What the Hell is a Shoulder Labral Tear?

What the Hell is a Shoulder Labral Tear?

Understanding A Shoulder Labral Tear

Shoulder glenoid labrum injuries are common in sports that require repetitive overhead movements and physical contact. The shoulder enjoys more range of motion than any other joint in the human body. Unfortunately, it also consists of a very shallow ball socket joint that makes it vulnerable to injury.

The clavicle, humerus, and scapula are the three bones that comprise the shoulder joint. A combination of connective tissues, joint capsule and ligaments hold the proximal head of the humerus (upper arm bone) in place. The labrum’s fibrous tissue “cups” the head of the humerus, holding it within the glenoid cavity. The labrum helps ensure stability within the mobile joint, but may tear due to a shoulder joint injury or repeated strain.

Shoulder labral tears may also occur when the biceps muscle contracts against the labrum, such as when throwing a baseball. SLAP is an easy acronym that stands for “superior labral from anterior to posterior,” which is used to describe a superior labrum tear commonly seen in pitchers. Conversely, an anterior labrum tear is referred to as a Bankhart tear, which is often associated with shoulder subluxations and dislocations. Less common posterior labrum tears involve pinching of the rotator cuff and labrum.

It was markedly difficult to identify the cause of shoulder pain prior to the dawn of arthroscopic surgery and subsequent ability to see the inner workings of a joint. This, in turn, limited labrum tear treatment within the sports medicine community. Thankfully, this is no longer the case.

Signs and Symptoms of Shoulder Glenoid Labrum Injury

  • A ‘catching’ feeling with overhead movement
  • Pain on the anterior or posterior side of the shoulder
  • A sense of hesitancy and insecurity during exercise that requires shoulder strength and range of motion
  • Deep aching and/or grinding within the shoulder joint
  • Unexplained weakness of the shoulder and surrounding muscles
  • Decreased shoulder range of motion

Physical examination may not always immediately link shoulder joint labral tear symptoms with the precise injury. Consequently, correct diagnosis may require an MRI-arthrogram to properly assess the presence and location of the tear.

Professional Treatment for a Torn Labrum

  • Discontinue overhead shoulder activities.
  • Utilize the latest physical therapy modalities and rehab devices available to reduce swelling and pain.
  • Massage the chest muscles, upper traps and posterior shoulder rotator cuff muscles to help reduce pain and foster pain-free range of motion.
  • Work with a physical therapist to properly strengthen the rotator cuff and surrounding musculature while improving biomechanics of the shoulder girdle during activities of daily living (ADLs).
  • Seek out arthroscopic surgery options, but only after an aggressive non-invasive rehab plan is given sufficient time to reduce symptoms.

 

Ask the Right Questions Like a Pro

Here’s what smart pro athletes would ask their sports medicine specialist to ensure a fast and safe return to the game they love:

1. Is an MRI or MRI-arthrogram required to confirm the diagnosis of a torn shoulder labrum?

2. Which specific physical therapy activities should I focus on to speed up recovery?

3. What is the likelihood that surgery will be required?

4. How much healing time is required before I can return to my sport?  Moreover, can you provide me with a general plan to follow as I anticipate my return to athletics?

5. What else can I do on my own to avoid a re-injury?

Elite Sports Medicine Tips from Mike Ryan

  • Ice, Ice, Baby – Icing immediately after a workout or rehab is the simplest way to control swelling and reduce pain.
  • Pay Attention – Do not disregard recurring shoulder pain. A failure to diagnose a shoulder labrum tear early on can increase the need for surgery later.
  • Listen Up – If you experience shoulder pain following any activity, listen to your shoulder to help pinpoint the specific movement or activity that aggravated the injury.
  • Stretch and Stretch Some More – Stretching/warming up the shoulder joint and its associated muscles, tendons, ligaments and fascia prior to any physical activity will help keep you in the game.
  • Remember It’s a Marathon, Not a Sprint – Take your rehabilitation program seriously to help keep you in the game and hopefully avoid further downtime and surgery down the road.

Referred shoulder pain is a condition in which pain is experienced in the shoulder area although it originates a different area of the body, commonly in the neck or spine. Perhaps the most commonly known example of referred pain is the pain experienced in the left arm during a heart attack.

Understanding Referred Shoulder Pain

Referred pain is common in the human body due to the many nerves that originate in the spinal cord and branch out into the trunk and limbs. These nerves pass through or around varied structures, joints, and tissues.  Referred shoulder pain is sometimes related to structural damage in the shoulder joint, ligaments, or tendons, but can also result from problems in the cervical spine, chest, or abdomen. Additional causes include infections and neurological disorders.

Referred shoulder pain or “shooting pain” is sometimes associated with movement pathologies within the shoulder. A thorough evaluation from a medical professional is needed to ascertain the pain’s true origin. Muscle impingement in the upper back is sometimes responsible for referred shoulder pain in sports, specifically. This is most often associated with activities involving aggressive twisting and bending movements in the upper torso such as baseball, football, tennis, and martial arts.

Signs & Symptoms of Referred Shoulder Pain

  • Sharp, intense pain in the shoulder
  • Dull, enduring shoulder pain
  • Weakness in the shoulder and upper arm
  • Numbness within the shoulder and upper arm
  • Changes in skin color
  • A feeling of coolness or clamminess in the shoulder and/or any part of the arm

Professional Treatment for Referred Shoulder Pain

  • Rest the affected shoulder.
  • Discontinue all activities that create pain in the shoulder or neck.
  • Utilize the latest physical therapy modalities and rehab devices to reduce swelling and decrease pain.
  • Perform physical therapy exercises to stretch the neck and upper back.
  • Consult with a medical professional if pain continues or limits activity.

Ask the Right Questions Like a Pro

Here’s what smart pro athletes would ask their sports medicine specialist to ensure a fast and safe return to the game they love:

1. Is my pain due to shoulder damage or something else?

2. How common is this injury in athletes who play my sport?

3. Will I need an MRI?

4. What is the recovery timeline for this injury?

5. Should I consult with a physical therapist, or is self-management indeed possible?

Elite Sports Medicine Tips from Mike Ryan

  • Ice it! – Treat any signs of inflammation or pain with regular icing intervals: twice an hour for 10-15 minutes should do the trick! Sure, it’s a chilly process, but icing is crucial to help decrease the pain.
  • Unsure? Be Sure – If you don’t know the source of your shoulder pain, stop all activity and see a doctor to get some answers.
  • Fix the Real Problem First – Pain located further down the arm can only be treated by first addressing the true source of the pain.
  • Know Your History – When considering referred pain of any type, it is important to know your medical history in an effort to help your doctor determine the cause of the pain.
  • Implement a Plan – After receiving an accurate diagnosis for your referred shoulder pain, be sure to adhere to a strict plan of treatment and time off to prevent re-injury.

Finding a Relief Pitcher for Rotator Cuff Tendonitis – Supraspinatus Tendonitis

Supraspinatus tendonitis is a common injury in many sports that include aggressive overhead movements. The supraspinatus is a muscle located on the top of the shoulder blade or scapula, which mechanically connects the upper arm (humerus) to the scapula. Inadequate dynamic muscle balance, overuse, and poor range of motion prior to physical activities are all causes of supraspinatus tendonitis. Sports commonly associated with supraspinatus tendonitis are weight lifting, swimming, baseball, tennis, and racquetball. Any rapid overhead motion, and especially those where resistance against this movement is involved, are activities which put the supraspinatus at risk of injury.

Finding a Relief Pitcher for Rotator Cuff Tendonitis – Supraspinatus Tendonitis

Understanding Supraspinatus Tendonitis

The supraspinatus is a muscle located on the top of the shoulder blade or scapula, which mechanically connects the upper arm (humerus) to the scapula. Consequently, supraspinatus tendonitis is a common injury in many sports that call for aggressive overhead movements.

One of four muscles that comprise the rotator cuff, the function of the supraspinatus is to both stabilize the shoulder joint and allow for circular motion in the shoulder. Supraspinatus tendonitis occurs when abnormal stress or trauma damages the tendon and/or its sheath, and symptoms are associated with tendon inflammation. Causes of supraspinatus tendonitis include inadequate dynamic muscle balance, overuse, and poor range of motion prior to physical activity.

Athletes involved in weightlifting, swimming, baseball, tennis, and racquetball are apt to experience supraspinatus tendonitis. Any rapid overhead motion, especially when resistance is involved, puts the supraspinatus at risk of injury. Specifically, athletes who suffer from shoulder impingement syndrome are at increased risk to develop supraspinatus tendonitis.

Signs & Symptoms of Supraspinatus Tendonitis

  • A sudden or gradual onset of pain following activities that involve shoulder movement
  • Pain felt in the front of the shoulder on palpation when the arm is rotated internally and extended (as if tucking your shirt into the back of your pants)
  • Limitation in normal range of motion
  • Weakness and/or pain when lifting the arm overhead
  • Pain while lying on the affected shoulder
  • Localized swelling/puffiness in the front of the shoulder, below the outer edge of the clavicle bone (with chronic impingement syndrome)

Professional Treatment for Supraspinatus Tendonitis

  • Apply ice to the affected shoulder 3-5 times per day.
  • If the pain and weakness become severe, use a sling to immobilize the affected shoulder.
  • Embrace a healthy nutritional diet that includes antioxidants and natural anti-inflammatories found in fruits and vegetables.
  • Utilize the latest physical therapy modalities and rehab devices to reduce swelling and pain.
  • Consult with a medical specialist to confirm the extent of the damage and implement the necessary treatment plan.
  • Implement a physical therapy strengthening program to facilitate proper healing (if surgery is not required).

Ask the Right Questions Like a Pro

Here’s what smart pro athletes would ask their sports medicine specialist to ensure a fast and safe return to the game they love:

1. Is this supraspinatus tendonitis or shoulder impingement syndrome?

2. What steps should I take to ensure a rapid and safe recovery?

3. What will my recovery time look like until I am pain-free?

4. Should I consult with a physical therapist?

5. Is any diagnostic testing or surgery required for my injury?

Elite Sports Medicine Tips from Mike Ryan

  • Rest Up – Don’t underestimate the benefits of rest with this injury to make decreased pain a part of your game plan.
  • Ice is Your friend – As with any muscle or muscle group, icing the injured area is necessary to reduce pain and inflammation.
  • P.R.I.C. – Protection, rest, immobilization, and compression are key!
  • On a Serious Note… – Do not take any injury to the shoulder lightly.
  • Use a Heavy Rotation – Resistive external rotation is the most important strengthening exercise for a safe recovery.
  • Start Small – When returning to physical activity, tread lightly.

How to Thaw a Frozen Shoulder

Older athletes are more prone to suffer from the frozen shoulder syndrome, also referred to as adhesive capsulitis. Frozen shoulder is a condition that affects the shoulder joint capsule; a fibrous covering of the synovial lining of the shoulder joint. When the capsule becomes inflamed, it results in pain and significant stiffness of the joint. Due to these symptoms, the athlete quickly demonstrates a characteristic limitation in the range of motion of the shoulder.

How to Thaw a Frozen Shoulder

Understanding Frozen Shoulder/Adhesive Capsulitis

Frozen shoulder is a condition that affects the shoulder joint capsule: a fibrous covering of the synovial lining of the shoulder joint. When the capsule becomes inflamed, pain and significant joint stiffness ensue. Due to these symptoms, the athlete quickly experiences resulting limitation in the shoulder’s range of motion. Older athletes are more prone to suffer from frozen shoulder syndrome, also referred to as adhesive capsulitis, than their younger counterparts.

Restricted movement occurs with respect to both active and passive range of motions:

Active Motion: When the individual moves the joint with his own muscles

Passive Motion: When someone or something else moves the joint without active involvement from the individual

Individuals between the ages of 40 and 60 comprise the majority of those diagnosed with this injury, with women more prone than men. Interestingly, adhesive capsulitis is also more common in individuals previously diagnosed with diabetes. Shoulder pain is usually constant and aggravated by weather changes, keeping the joint in one place for too long, or activities requiring excessive shoulder movements.

Common Causes of Frozen Shoulder

  • Prolonged Immobilization: secondary to a rotator cuff injury, arm fracture, post-surgery immobilization, stroke, etc.
  • Premorbid Status: related to systemic diseases such as diabetes, abnormal thyroid function, tuberculosis, and chronic heart abnormalities
  • Any Shoulder Injury: specifically ailments that produce excessive inflammation such as tendonitis, bursitis, and inflamed rotator cuff muscles/tendons.  The four muscles that form the rotator cuff are the supraspinatus, infraspinatus, teres minor and subscapularis.

The typical course of frozen shoulder syndrome is broken into three phases, spanning almost a year’s worth of time:

1)    The “Freezing” Phase: The individual/athlete slowly develops tolerable pain and stiffness around the shoulder joint. Range of motion reduces almost proportionally to increased levels of pain. Discomfort leads the individual to subconsciously suppress active movement, resulting in a loss of range and strength. The pain is often worse at night, especially when laying on the affected side.

2)    The “Frozen” Phase: This stage’s inception is marked by the end of increasing discomfort, which the athlete subconsciously perceives as a decline in pain. Meanwhile, stiffness and reduced range of motion remain, regular routines are difficult, and muscle wasting (atrophy) becomes more evident. Rotating the arm outwards (external rotation) can become very difficult in this phase, which can last anywhere from about four months to a year.

3)    The “Thawing” Phase: Also called the recovery phase, range of motion in the shoulder starts to improve during this time. Strength and functional capacity gradually return, and this phase typically lasts 2 to 3 months.

Signs and Symptoms of a Frozen Shoulder

  • Increasingly stiff/immobile shoulder with pain around the joint
  • Dull, aching pain that occurs with motion and at rest
  • Shoulder girdle stiffness that restricts full range of motion with both active and passive movement
  • Localized pain felt throughout the outer shoulder area and upper arm
  • Sleep deprivation and possible transient insomnia

Professional Treatment for Frozen Shoulder/Adhesive Capsulitis

  • Intermittent icing with immediate range-of-motion exercises helps decrease pain and regain range of motion while the surrounding tissue is “numb” from the ice.
  • Work directly with a physical therapist, and if prescribed, anti-inflammatory medications can help when taken immediately prior to rehab sessions.
  • Gentle stretching exercises increase shoulder girdle range of motion.
  • Exercise the shoulder joint during activities of daily living (ADLs) to help foster motion.
  • In cases where aggressive rehab is ineffective or range-of-motion limits become excessive, a physician may recommend shoulder joint manipulation (performed under general anesthesia) to break up adhesions/tightness.

Ask the Right Questions Like a Pro

Here’s what smart pro athletes would ask their sports medicine specialist to ensure a fast and safe return to the game they love:

1. Could this be a secondary complication of arthritis or another injury involving my shoulder joint?

2. Do I need an MRI to rule out other possibilities?

3. What is a realistic outcome for my injury?

4. What is the best rehabilitation facility in this area?

5. How soon can I return to my normal activities?

Elite Sports Medicine Tips from Mike Ryan

  • Take Rehab Seriously – Be proactive with your physical therapy, as its success will dictate your shoulder use for the next 1-2 years, period.
  • Know the Formula for Success Reducing inflammation + reprogramming muscles that move the shoulder joint = treatment victory
  • Don’t Panic Though our minds sometimes wander to the “Big C,” rest easy knowing a frozen shoulder is rarely associated with cancerous pathologies.
  • Stay Cool Warm Under Pressure Know that once cured, a frozen shoulder almost never comes back.

What is a Long Head Bicep Rupture?

Proximal biceps brachii tendon ruptures (bicep rupture) are more common than most would assume. High intensity athletes, especially in contact sports, are prone to this injury. This injury is commonly linked to high force weight lifting activities with determined athletes trying to get to the top of their game. Learn more about a bicep rupture!

What is a Long Head Bicep Rupture?

Understanding a Long Head of Biceps Brachii Tendon Rupture

Proximal biceps brachii tendon ruptures (bicep ruptures) are more common than one would think. High intensity athletes, especially those involved in contact sports, are prone to this injury.

These cases involve injuries to the long head of the biceps brachii, rather than the short head. Specifically, the long head is more vulnerable to injury as it passes over the shoulder joint and attaches to the top of the glenohumeral joint.

A biceps tendon rupture involves a longitudinal laceration along the tendon of the long head. This vulnerable tissue attaches a group of fibers from the belly of the biceps muscle higher up at the shoulder joint itself.

This injury is seen mainly in active individuals as a direct result of repetitive forces experienced at the attachment mentioned above. Specifically, it is linked to intense weightlifting activities performed by determined athletes trying to reach the top of their game.

Fractures are sometimes a factor, especially stress fractures located in the neck of the upper arm or humerus bone. Tears of the long head of the biceps can be partial or complete, and partial tears can progress into the latter variety if left untreated. Secondary complications such as an impingement syndrome, rotator cuff tendon tear, and labral tears are sometimes directly related to chronic proximal bicep issues.

At the time of a long head tendon rupture, the athlete may feel/hear a pop or snap. Perhaps surprisingly, this is often not overly painful.

It is important to confirm the injury is indeed a tendon tear and not a topical tendon inflammation (tendinitis), as these present with similar signs and symptoms.

Signs and Symptoms of a Ruptured Long Head of Biceps Brachii Muscle

  • A “spasm bulge” in the lower part of the arm. This is due to the biceps brachii muscle belly involuntarily contracting without its regular check by the long head tendon attachment above the shoulder joint. The intact short head is able to hold the muscle in position but is not overly effective.
  • Localized sharp pain originating in the front of the shoulder and radiating downward to the muscle belly
  • An audible pop or snap at the time of injury
  • Rapidly fatiguing biceps muscle with activity
  • Pain, tenderness, weakness and considerable difficulty eliciting shoulder and elbow movements

Professional Treatment for Ruptured Tendon of Long Head of Biceps Brachii

  • Rest the shoulder and elbow joints while consistently icing the anterior shoulder and upper arm to minimize both swelling and pain.
  • Avoid strenuous arm activity for at least two weeks and:
    • Utilize the latest physical therapy modalities and rehab devices to reduce swelling and pain.
    • Increase your Vitamin C intake to assist your body’s ability to produce fibroblasts, which synthesize ever-important collagen.
    • Restore flexibility and range of motion of the shoulder joint, shoulder girdle and elbow joint.
    • Discuss treatment options with your physician. Non-operative approaches are most common, but consider surgical options when specific issues such as past medical history, intended level of activity, and degree of limitation merit the need for surgery.
    • As range of motion and pain improve, integrate progressive resistive (strengthening) exercises into the rehab plan.  Carefully monitor isolated bicep curls and resistive shoulder flexion exercises, which should progress more slowly than other motions due to stress placed on the shoulder joint.
    • Be diligent in your physical therapy regimen, which should include strengthening, flexibility, proprioception, and cardiovascular exercises.

Ask the Right Questions Like the Pros

Here’s what smart pro athletes would ask their sports medicine specialist to ensure a fast and safe return to the game they love:

1. Is this injury a ruptured biceps muscle tendon or a partial tear?

2. Are additional diagnostic procedures needed to rule out the possibility of other injuries?

3. Is there secondary damage to any other structure(s) around my shoulder?

4. Do you think surgery is required for this injury?  If not, what are the short and long-term risks of conservative treatment?

5. Where are your top three physical therapy recommendations to rehabilitate this injury?

6. In your opinion, what is the timeframe needed before I can return to my usual routine?

Elite Sports Medicine Tips from Mike Ryan

  • Relax – The right frame of mind proves a helpful tool with this type of injury.  Managing a rupture the correct way will foster a quick return to your normal activities.
  • Rehab Diligently – Don’t let distractions hinder you from executing your physical therapy plan.
  • Realize the Risks – If you fail to rehab your shoulder/arm properly, altered shoulder mechanics may predispose you to other injuries such as an impingement syndrome, bursitis, tendonitis, and early arthritis.
  • Refrain from Pain – Thoroughly evaluate your daily routine, avoiding activities that aggravate your biceps muscle and shoulder joint and in turn stall your progress.

Subacromial Bursitis Made Easy

Subacromial Bursitis Made Easy

Understanding Shoulder Bursitis

The subacromial bursa is a thin, sac-like structure located just under the acromioclavicular, or AC, shoulder joint. It acts as a lubricating buffer between the rotator cuff, undersurface of the lateral clavicle and scapular acromion process.

Specifically, the bursa’s main function is to reduce friction in the upper layers of the rotator cuff and humeral head during shoulder motion.  As a thin, fluid-filled sac, similar to a slim water balloon, it is quite efficient at specifically doing so with respect to the head of the humerus, long-head of the biceps tendon and the (all-important) rotator cuff.  Given the level of motion and stress associated with the shoulder joint, the subacromial bursa certainly faces a trying task every single day. However, this does not even involve direct contact with the shoulder girdle.

Rotator cuff tendonitis and shoulder impingement syndrome are other conditions commonly associated with chronic subacromial bursitis. Additionally, it is not unusual for a chronic rotator cuff injury that alters shoulder joint mechanics to result in subacromial bursa inflammation. It is therefore extremely important to assess for any additional upper extremity or torso imbalances/injuries that require treatment when an athlete presents with a bursitis involving the shoulder.

Signs & Symptoms of Subacromial Bursitis

  • Generalized stiffness of the shoulder joint, mostly on the top and front of the shoulder
  • Symptom escalation generally associated with either a direct blow to the front of the shoulder joint or increased shoulder use, usually involving overhead-type activities
  • A sense of weakness or loss of strength with activities involving the shoulder
  • Localized puffiness or a pocket of swelling in the upper-front area of the shoulder, just below the AC joint, which becomes more evident when the arm is extended at the shoulder
  • Weakness with active shoulder elevation and abduction

Professional Treatment for Subacromial Bursitis

  • Eliminate all routines that contributed to the bursitis. This can include excessive overhead activities, trauma or contact to the shoulder, weight training above shoulder level, painful motion during activities of daily living (ADLs) or carrying heavy objects like luggage with the affected shoulder.
  • Consistently ice the front, top and back of the shoulder.
  • Utilize available therapy modalities to decrease pain and swelling.
  • Do easy pendulum swings with no more than 5 pounds of weight.
  • Perform passive and pain-free range of motion (ROM) shoulder joint exercises, to include flexion, abduction, horizontal abduction and external rotation. At the same time, minimize shoulder extension and horizontal adduction motions.
  • Employ progressive resistive strengthening of external shoulder rotation, if pain free.
  • Avoid sleeping on the affected shoulder if still swollen and/or painful.

Ask the Right Questions Like a Pro

Here’s what smart pro athletes would ask their sports medicine specialist to ensure a fast and safe return to the game they love:

1. Is this an isolated bursitis, or do I need to treat other shoulder issues as well?

2. Is my rotator cuff damaged?

3. What do you believe caused this injury, and how can I avoid these types of injuries in the future?

4. Should I expect future anti-inflammatory injections for this bursa?

Elite Sports Medicine Tips from Mike Ryan

  • Looks Can Be Deceiving – Bursitis often looks worse than it feels.
  • Get it Right the First Time – Don’t let the lack of initial pain fool you – with the bursa’s proximity to the rotator cuff, seek swift, appropriate treatment to avoid a chronic nightmare.
  • Ice, Ice Baby – It’s said time and time again, but the “ice thing” is a key tool to quiet down bursitis and reduce localized swelling.
  • Pinpoint the Source – If the reason for bursa swelling is unknown, dig deeper to find out why.  Quickly finding the source helps avoid major shoulder complications down the road.
  • Avoid the Knife – Some doctors are quick to offer a “simple surgical solution.”  Run away quickly and reread this article.

Impingement Syndrome of the Shoulder: Tennis Shoulder

Impingement Syndrome of the Shoulder: Tennis Shoulder

Years back, a friend of a former colleague came to see me with left shoulder pain. I had helped him resolve prior issues in this other shoulder, so I took it as a compliment that he came back to see me when a new problem arose on the opposite side.

Given that his case was fairly typical, I think it provides a helpful example of how to quickly and properly manage acute “tennis shoulder.”

The Athlete:

  • Approximately 38 years old
  • Active military, excellent health, top-notch strength and conditioning
  • Right-hand dominant (with a history of impingement syndrome in the right shoulder), but favors his left arm when playing tennis

The Symptoms:

  • Significant sharp shoulder pain in the left AC joint
  • Approximately 50% strength loss in functional activities such as turning the steering wheel in car or holding something away from the body
  • Shoulder pain while lifting the arm
  • Inability to sleep on the left shoulder due to pain

The History:

  • No falls, accidents or episodes that would lead to shoulder symptoms
  • Competitive tennis player in his youth; recent tennis activity with his daughter on a frequent basis
  • Over the last two weeks, an increase in localized shoulder pain while lifting his arm, along with more intense point tenderness on the AC joint (tip of the shoulder)

The Examination:

  • Point tenderness, approximately the size of a dime, was easily located at the end of the left collarbone on the front of the AC joint.
  • Intense pain occurred with active motion when attempting to reach across the body with the left hand to touch the back of the right shoulder.
  • Passive extension of the shoulder, with the elbow extended and wrist pronated, maximized the stretch on the longhead of the biceps brachii muscle.
  • Manual muscle tests used to assess shoulder strength with motions including external rotation, flexion, abduction, supraspinatus elevation and extension demonstrated approximately 70% less strength than observed in the right shoulder.
  • Other tests performed to rule out issues such as shoulder joint instability, AC joint separation, nerve pathologies and an SC joint sprain were normal and symptom-free.

The Diagnosis:

Acute Impingement Syndrome of Shoulder, aka Tennis Shoulder

The Plan:

  • Discontinue tennis and all other activities that lead to shoulder symptoms for two weeks.
  • Perform consistent pendulum swings with a light weight.
  • Implement an aggressive one-week strengthening routine for external rotation (ER).
  • If strength in ER returns to approximately 90% in one week, resume pain-free weight training while continuing to avoid all overhead lifting and exercises involving the left arm crossing the midline of the body.
  • Improve posture with pain-free chest and anterior shoulders stretches.
  • Consistently massage chest muscles immediately before exercising the upper-mid back with shoulder blade retraction or “pulling together” exercises.
  • Ice the shoulder three to five times per day.
  • Consume over-the-counter anti-inflammatory medicine for a short period of time, only as needed for pain.
  • Avoid sleeping on left shoulder for two weeks.
  • Nail down a successful pre-tennis routine that will:

> Warm up the shoulder joint, AC joint and surrounding musculature

> Allow for normal mechanics and patterns for movement

> “Fire up” the shoulder’s external rotators to help decelerate the arm during the follow-through phase of the tennis swing

It was a pleasure working with this gentleman, who understood he may need to permanently limit his overhead lifting and consistently focus on the strength of his external rotators bilaterally based on his history. More imminently, I expected him to be able to return to his normal activities as an active military specialist and tennis vet within three weeks following his exam. Game, set, match!

How to Survive a Rotator Cuff Tear

How to Survive a Rotator Cuff Tear

While thinking up the title for this article, I actually laughed out loud. Given the diversity of sources available to learn about rotator cuff injuries and boatload of corresponding data, surviving the information tsunami is more like it. Yet, knowledge is power, and here we are talking about it once more. Hopefully my colleagues will read this article and share in my humor without questioning the blatant hyperbole.

Okay, time to get serious. The rotator cuff is a group of four independent muscles that function to dynamically stabilize the glenohumeral (shoulder) joint.  The muscles bind to a cuff-like covering of the humerus (upper arm) bone to provide the shoulder joint with control and strength in both rotational and directional movements. Specifically, their main functions are:

  • Supraspinatus Muscle – Lift the arm out to the side (abduction) and slightly forward
  • Infraspinatus Muscle – Rotate the shoulder externally
  • Teres Minor Muscle – Rotate the shoulder externally
  • Subscapularis Muscle – Rotate the shoulder internally

Rotator cuff symptoms vary based on the degree and exact location of the injury. The most common rotator cuff injury is a strain or tear in the supraspinatus. Specifically, active individuals who perform a large amount of overhead throwing and lifting activities place excess strain and trauma on rotator cuff tissue.  In addition, external rotation (the weakest shoulder motion) contributes to the prevalence of impingement mechanisms upon the rotator cuff.

Rotator cuff injuries are grouped into two categories:

1. Tendinopathy – Inflammation or degeneration of a tendon

2. Tear or Strain – Disruption of a tendon and/or muscle

Signs and Symptoms of a Rotator Cuff Injury

Tendinopathy Symptoms:

  • Discomfort that can range from an ache to sharp, localized pain
  • Front shoulder tenderness that is more palpable when reaching behind the back, alongside general lateral deltoid pain with no associated tenderness in that area of the shoulder
  • Increased symptoms when raising and lowering the arm, especially when using a horizontal or shoulder-level range of motion
  • Noticeable weakness in most shoulder movements, especially when lifting the arm overhead and with resisted external rotation

Acute Rotator Cuff Tear Symptoms:

*Common causes of injury are suddenly falling on an outstretched arm or experiencing a rapid impact to the shoulder muscles, such as from the ground or an opposing player.*

  • Tearing sensation felt within the shoulder, immediately followed by significant pain throughout the shoulder girdle
  • Severe pain in a specific location followed by spasms and general shoulder joint stiffness
  • Weakness that ranges from minimal to severe enough to impair any active arm abduction (moving away from the side of the body), depending on the degree of tendon/muscle disruption
  • Limited active shoulder movement secondary to pain and weakness

Chronic Rotator Cuff Tear Symptoms:

*Chronic rotator cuff injuries develop over a period of time.  Due to excess impingement-type friction related to chronic pathology, the tear usually occurs at or near the tendon, typically on the dominant side. Athletes with this condition are generally over the age of 34.*

  • Ongoing symptoms with a gradual increase in both pain and weakness, both of which may become severe
  • Increased symptoms during rest and while sleeping on the involved side
  • Range of motion limitations and weakness that vary based on the location and severity of injury

Treating a Rotator Cuff Injury

  • It is important to obtain a detailed history of trauma to the shoulder, neck, chest and upper arm to help outline treatment based on the specific body part and tissue type.
  • A thorough bilateral assessment can point to major limiting factors: weakness, range of motion, and/or pain.
  • Work to progressively regain range of motion in the shoulder from the onset of the injury.
  • Apply ice to address any increase in shoulder joint warmth and soreness. When dealing with a chronic injury, utilize a contrast of warm/cold treatments to help increase blood flow.
  • Increasing strength without amplifying symptoms is a top priority when treating any type of a rotator cuff injury.  Employ a treatment program where special attention is paid to this balance, increasing the strength of external rotators while applying caution in overhead exercises.
  • Soft tissue massage and manual therapy to the shoulder, upper back and neck helps normalize mechanics of the entire shoulder girdle.
  • Implement scapula (shoulder blade) exercises early on in the rehab plan.  Enhance the strength and endurance of the shoulder stabilizers with activities such as planks, isometric arm holds and upper extremity weight-bearing medicine ball rolls.
  • Help improve proximal shoulder strength with distal extremity work such as hand-gripping, wrist curls and triceps extensions.
  • Sport-specific activities can be added to the treatment plan when shoulder strength returns to at least 75%, with extra caution given to all throwing and overhead activities.

Ask the Right Questions Like a Pro

Smart professional athletes with a rotator cuff injury who want to safely return to the field or court should ask their sports medicine specialist the following questions:

1. Are my rotator cuff symptoms due to an actual tear, or are they related to a tendinopathy?

2. Is an MRI or MRI Arthrogram needed to properly diagnose my injury?

3. How would you grade the strength in my affected shoulder, compared to the other side?

4. Do you think I will need rotator cuff surgery now or in the future?

5. Which physical therapist(s) do you recommend to rehab my injury?

Sports Medicine Tips for Living With a Rotator Cuff Injury

Get on Your Nerves – Body nerves can be fickle, so be sure your sports medicine specialist thoroughly evaluates your neck, muscles and shoulders to avoid missing any nerve-related reasons for your weakness.

Be a Chatty Cathy – That concussion last month…the pins and needles feeling you get when you sleep on that arm…these things do matter.  Tell your doctor anything and everything you know about signals from your body and let him/her figure out what’s not important.

Break Out Your Mental Scale – Don’t let the fact that you have a rotator cuff tear make you believe surgery is inevitable.  Weigh your lifestyle factors and corresponding limitations, along with the medical opinions of trusted professionals, before making the decision to go “under the knife.”

Take the Long View – Surgery or not, a rotator cuff injury dictates a long-term treatment plan.  This will provide a clear roadmap of stretches and strengthening exercises that you will do along with vulnerable activities/exercises you will not do.  Knowing both is important for an active future.

Shoulder Therapy Made Easy

Shoulder Therapy Made Easy

If you are experiencing general shoulder pain and want to work out the kinks and reduce your shoulder soreness, this article is for you. Rather than address any one specific injury or diagnosis, I’m excited to share my general philosophy for shoulder treatment along with exercises that may save you thousands of dollars in medical bills.

With that said, it’s important to stress that I believe you’re always better off turning to your healthcare providers before implementing any therapy plan, and I encourage you to do so.  More specifically, I want to enlighten you with tips and knowledge to help you ask better questions to help strengthen these meetings with your wonderful sports medicine specialists as you, quite literally, place your shoulder in their hands.

Now, back to your treatment…So you have a sore, stiff, cranky, catching, aching and/or unhappy shoulder? And you want to learn what to do and what to avoid as you work to get your shoulders, upper back and chest stronger, more flexible and symptom free—right?

A smart starting point is to first understand your anatomy:

Your shoulder girdle involves three main bones, four articulations or joints, 20+ muscles and plenty of miscellaneous “stuff.”  The humerus is better known as the upper arm bone, the clavicle the collar bone, and the scapula the shoulder blade.

The shoulder, or glenohumeral, joint is located where the upper arm bone connects to the scapula.  Structurally, this is a mechanically weak area and a common source of stability issues and sequential shoulder pain.  Most shoulder joint therapy is focused on increasing range of motion (ROM) and improving muscle strength.

The acromioclavicular (AC) joint is where the clavicle and scapula come together.  This is located at the side or “tip” of the shoulder and rests directly above the shoulder joint. AC joint injuries, common when someone lands on the side of his/her shoulder, are sometimes more painfully debilitating than seen with a sprain or “shoulder separation” (addressed in this article) [Insert link to article].

Lastly, the sternoclavicular, or SC, joint is located in the upper and inner chest region where the clavicle and sternum merge. An SC sprain is not common and rarely requires surgery. However, when this injury does occur, it is not quick to heal. Limited motion typically persists due to this impairment.

Shoulder Exercise Dos & Don’ts

One of my goals as a physical therapist is to ensure an athlete returns to the field or court safely.  Those I train of course have the same goal. The following tips are the same rules I use with my professional athletes and can help you, too, get back in the game quickly and safely.

Shoulder Therapy Dos:

  • DO perform a 5-to-10 minute warmup of the four joints and countless shoulder girdle muscles prior to any exercise or shoulder treatment.
  • DO focus on strengthening the rotator cuff, especially if the injured shoulder is not as strong as its partner.
  • DO listen to your shoulder and follow its lead.  If your shoulder exercises tell you that a specific exercise worsens your symptoms, discontinue or adjust the plan.   This may sound too simple, but trust your instincts and your insight.  I always tell both my athletes and myself: “Work with your body, not against it!”
  • DO work hard to increase the pain-free range of motion for your shoulder joint and shoulder girdle.

Shoulder Therapy Don’ts:

  • DON’T sleep on the injured shoulder.
  • DON’T engage in shoulder exercises with the thumb pointed downward, which has a tendency to create rotator cuff impingement syndrome.
  • DON’T perform high-intensity shoulder exercises above the shoulders unless it’s a functional position your sport.  Comfortable stretching of this area is great, but aggressive strengthening is usually too risky.

Ask the Right Questions Like a Pro

Prior to exercising your shoulder, mirror what professional athletes with shoulder pain do to ensure a safe return to sport: ask their sports medicine specialist the following questions:

1. Is my rotator cuff damaged, and if torn, is it partial or full thickness?

2. What specific shoulder exercises or motions should I avoid in my shoulder therapy?

3. What can I expect with this injury over the next 2-6 weeks?

4. When testing the external rotation (ER) strength for both shoulders, what would you grade the percentage strength on my injured side versus my healthy one?

5. Do you think I presently have or am at risk for impingement syndrome?

Sports Medicine Tips for the Best Results

  • Know Your Priorities – Ask yourself: “What do I really need from this shoulder?”  If the answer is “less stiffness,” focus on stretching.  If it’s “better function,” focus on strength. “Less aching and pain?” Prioritize pain-free motion and icing.
  • Seek Stability – Your shoulder is not a stable joint, so avoid any position that risks furthering the injury in an unstable manner.
  • Ice is Your Friend – Ligaments, bursas, and muscles…oh my! With so much “stuff” around the shoulder joint and shoulder girdle, ice is a high priority.  Its chill may sting, but ice is exactly what the doctor orders for almost every shoulder injury.  The pros will tell you that ice is their best teammate, so stop complaining and do what you know you need….ICE and lots of it.
  • Hands on the Ground – Add a new wrinkle to your shoulder treatment that will open a new door for your stretches, stability exercises and strengthening.  Put your hands on the ground and use your body weight to engage the muscles that surround the shoulder girdle.  It’s very safe for most shoulder injuries as well as a fun change.  I know it sounds kind of yoga-ish, so channel your inner yogi and give it a try.
  • Long in the Front & Short in the Back – Improving the resting position of the shoulder girdle is a key part of almost every shoulder therapy program.  In today’s busy lifestyle that sometimes includes staring at a computer all day, rounded shoulders are a common problem. Thereby, it is important to lengthen the front of the shoulders (stretching the chest and internal rotators) while shortening the back of the shoulders (strengthening the upper and middle back and external rotators).

Avoiding Long-Term Problems with a Dislocated Shoulder

Avoiding Long-Term Problems with a Dislocated Shoulder

Shoulder dislocation is an all-too-common injury for many athletes.  Although possible in any direction, approximately 90% of these injuries occur in an anterior, or forward, direction.  With a shoulder dislocation, the head of the humerus (upper arm bone) is forced anterior from its shallow joint, and the glenohumeral (shoulder joint) is disrupted.

This injury typically occurs when the arm is raised away from the side (abduction) at an angle greater than 70 degrees and then externally rotated.  This is referred to as a “throwing position.”  If your arm or hand is forced past the normal range of motion in this position due to a fall, contact with an object or strike from another person, the humeral head dislocates from the joint and causes damage to the stabilizing structures.

Dislocated shoulders are more common than other joint injuries for two reasons:  First of all, the shoulder joint is very mobile and thereby not very stable.  As with any structure, the higher the mobility, the lower the stability.  Secondly, many sports require the athlete to employ the throwing position of shoulder abduction and external rotation described above.

What is a Shoulder Subluxation?

Less severe disruption of the shoulder joint can occur where the humeral head starts to dislocate but returns safely to the joint.  This is referred to as a shoulder subluxation or separation.  Some tissue damage can occur with this injury, which can predispose you to future shoulder dislocations.

What Happens When You Have a Dislocated Shoulder?

Tissue surrounding the shoulder girdle may become damaged when a shoulder dislocation takes place.  The capsule, which surrounds the joint and holds vital lubricating (synovial) fluid, is stretched and damaged as the humeral head relocates outside the joint.  Numerous ligaments reinforce the capsule, which gives stability to the shoulder joint.

Shoulder dislocations can also tear the glenoid labrum, a cartilage ring that surrounds the base of the shoulder joint and deepens the glenoid fossa. The now deeper bowl-like joint surface allows the humeral head to rest, forming the Glenohumeral (or shoulder) joint.  As expected, any joint disruption can injure surrounding ligaments, bones, blood vessels, nerves and tendons.

This injury can fester as a recurring problem, and damage to tissues surrounding the joint will result in instability. A well-balanced rehabilitation program may decrease the likelihood of a chronically unstable joint but cannot completely prevent additional shoulder dislocations.

Signs & Symptoms of a Shoulder Dislocation

  • An acute or sudden dislocation usually results in significant pain encompassing the front half and top of the shoulder.
  • A “pop” is often heard as the upper arm shifts, usually in an anterior and downward manner.
  • It is difficult to move the arm due to pain and the inability to voluntarily contract the musculature surrounding the shoulder joint and upper arm.
  • The arm (supported by the uninjured arm) is most comfortably held in a position slightly away from and in front of the body while leaning forward and toward that side.
  • The shoulder takes on a flat and deformed-like appearance, unlike its typical, rounder shape.
  • If blood vessel or nerve damage occurs, numbness and/or a pins-and- needles feeling may present in the shoulder, arm and hand.

Treating a Dislocated Shoulder

Trained medical specialists should attend to shoulder dislocations that require reduction (moving the joint back in place) in a hospital setting.  Serious secondary injuries to nerves and blood vessels can easily occur when reducing a dislocated joint.

  • Lean on an X-ray and/or MRI to look for any fractures, labral tears or extensive soft tissue damage following a reduction.
  • A thorough evaluation by a shoulder-oriented orthopedic surgeon is extremely important to confirm an exact diagnosis and solid rehab protocol. This is a crucial first step that ultimately sets the course toward either a full recovery or, in its absence, a chronic, life-long problem.
  • Applying ice to the area helps decrease pain, spasms and swelling. Do this every hour for 15 minutes with ice bags covering the front, top and back of the shoulder.
  • Wear a sling for the first three to seven days post-injury. This helps support the weight of the arm and allows it to rest while restricting motion of the injured tissue.
  • If a fracture is ruled out, perform easy range-of-motion (ROM) activities, beginning with elbow motion and pendulum rotations.
  • When the time is right, a physician can recommend and monitor a progressive strengthening program for the shoulder, arm and core.
  • ROM exercises, strengthening programs and activities of daily living (ADLs) should not include any activities that place the arm in an “up and away” position, typically referred to as a throwing motion position.
  • The specific protocol, including the timeframe for sling use, range of motion (ROM) progression, strengthening plan and return to play procedures, must be directed by a physician rather than this article, the purpose of which is to provide a general overview of this injury.

Surgical Options for a Shoulder Dislocation

Surgical shoulder repair is sometimes necessary after a dislocation.  The main objective for the surgery is typically to improve joint stability, hence improving the function of the entire upper extremity.

Parameters for surgery as well as the types of surgeries available for this injury are beyond the scope of this article.

Both the doctor and athlete will typically assess the following variables to determine the need for surgery:

1. Degree of shoulder instability and secondary injuries

2. Sport(s) of interest

3. Projected lifestyle and quality of life adjustments

4. Athlete’s ability to put forth the necessary effort with post-operative rehabilitation

5. Many shoulder-stabilizing surgical procedures result in a permanent reduction in some shoulder motion such as external rotation. Consider this important factor when determining the type of surgery and rehabilitation protocol.

Ask The Right Questions Like a Pro

To ensure you receive the best possible care for your injured shoulder, ask questions like smart professional athletes who seek help from their sports medicine specialist to quickly and safely return to their sport:

1. In which direction did my shoulder dislocate?

2. Do I have multidirectional instability?

3. How would you describe the extent of the damage to my shoulder joint surfaces, capsule, ligaments and muscles?

4. Do I need surgery, and if so, which type would you recommend and why?

5. When can I get out of my sling and start my ROM drills/strengthening exercises?

6. Is there a detailed rehab protocol I can follow during my recovery?

Sports Medicine Tips for a Quick Recovery

  • The RC Rules – Shoulder joint stability is important, but the rotator cuff drives that train.  It’s crucial to strengthen the RC but in a smart manner to avoid chronic issues with both.
  • Don’t Let the Labrum Scare You – Labral tears in the shoulder mimic small cartilage tears in the knee.  If your doctor finds a labral tear, don’t panic – many of us have them and do just fine.
  • Honesty is the Best Policy – Be true to yourself and consider factors related to both your shoulder and lifestyle when considering surgery.  If your shoulder is unstable and activity level ambitious, stability is a must.
  • Be Mindful of the Big A – You want to minimize arthritis, or it’s cooler name of Degenerative Joint Disease (DJD).  A combination of poor mechanics and a “sloppy” or loose shoulder is the easiest way to accelerate DJD in a very active athlete.
  • Rehab With Passion – As with any injury, physical therapy is key to your recovery and beyond.  Put your heart into your one opportunity to gain back your range of motion and strength. Focus right now, kickstart a great maintenance program and get back in the game!