Do you ever suffer from shoulder pain or hip pain that makes it difficult for you to dance, exercise, or even do daily activities? If you do, do you know the cause of shoulder pain and hip pain?
It’s frustrating to be limited in this way, and sadly, it’s something that happens to a lot of people. What’s even worse, is that sometimes you might go to see a health professional about the pain, and end up with a misdiagnosis that leads to treatment recommendations that don’t help you get better, and sometimes can make it worse. All too often people are told to stop activity, which can lead them down a path to total inactivity and less and less mobility.
Sometimes rest is the best cure, and sometimes it isn’t. So let’s delve into one of the common problems that I come across in the women who dance with me, which is bursitis often of the hip or shoulder.
To get to the bottom of what bursitis is, and the treatment options, I had a chat with David Wilson, partner at MyPhysioSA, which is where I go for treatment when I’ve got an injury or muscle or joint pain.
If you’d like to jump straight to punchline, here it is. Bursitis is often caused by the way you move, and visiting a physiotherapist will help you to learn how to move in a way that doesn’t aggravate the bursitis. Anti-inflammatories, including oral tablets and cortisone injections, can reduce the inflammation, but won’t stop the problem re-occurring.
I’ve got how many bursas?
David started by explaining what a bursa is.
“Technically you have bursas all around your body. A bursa is like a friction pad that stops tendons rubbing onto bones, or bones putting pressure on tendons, so the tendons can glide and slide. If you use certain muscles and tendons a lot it can cause extra pressure on the bursa underneath it and the bursa can thicken and swell. This is what is called bursitis.”
Bursas and pain
“It’s quite common to have a bursa that’s enlarged or thickened. It’s like a sack with fluid in it and most are only a few mm thick. In the shoulder, there is not a lot of space for it, and there are bony bits all around. In bursitis, the bursa can thicken to 5-8mm, which can cause pinching. We call this shoulder impingement.”
David described the pain associated with this kind of impingement as a ‘painful arc’ that would be called a shoulder impingement, but stresses that this isn’t necessarily caused by bursitis.
“I’m talking about the arc of movement from when your arm is next to your leg until it is up over your head. This is a 180 degree arc. At 90 degrees, when your arm is at shoulder height, it’s most likely to be pinching the most, and then the pain with lessen as you lift it higher than shoulder height.”
Diagnosis of bursitis
“If someone had shoulder pain and presented to physio like this, we would label them as impingement, but wouldn’t know what is pinching. It could be a bursa, or it could tendonitis. Bursitis is normally diagnosed formally when someone goes and gets a scan.”
According to David, the thing with getting a scan is that pretty much anyone with any sort of shoulder pain who gets a scan normally gets a bursitis diagnosed. But it doesn’t mean that’s the cause of the pain.
“Bursitis is reasonably common in both shoulders for anyone at any time” he explained. “This is where it gets complicated – trusting scans. Often there are all sorts of things on the scan like bulged discs or arthritis. But quite often it’s none of those things giving them trouble. In the 45 plus age group, 80% will have a disc bulge at any one time. This is people with no pain. Just because something shows up on a scan doesn’t mean it is actually where the pain is coming from or that it is the problem.”
“Every scan I’ve had back in the last few years has shown some bursitis. But sometimes it doesn’t fit the clinical pattern of bursitis. I had a lady come in two days ago who could hardly move her shoulder. She’d had a scan and was told it was bursitis. She was given an injection and it didn’t help. I checked her shoulder and discovered she has frozen shoulder, which is a completely different shoulder problem where your shoulder capsule is damaged. Frozen shoulder can take up to two year to recover from, but it doesn’t show it up scan.”
The take home point on this is that a scan and injection is costly, and may not even be addressing the real cause of pain anyway.
“Physios have done all these years of study in these areas, and can get most people better without needing scans and avoiding having to see specialists and scans. Ultrasound scans with an injections is often between $300-400. For that amount, you could get quite a few physio appointments, a natural treatment without needing injections, which is a longer term fix. An injection just settles down the inflammation around the bursa, but doesn’t solve what caused the inflammation in the first place.
The causes of bursitis
As David explains, you can get bursitis because of something sudden, or it can creep up on you.
“Bursitis can be caused by a trauma or fall or car accident or it can be jarred or wrenched, for example if you fall out of a tree and grab a branch. But most times it’s a biomechanical imbalance. And the biggest thing is the shoulder blade not sitting in a good position or not moving properly. When you lift your arm up your shoulder blade abducts, which means it rotates and elevates. So there are two different things happening at the same time and they need to work in unison. If they don’t, something goes wrong.”
As David explains, it’s not surprising things can wrong with the shoulder joint, because it’s the most complicated join in the body.
“You have the socket and the ball, and at any one time only 30% of the ball sits in the socket. As opposed to the hip, which has a really deep socket and sits inside snugly, so it’s a lot more stable. You can easily dislocate a shoulder because so little of the ball is in the socket. Shoulders need a lot of muscle control and coordination to control the ball in the socket. You just need one little thing to go wrong and the shoulder can wrong.”
“Your shoulder is very vulnerable if you are doing repetitive overhead movements of putting a lot of your body weight through your shoulders, like in cartwheels or push-ups., especially if something is not in balance. To avoid this, you need to learn how to move. We do a lot of training to make sure people know where their shoulder blades sit and how they move. If you have a clicky shoulder but it’s not painful, a lot of the time it will eventually become painful and become a full impingement.”
When do you need treatment?
If you are an office worker or do something where you don’t need to lift or carry things about shoulder height too often, you have a low risk of having a shoulder problem. If you are someone that is an office worker but does gymnastics or repetitive heavy lifts, you have a good chance at some stage if your imbalances are likely. If you feel a pinch you should go to see your physio.”
“One thing that can be an early sign of shoulder bursitis is pain sleeping on your shoulder at night and causing an ache that makes it difficult to go to sleep and when you wake up with pain.”
David stressed that waking up with pain on one day isn’t something to be alarmed about.
“There was some worldwide research done recently that asked people if they got pain every week, and 97% of Australians said they did. We are the highest nation in the world with pain. This doesn’t mean you should run out and see the physio and the doctor. You might have an ache that comes up for no reason and goes, then you don’t need to see the physio. But if it doesn’t settle in a few days, see someone. If it is going on for more than a week or two then get it checked.”
Treatment options
I asked David about his thoughts about treatment options. To be honest, I wanted to get his take on the use of cortisone injections, because I’ve known a number of people who this has worked for, and a number of people who have found it stopped working after a while. My concern has been that people go to their GP, who jumps straight to scans and cortisone, whereas from what David told me, it should probably be the other way around. Start with your physio, and if that doesn’t help, then see your GP.
Anti-inflammatories
“One treatment option is medication, in other words, pain relief. You can take anti-inflammatories, which is better than taking just paracetamol, because anti-inflammatories act at the site. If it goes away, you are all good. If it doesn’t go away within a few weeks, then there is something more to it and there must be something biomechanical going on that needs to be addressed. This is where a physio can help.”
Cortisone
“A cortisone injection does the same thing as anti-inflammatories. It reduces inflammation. But when you take an oral anti-inflammatory it goes all around your body and has a small effect everywhere. An injection is more localised. If someone truly has bursitis and all pain is coming from an inflamed bursa, there’s a good chance it will help. But if you haven’t addressed what caused it in the first place it is only a matter of time before it happens again. Cortisone will address the symptoms, but only temporarily.
Physiotherapy
“A physio can find out how the shoulder pain is behaving and that gives us hints as to what imbalances could be causing it. We then do a whole lot of tests to see how the shoulder blade is moving, and also check your neck and mid back, because they could be part of your shoulder is giving you trouble. We also need to check for nerves, because sometimes it can be neck referring pain in the shoulder. Physios are good at chasing that stuff. If you just saw a massage therapist they’d probably just massage the area and not be very diagnostic.”
The last resort
“The last resort if things aren’t getting better is to go to a doctor and then get scans. If you have lots of night pain that started for no reason and some other flags, and it’s going on for more than six weeks, you’ll normally get a scan to rule out cancer or an inflammatory disorder. If you see a physio, the physio will work you and together you can quickly decide if you’re getting better quickly enough. The physio can then write to your doctor and offer a Plan B.”
Stay in touch with your physio
“It’s best if you keep in touch with your physio all the way through. At the end of the day, if the pain is caused by an inflamed bursa that doesn’t improve with physio treatment, and you do need a cortisone injection, you also need to make sure that you get any imbalances corrected. The physio can do this, and give you a proper rehab program so that your shoulder is even stronger than it was before.”
Physio treatment for shoulder bursitis
When I asked David how a physiotherapist would treat shoulder bursitis, he said there are a number of things they might do.
“All physios are a bit different, but we have lots of techniques we can use. Early on taping the shoulder can give a lot of relief. There will be a certain position you can put the shoulder and shoulder blade in which will relieve it a lot. Then we can do massage, trigger point therapy, acupuncture, and mobilisation. So quite a few hands on techniques that we can use to help someone move their shoulder with less pain. Then we give exercises to do at home.”
“If the physio isn’t helping enough then we would recommend a scan and possible injections. I would always try some physio because around 80% of people we see here never need a scan or injections, so a pretty good success rate of settling a shoulder down and not needing to spend lots of money and time. Plus, it’s a natural solution.”
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An unexpected statistic
I mentioned to David that I have found many people go to their doctor first, and he surprised me with a statistic I didn’t expect.
“Only about 10% of the population really know about physios and what we do and what we can help with. So one of the things we spend a lot of time on educational marketing. Our marketing is educational because we want to get the message out there that we are a solution to all these different problems. Lots of doctors don’t know much about physio and feel like it’s a risky thing to tell their patient to go to physio because they’re not sure if we can help them, so we spend a lot of time educating doctors on what we do and how to refer to us. If they say ‘you can try physio, it might help, if it doesn’t I can do a scan and injection’, then you probably won’t feel very confident about visiting a physio. But if you doctor says ‘the vast majority of people find a physio helps’ than I’m sure you’ll be more confident about visiting a physio.”
I have to say that one of our clients at Dragonfly Dance has had a lot of problems with his knees and ankles, and just won’t go and see a physio. He keeps going to his doctor and getting cortisone injections and now he’s stopped coming to ballet because of the pain. He said he thought physios were a bit ‘woo woo’, which I was stunned about. A physiotherapist is a highly trained scientist and health practitioner.
Teaching people about physio
This idea that people don’t understand what physiotherapists do drives a lot of the marketing that MyPhysioSA do.
“Part of our marketing is based on knowing that people don’t make the decision to see a physio, because they don’t know enough about it or they think their problem is unique. We do our ‘can physio help me’ session which is a free 15 minute session for people who are not sure about whether physios can help. We sit them down, check them over, explain the diagnosis. We let them know, what the plan of attack would be, how many sessions it will be, and give them that info so they can make a better decision. This is to help people make better decisions, because most people just put up with pain instead of making a decision.”
Keep doing what you love
David is on exactly the same page as me when it comes to how to manage pain and injury. Don’t stop moving. Like the Tin Man in Wizard of Oz, you’ll seize up. Keep moving, but listen to your body and take it easy when you need to.
“The beauty of physios is that we are here to help people keep doing what they love doing. If people see a doctor they’ll often get told not to do dancing for the next 12 weeks. We’ll say ‘you need to modify your dancing and do this etc’. It’s super important that people keep doing that they love. We do it with athletes all the time. We give them whatever training we can do, so we don’t pull them out and tell them to sit at home. Try to modify and keep it safe and do a staged return.”
No ‘one size fits all’ solution
I asked David if he could advise on some exercises that can help with bursitis.
“It depends on what’s causing it” he replied. “So it’s a complicated answer, and it’s not simple. We have a three-video series, which goes from gentle starter ones that work on shoulder blade position and control, through to strengthening the rotator cuff muscles, which are the deep support muscles that control how your shoulder ball moves in the socket.”
“It’s not a ‘one-size fits all’ solutions because the shoulder is a very complicated joint. Some people have pain when they reach behind, some in front, some only when they reach to the side. You do have to customise your exercise, ideally, depending on what is the cause of your problem. So go to your physio to get tailored exercises and learn how to move correctly.”
How to keep dancing
For people who love dancing, it can be frustrating to have to stop for a while, so I asked David for his advice on whether continuing to dance is a good idea or not.
“There are lots of things you could still do with dancing. In an acute phase, and if you haven’t ever had it checked and you aren’t sure what is going on, there will be certain movements and activities that will give you a sharp pain. You can’t do them. Avoid those key aggravating things. Things like putting body weight on hands. Some people might even find flinging arms into the air could cause pain. So you need to work out what dance moves give you acute (sharp) pain.”
“Bursitis starts to pinch at about shoulder level, so avoid the painful arc. And then once, if you have it diagnosed and you are doing rehab at the physio, they’d give very specific things about what to avoid once they’ve tested your shoulder. Shoulders are one area of the body where you should not push through pain. If something hurts, avoid it or change the movement so that it doesn’t hurt. If you feel pain, stop what you are doing. If you don’t feel pain proceed with caution.”
What to look for in a physiotherapist
If you’re feeling any kind of muscular or joint pain, I thoroughly recommend seeing a physiotherapist. MyPhysioSA has offices in North Adelaide and Mount Barker, but there are plenty of physios around. In looking for a physiotherapist, make sure you find out what kind of experience they have in sports or dance physiotherapy. When you visit them, take notice of whether they explain what is happening in your body and give you exercises to do at home to help.
Dragonfly Dance offers dance classes to adults of all ages in ballet, contemporary, jazz, and tap. We pride ourselves on offering you a place to indulge your love of dance, whether you’re a complete beginner, had a long break from dance, or danced all your life. Our classes have a broad mix of ages, and our philosophy is that you are never too old to dance, it is never too late to start, and you can dance forever!
If you have any questions, give us a call on 08 7073 2069 info@dragonflydance.com.au