a small tear in one of the tendons. However the fact that it was only slightly weak indicated that it was unlikely that there was a large or complete tear of the tendon.

I explained to Ann that broadly speaking there are three main approaches to treating low grade tears of the rotator cuff – physiotherapy exercises, injection with steroid and surgical intervention. We ruled out surgery immediately as this is a last resort in these cases. We therefore debated the pros and cons of injection versus physiotherapy exercise. Exercise is usually the first line of treatment. However in cases where there are signs of inflammation and the pain is so severe that the exercises cannot be carried out effectively, injection is indicated. In Ann’s case she had some signs of inflammation (waking in the night). However she elected to try a course of exercises first and if they were too painful would consider the injection.

Ann underwent the following key phases of treatment

1)     Shoulder pain reduction

The first stage of her physiotherapy was to carry out gentle exercises to strengthen the part of the rotator cuff that was not injured. This is because the different tendons of the sling of the rotator cuff are so closely related that they can take over each others’ roles. The aim was to activate the healthy part of the rotator cuff to take over the role of the damaged part in centring the ball in the socket. In addition she went to her GP and was prescribed anti-inflammatory medication.

Within three weeks of carrying out the initial exercises and taking the anti-inflammatories, Ann reported that her shoulder pain had reduced by 50% and she was no longer waking up at night. She now had little or no pain on everyday life apart from when she tried to do sustained overhead activities such as cleaning windows. She was not yet able to play tennis.

2)     Improving strength of the injured tendon

Now that Ann’s pain was reduced, it was time to start rehabilitating the injured tendon. Rotator cuff tendons have a poor blood supply. Therefore tears tend to not heal. However by strengthening the remaining part of the tendon, you can achieve a fully functional outcome. Therefore the next phase of physiotherapy involved specific exercises to strengthen the injured tendon.

Ann carried out these exercises daily and steadily over the subsequent 6 weeks improved to the point that she could carry out light overhead activities without any pain.

3)     Functional rehabilitation

Ann’s main goal was to get back playing tennis and she was dying to get back on the court. In fact it had taken all of her will-power to take my advice and completely rest from playing. The next phase of physiotherapy was to incrementally get her back to fully competitive tennis.

We started with strengthening exercises in all the key positions that a tennis player puts the shoulder in – gradually working towards the most difficult and strenuous one – overhead and end-of-range strengthening. We then added speed and ballistic movements – again in increasingly awkward and difficult positions. At this stage she was allowed to “knock-up” on the tennis court and practice underarm shots in a controlled non-competitive environment. This steadily progressed to practising overhead shots including serving. We even got out of the clinic for an hour and I spent some time giving her drills to improve strength and control during these shots.

Ann demonstrated the required patience for this type of rehabilitation. Full tissue healing takes about 3 months- approximately the same amount of time that it takes to fully strengthen a muscle. Therefore it was no surprise to me that after approximately three months of rehabilitation, Ann was ready to play a fully competitive game of tennis. Neither of us were worried about her shoulder for this first game as the rehab had gradually delivered her to the point where a full game was not a step-up from her exercises and drills. In fact she said that the game was welcome relief from her exercises!

Ann’s result was excellent – she was back playing regularly without any shoulder pain but with strict instructions to only build up the amount that she was playing very gradually.