big-air.jpg



BY ALAN GJEDSTED MD

Pain in the shoulder is a common problem among athletes who participate in overhead types of sports, throwing sports and, particularly, in weight lifters. It is also very common in the non- athletic population, in general.
Shoulder pain frequently, but not always, starts without any specific injury or trauma It may begin as a "twinge" of discomfort, not even enough to think about, and progress to the point where nearly any movement, especially lifting the arm, causes severe pain. The most common presentation is one of a nagging, dull, aching, pain, which worsens with certain motions in the shoulder. It may awaken the sufferer at night with pain and it often has been present, to some degree, for awhile, before it becomes severe enough to seek medical attention.


Why is the shoulder particularly prone towards injuries?

The shoulder is a very unusual joint in the body. There are no other major joints quite like it it: the shoulder joint is designed to move through nearly a full 360 degree arc and move in different planes. Can your knee do that? How about your hip? No! The way the shoulder is able to perform this miraculous feat is by having a very shallow "ball & saucer" socket (imagine a golf ball sitting on a tee), along with having relatively loose and elastic supporting structures, such as ligaments and tendons. Were any of these structures too tight, or too constricting, one would have a very restricted range of motion in their shoulder.

Firefox


So, you might be thinking, loose ligaments, muscles and tendons in the shoulder are a good thing, right? Yes, to a point. The problem arises when these stabilizing tissues are so loose that they allow the shoulder joint too much movement; that is, too much sliding around of the ball in the very shallow saucer. When this happens, one frequently begins having the pain of tendonitis, bursitis, and ROTATOR CUFF inflammation and tears, that can occur when there is repetitive injury to these surrounding structures. These kinds of excessive motion injuries are particularly common in the throwing sports. Also, because of the distinctive bony makeup of the shoulder, it is easy to "pinch", or IMPINGE certain tissues (especially a bursa or a tendon) between two bony structures, causing a low level of inflammation that may not give symptoms for many months or even years. This type of injury is common m the overhead sports (swimming, tennis, or jobs that require a lot of overhead reaching. Between the Humerus (upper arm bone) and the Acromion (a bony shelf you can feel on top of your shoulder), there are a number of structures, including a large bursa, which is a fluid-filled sac that prevents excessive friction, and Tendons (enveloped by the bursa). When you raise your arm over your head, you may start to pinch that bursa and those tendons between these two bones. Over time, this can cause inflammation. and, ultimately, pain.
Also, the Biceps Tendon rides. in a narrow bony groove across the top of the humerus, where it can become inflamed or traumatized.

What tests should be done to help with making the correct diagnosis?:

There is no specific test that "must be done" to make the diagnosis of the cause of shoulder pain. As with many problems involving the joints and tendons, the history and the exam are the most important facets in making a diagnosis.
Often, a regular xray is done, which will show problems with the joint and bones of the shoulder, such as arthritis, calcium in tendons or the bursa, degenerative spurs and narrowing of the space where the bursa and tendons reside
MRI gives good visualization of the soft tissues, such as tendons, muscles and ligaments. It is the best test if there is a question of a torn, or partially torn, rotator cuff tendon; it is usually not required early in the course of shoulder pain not caused by an acute trauma, as the initial therapy does not differ based on its findings.
In the case of a possible complete Rotator Cuff Tear, especially after trauma, in some cases after Shoulder Dislocation, or in cases of possible tumors or infections, the MRI is the best test.
When there is question of joint capsule pathology, joint ligament injuries or complete rotator cuff tears, ARTHROGRAM, especially CT-ARTHROGRAM, is frequently the test of choice.
In persons where there is a suspicion of possible infection or tumor, blood tests will also be done
As all forms of "indirect" visualization (MRI, Arthrogram, Xray) are subject to some degree of error, sometimes, the only way to get a true picture of what is going on in the shoulder is by direct visualization, i.e. Arthroscopy, a fiber-optic scope, inserted through surgical Incisions, that looks dfrectly at the various structures within the shoulder.


What Can Be Done to Treat and Prevent the Problem?
The treatment of the painful shoulder has a number of steps in common with the treatment of any inflamed joint or soft tissue structure.
First, you should REST the injured part, to the extent that you are limiting activities to those that do not worsen the discomfort. For the athlete involved in an overhead-type or throwing sport, you will have to either change technique (sidearm throwing or breast-stroke swimming), or avoid these sports until you have started an aggressive rehabilitation program, outlined below. For the worker, doing overhead work, you should switch to a job activity that does not require this motion until you are beginning to improve, as well.
Second, you can begin using ANTI-INFLAMMATORY MEASURES, such as Aspirin, Ibuprofen, or Naproxyn (assuming you are not allergic to them and have no history or ulcer problems). You can also begin using an ICE PACK, wrapped in a towel, over the painful area, for 10-20 minutes, 3-6 times a day.

Exercises Specifically for the Shoulder:
In a large percentage of persons suffering from shoulder pain, NOT caused by an "acute" trauma, the pain is from repetitive motion-induced tendonitis or bursitis, and tightening of the support Structures of the shoulder joint is the first step of therapy. As we cannot really "tighten" or strengthen a ligament, it is important to concentrate our efforts on those things we can effect; that is, the muscles of the Rotator Cuff.
There are 4 muscles (Supraspinatus, Infraspinatus, TeresMajor, Subscapularis), along with their associated tendons, that comprise the Rotator Cuff, which is so named because it forms a stabilizing "cuff" that surrounds the shoulder joint, holding it tightly in place and preventing excessive sliding in the very shallow "saucer."

REHABILITATING THE
THE MUSCLES OF THE ROTATOR CUFF.


Through the links below, you will find some exercises to rehabilitate the shoulder, which include both Strengthening and Stretching of the most important muscles and tendons of the shoulder.

STRENGTHENING
You can, if you wish, use an elastic stretch band, Theraband, or even an old bike inner tube, tied to an immovable object. Or use a #3-5 lb. hand weight.
There is some important notes be made at this time: 1). When working on strengthening the muscles of the shoulder, you should only do those exercises that do not cause or aggravate the pain (some persons, early in their rehab, are able to do only limited range of motion exercises). 2). Avoid working on the Deltoids (doing what are known as "Lateral Flies") as the Deltoid muscle has a tendency to pull the arm up in such a way as to narrow the space between itself and the Acromion "roof" even more, thereby increasing the chances of "Impingement" in those structures explained earlier, and 3). There is no need to exceed 5 LB weights when doing this training.

STRETCHING
Here are some easy stretches for the shoulder joint. Remernber: The strong, stretched muscle is the one that resists re-injury. Strengthening a muscle without adequately stretching is a common cause of recurrent injury or persistent inflammation. Hold each stretch 10-sec; repeat 3-5 times.

Physical Therapy:
Some people find it difficult to do the exercises themselves, or find they get no benefit from doing them on their own. For this group of patients, a referral to our Physical Therapy department is appropriate. Ask the doctor that examined you about a referral, if you feel you need this service.


Cortisone Injection:
When the conservative type of rehab is not working, or if the discomfort and the limitation of mobility are very severe and keeping you from effectively doing the rehabilitations exercises and stretches, your doctor may recommend an injection of a cortisone-like medication into the area of the inflammation. This line of therapy can be very effective over the short-term. It sometimes needs to be repeated. You can discuss the risks and the indications with your doctor.

Surgery:
There is definitely a place for surgery in shoulder problems: 1) In certain cases of an acutely injured Rotator Cuff; 2) In stubborn shoulder pain that does not respond to a trial of conservative treatment, either home or by Physical Therapy, along with Cortisone therapy: 3) In those persons determined to have degenerative changes that would respond to surgical therapy: and, 4) In persons who have had recurrent Dislocations of the shoulder joint.
There are various types of surgical interventions on the shoulder, depending on the underlying problem. Some of the problems can be handled using an arthroscopic technique which entails a shorter recovery and smaller scarring from the incisions. If your doctor feels you will require surgery, you can discuss with your Orthopedic Surgeon the type of procedure you will need.



What should I expect?
Pain from an inflamed shoulder tendon or bursa that has come about through repetitive, minor injuries, as noted above, can be expected to take some time to fully resolve.. The thing to remember is that the inflammatory process has been present long before the pain started (sometimes years) and therefore, it will take a greater amount of time for it to fully resolve. Pain from an acutely injured shoulder, especially an injury to one of the tendons or muscular structures of the shoulder, often responds fairly quickly (few weeks). More prolonged pain or weakness in this setting frequently will require cortisone injections and/or surgery.
The important thing to remember is: if you are continuing to have problems, despite yours and our best efforts to rehab the shoulder, you must contact your doctor for a re-examination and further testing. Typically, shoulders, without a problem requiring surgery, will improve significantly in 6 weeks or less.