What the Hell is a Shoulder Labral Tear?

Understanding Shoulder Labral Tear

Shoulder glenoid labrum injuries are common in sports where repetitive overhead movements and physical contact are present. The shoulder has more range of motion than any joint in the human body.  It’s constructed of a very shallow ball socket joint, which makes it vulnerable to injury.

The three bones that make up the shoulder joint are the clavicle, humerus, and scapula. The proximal head of the humerus (upper arm bone) is held in place by a combination of connective tissues, joint capsule and ligaments.  This fibrous tissue of the labrum ‘cups’ the head of the humerus and holds it within the glenoid cavity. The labrum of the shoulder is important in ensuring stability within a mobile joint.  During injury to the shoulder joint or with repeated strain, tear of the glenoid labrum may occur.

Prior to the development of arthroscopic surgery, treatment for labrum tears within the sports medicine community was quite limited.  Before the ability to easily see the inner workings of a joint, identifying the cause of shoulder pain was much more difficult.

Shoulder labral tears are also attributed to the contraction of the biceps muscle against the labrum. Throwing a baseball, for example, is a common cause of this type of tear. SLAP stands for ‘superior labral from anterior to posterior’ and is the acronym used to describe a superior labrum tear common in pitchers. A tear of the anterior labrum is referred to as a Bankhart tear and is often associated with shoulder subluxations and dislocations. Posterior labrum tears are less common and involve pinching of the rotator cuff and labrum.

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 with shoulder 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.

Symptoms of a labral tear within the shoulder joint is not always immediately linked to the precise injury during physical examination. A correct diagnosis of this injury may require an MRI-arthrogram to properly determine the presence and the location of a labral tear.

Professional Treatment of Torn Labrum

  • Discontinue overhead shoulder activities.
  • Utilize the latest physical therapy modalities and rehab devices to reduce swelling and decrease pain.
  • Utilize massage of the chest muscles, upper traps and posterior shoulder rotator cuff muscles to help reduce pain and increase pain-free range of motion.
  • Working with a physical therapist to properly strengthen the rotator cuff and surrounding musculature along with improving the pain-free biomechanics of the shoulder girdle during activities of daily living (ADL).
  • Arthroscopic surgery may be required but only after an aggressive non-invasive rehab plan has been given sufficient time in an effort to reduce symptoms.

Asking the Right Questions Like a Pro

Here’s what a smart pro athlete would ask his/her sports medicine specialists to ensure a fast and safe return to sports: 

  1. Do I need an MRI or MRI-arthrogram to confirm the diagnosis of a torn shoulder labrum?
  2. What are the key physical therapy activities that I need to focus on to speed up my recovery?
  3. What do you consider to be the likelihood of me needing surgery on my shoulder?
  4. How long should I allow for this injury to properly heal before returning to my sport?  Can you write me a general progression to follow as I plan to 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 Early & Often – 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. Inability to recognize a shoulder labrum tear early on can increase your risk of requiring surgery later.
  • Listen Up – If you experience shoulder pain following any activity, listen to your shoulder to help determine the specific movement or activity that aggravated the injury.
  • Stretch – Stretching/warming up the shoulder joint and it’s associated muscles, tendons, ligaments and fascia prior to any physical activity will help keep you in the game.
  • It’s a Marathon – Shoulder labral tears don’t heal so they just don’t go away.  Take your rehabilitation program seriously to help keep you in the game and hopefully avoid surgery and downtime.

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, which run from the spinal cord to the entire body and limbs. These nerves pass through or around many different structures, joints, and tissues.  Referred pain in the shoulder can also be due to structural damage of the shoulder joint, ligaments, or tendons. If this is not the case the most often seen cause of referred shoulder pain is a problem in the cervical spine, chest, or abdomen. Additional causes include infections and complete neurological disorders.

Referred shoulder pain or “shooting pain” can be associated with movement pathologies within the shoulder.  A thorough evaluation by a medical professional is the best only way to ascertain the pain’s true origin. When considering the source of referred shoulder pain in sports, the cause can be a muscle impingement in the upper back. This is most often associated with activities involving aggressive upper torso movements such as twisting and bending. Several examples of these are baseball, football, tennis, and martial arts.

Signs & Symptoms of Referred Shoulder Pain

  • Sharp intense pain in the shoulder.
  • Dull shoulder pain with long duration
  • Weakness in the shoulder and upper arm.
  • Numbness within the shoulder and upper arm.
  • Changes in 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.
  • Utilize physical therapy to stretch the neck and upper back.
  • If pain continues or limits activity consult with a medical professional.

Asking the Right Questions Like a Pro

Here’s what a smart pro athlete would ask his/her sports medicine specialists to ensure a fast and safe return to sports:

  1. Is this pain due to damage to my shoulder or is it something else?
  2. How common is this injury within my sport?
  3. Will I need an MRI?
  4. What is the length of recovery time I can expect with this injury?
  5. Would I benefit from consulting with a physical therapist or can I manage this on my own?

Elite Sports Medicine Tips from Mike Ryan

  • Ice it! – Treat any signs of inflammation or pain with regular intervals of ice! Twice an hour for 10-15 minutes should do the trick.  Sure, ice will make it stiff but it will help decrease the source of the pain.
  • Unsure? Be Sure – If you are unsure of the cause of your shoulder pain, stop the activity and see a doctor to find the answer.
  • Fix the real problem first – Pain down the arm can only be treated by first treating the true cause of the pain.
  • Follow a plan – Following a correct diagnosis of the referred shoulder pain cause be sure to follow a strict plan of treatment and time off to prevent re-injury.
  • Know your history – With referred pain of any type it is important to know your medical history in an effort to help your medical professional determine the cause of the pain.

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.

Understanding 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.

The function of the supraspinatus is to both stabilize the shoulder joint and to allow the shoulder to move in a circular motion.  It is also one of the four muscles which make up the rotator cuff. Supraspinatus tendonitis occurs when the tendon and/or the sheath of the tendon becomes damaged as a result of abnormal stress or trauma. Symptoms of tendonitis in the supraspinatus are associated with inflammation of the tendon.  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. Athletes who suffer from a shoulder impingement syndrome are considered to be at increased risk for developing supraspinatus tendonitis.

Signs & Symptoms of Supraspinatus Tendonitis

  • A sudden or gradual onset of pain following activities that involve shoulder movement.
  • With the arm internally rotated and extended, as if tucking your shirt into the back of your pants, palpation of the front of the shoulder will demonstrate a painful spot on the front of the shoulder where the supraspinatus anchors into the upper arm bone.
  • Limitation in normal range of motion.
  • Weakness and/or pain when lifting the arm overhead.
  • Pain while lying on the affected shoulder.
  • With a chronic impingement syndrome, the shoulder will demonstrate some localized swelling/puffiness in the front of the shoulder below the outer edge of the clavicle bone.

Professional Treatment for Supraspinatus Tendonitis

  • Apply ice to the affected shoulder 3-5 times per day.
  • If the pain and weakness become severe, immobilize the affect shoulder using a sling.
  • Embrace a healthy nutritional diet to include natural antioxidants and natures’ anti-inflammatories with fruits and vegetables.
  • Utilize the latest physical therapy modalities and rehab devices to reduce swelling and decrease pain.
  • Consultation with a medical specialist to confirm the extent of the damage and to implement the necessary treatment plan.
  • If surgery is not required then a physical therapy strengthening program should facilitate proper healing.

Asking the Right Questions Like a Pro

Here’s what a smart pro athlete would ask his/her sports medicine specialists to ensure a fast and safe return to sports:

  1. Is this supraspinatus tendonitis or shoulder impingement syndrome?
  2. What steps must I take to ensure a rapid and safe recovery?
  3. What do you consider to be my recovery time until I will be pain-free?
  4. Would I benefit from consulting with a physical therapist?
  5. Will I require any diagnostic testing or surgery?

Elite Sports Medicine Tips from Mike Ryan

  • Rest Up – Don’t underestimate the benefits of rest with this injury if a decrease in pain is part of your game plan.
  • Ice is Your friend – As with inflammation of any muscle or muscle group, icing the injured area will act to reduce pain and inflammation.
  • P.R.I.C. – Protection, rest, immobilization, and compression!
  • Take it Seriously – Any injury to the shoulder should not be taken lightly.
  • Heavy Rotation – Resistive external rotation will be the most important strengthening exercise for your safe recovery.
  • Start Small – When returning to your physical activities, progress wisely.

How to Heat up 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.

Understanding Frozen Shoulder/ Adhesive Capsulitis

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.

These restricted motions occur with 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 with no active involvement by the individual.

Individuals between the ages of 40 and 60 make up a majority of those diagnosed with this injury while more women out number the men.  Interestingly, adhesive capsulitis is also more common with individuals previously diagnosed with diabetes. Shoulder pain is usually constant and aggravated by weather changes, keeping the joint in one place for too long and activities that create excessive shoulder movements.

Common Causes of Frozen Shoulder

  • Prolonged Immobilization: Secondary to a rotator cuff injury, arm fracture, post surgery immobilizations, stroke, …etc.
  • Premorbid status: Athletes already dealing with certain systemic diseases such as diabetes, abnormal thyroid functions, tuberculosis, and chronic heart abnormalities.
  • Any injury to the shoulder can lead to frozen shoulder, especially 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.

Typically course of a frozen shoulder syndrome: Can be descriptively broken into three phases. Each phase could last from a few weeks to almost a year.

1)    The “Freezing” Phase: The individual/athlete slowly starts to develop tolerable pain and stiffness around the shoulder joint. Range of motion reduces almost directionally proportional to increasing levels of pain.  Some range and strength lost is due to subconscious suppression of active movement secondary to pain. The discomfort is often worse at night and especially when you lay on the affected side.

2)    The “Frozen” Phase: The inception of this stage is marked by a cessation of increasing pain, which the athlete subconsciously perceives as a decline in pain.  Meanwhile, the stiffness and reduced range of motion remains compromised, regular routines remain difficult during this phase, and muscle wasting (atrophy) becomes more evident. The frozen phase could last for about four months to a year. Rotation of the arm outwards (external rotation) can become very difficult in this stage.

3)    The “Thawing” Phase: Also called the recovery phase. Shoulder range of motion starts to improve. Strength and functional capacity are gradually regained. This phase can lasts a 2-3 months.

Signs and Symptoms of a frozen shoulder

  • The shoulder suddenly becoming increasingly stiff/immobile and painful around the joint. Dull aching pain occurs with motion and at rest.
  • Shoulder girdle stiffness restricts full range of motion with both active and passive movements.
  • Localized pain over 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.  This will help decrease pain and regaining range of motion while the surrounding tissue is “numb” from the ice.
  • Working directly with a physical therapy is very helpful for adhesive capulitis.
  • If prescribed by a physician, anti-inflammatory medications made be helpful when taken immediately prior to your rehab sessions.
  • Gentle stretching exercises to increase shoulder girdle range of motion.
  • Persistent motion of the shoulder joint during activities of daily living to help maintain motion.
  • In cases where an aggressive rehab plan is ineffective or the limited range of motion becomes too excessive, the physician may recommend a manipulation of the shoulder joint performed under general anesthesia to break up the adhesions/tightness.

Asking the Right Questions like a Pro Athlete

Here’s what a smart pro athlete would ask his/her sports medicine specialists to ensure a fast and safe return to sports:

  1. Could be this be a secondary complication of arthritis or another injury involving my shoulder joint?
  2. Do you think that I need an MRI to rule out other possibilities?
  3. What is a realistic outcome for me with this injury?
  4. Where is the best place in this area to rehab this injury?
  5. How soon can I return to my normal activities?

Elite Sports Medicine Tips from Mike Ryan

  • Good news – A frozen shoulder is rarely associated with any cancerous pathologies.
  • Take Rehab Seriously– Be proactive with your physical therapy. The success of your rehab will dictate the use of your shoulder for the next 1-2 years, period.
  • Simple Formula – Reduce inflammation while re-programming the muscles that move the shoulder joint.
  • One Timer – Once cured, it 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!

Understanding a Long Head of Biceps Brachii Tendon 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.

These cases are predominantly injuries to the long head of the biceps brachii compared to the short head. This is due to the fact that the long head is more vulnerable because it passes over the shoulder joint to its attachment at the top of the glenohumeral joint

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

It is seen mostly among active individuals as a direct result of repetitive shear forces that originate at the attachment. This injury is commonly linked to high force weight lifting activities with determined athletes trying to get to the top of their game.

Fractures can sometimes be a factor, especially when stress fractures are located at the neck of the upper arm or humerus bone. The tears can be partial or complete. Untreated partial tears of the long head of the biceps can progress into complete tears. Secondary complications such as an impingement syndrome, a rotator cuff tendon tear, and labral tears can be 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 but it is often not overly painful.

Be sure to confirm the injury is indeed a tendon tear and not a topical tendon inflammation (tendinitis) as these two could 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 involuntary contraction without its regular check by the long head tendon attachment above the shoulder joint. The intact short head is able to keep the muscle in position but not overly effective.
  • A localized sharp pain originating in the front of the shoulder and radiating in a downward direction 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.
    • Utilize the latest physical therapy modalities and rehab devices to reduce swelling and decrease pain.
    • Increase your consumption of Vitamins C to assist your body’s ability to produce fibroblasts, which synthesizes the ever-important collagen. The production of effective collagen requires Vitamin C.
    • Restore flexibility and range of motion of the shoulder joint, shoulder girdle and elbow joint.
    • Discuss options with your physician. The non-operative approach is the typical plan but surgical options are considered when specific issues such as past medical history, intended level of activity, degree of limitations and patient’s intentions merit the need for surgery.
    • As the range of motion and pain improve, progressive resistive (strengthening) exercises should be integrated into the rehab plan.  Isolated bicep curls and resistive shoulder flexion exercises are watched closely and progressed more slowly compared to other motions due to the stress on the shoulder joint.
    • Be diligent with your physical therapy program, which should include strengthening, flexibility, proprioception, and cardiovascular exercises.

Asking the Right Questions like a Pro Athlete

Here’s what a smart pro athlete would ask his/her sports medicine specialists to ensure a fast and safe return to sports:

  1. Is this a ruptured tendon of my biceps muscle or a partial tear of the tendon?
  2. Do I need more diagnostic procedures to rule out other injury possibilities?
  3. Do I have any secondary damage to any other structure around my shoulder?
  4. Do you think I need to have surgery for this injury?  If not, what are the short term and long term risks of conservatively treating this injury?
  5. Where are your top three physical therapy recommendations to rehabilitate this injury?
  6. In your opinion, what is the timeframe for me to return to my usual routine?

Elite Sports Medicine Tips from Mike Ryan

  • Relax – The right frame of mind will prove to be a helpful tool with this type of an injury.  A well-managed ruptured tendon will allow you to return to your normal activities quite quickly.
  • Be extra diligent with Rehab– Nothing should hinder you from following through with your physical therapy plan.
  • Realize the Risks – The reality is that if you fail to rehab your shoulder/arm properly, the altered mechanics of the shoulder may predispose you to potential injuries such as an impingement syndrome, bursitis, tendonitis and early arthritis.
  • Avoid complicating the joint – Thoroughly evaluate your daily routine and avoid activities that aggravate your biceps muscle and shoulder joint to stress that would slow your progress.

Subacromial Bursitis Made Easy

Understanding Shoulder Bursitis

The subacromial bursa is a thin sac-like structure that is located just under the acromioclavicular or AC joint of the shoulder.  The bursa lies over the top of the rotator cuff.  The bursa acts as a lubricating buffer between the rotator cuff and the undersurface of the lateral clavicle and acromion process of the scapular, both of which articulate with each other to form the AC joint.

The subacromial bursa’s main function is to reduce the friction on 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, the subacromial bursa is quite efficient in acting as a friction reducer for the head of the humerus, the long-head of the biceps tendon and the all-important rotator cuff.  With the amount of motion and stress associated with the shoulder joint, the subacromial bursa has a difficult task each and every day even without involving direct contact to the shoulder girdle.

Rotator cuff tendonitis or a shoulder impingement syndrome are commonly associated with chronic subacromial bursitis.  It is not unusual to have a chronic rotator cuff injury which would alters the mechanics of the shoulder joint resulting in an inflammation of the subacromial bursa.  That is why it’s important to determine if there are any additional upper extremity or torso imbalances or injuries that require treatment when a player demonstrates 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.
  • An increase in symptoms generally associated with either a direct blow to the front of the shoulder joint or a significant increase in shoulder activities usually involving overhead-type activities.
  • A sense of weakness or loss of strength with activities involving the shoulder.
  • A localized puffiness or pocket of swelling in the upper-front area of the shoulder just below the AC joint.  This isolated pocket of swelling becomes more evident when the arm is extended at the shoulder.
  • Active shoulder elevation and abduction demonstrates weakness.

Professional Treatment for Subacromial Bursitis

  • Eliminating all activities that contributed to the bursitis such as excessive overhead activities, trauma or contact to the shoulder, weight training above shoulder level, painful motions during activities of daily living or hanging heavy object like luggage on the involved shoulder.
  • Consistent icing of the front, top and back of the shoulder.
  • Utilization of the necessary therapy modalities to decrease pain and reduce swelling.
  • Easy pendulum swings with no more than 5 lbs.
  • Passive and painfree range of motion (ROM) of the shoulder joint to include flexion, abduction, horizontal abduction and external rotation while minimizing the motions of shoulder extension and horizontal adduction.
  • Progressive resistive strengthening of shoulder external rotation, if painfree.
  • Avoid sleeping on this shoulder while swelling and/or pain remains.

Asking the Right Questions Like a Pro

Here’s what a smart pro athlete would ask his/her sports medicine specialists to ensure a fast and safe return to sports:

  1. Is this an isolated bursitis or do I have other shoulder issues that I need to treat?
  2. Do I have any damage to my rotator cuff?
  3. In your opinion, why did I get this injury and how can I avoid these types of injuries in the future?
  4. Will I need to have this bursa injected with any anti-inflammatory medication in the future?

Elite Sports Medicine Tips from Mike Ryan

  • Looks Worse – Bursitis often looks worse than it feels.
  • Treat Right the First Time – It may not hurt at first but with it’s proximity to the rotator cuff, you don’t want it to spoil the party in the should and become a chronic nightmare.
  • Ice is Key – I know I wear out the “ice thing” but it’s a key tool to quiet down bursitis cool and to reduce localized swelling.
  • Find the Source – If the reason for the bursa swelling is unknown, dig deeper to find out why.  Find the real reason often avoids major shoulder complications a couple of weeks from now.
  • Avoid the Knife – Some will quickly offer a “simple surgical solution”.  Run away as fast as possible and reread this article.

Tennis Shoulder: Impingement Syndrome of the Shoulder

A friend of one of our coaches came to see me yesterday with left shoulder pain.  He had shoulder issues with his right arm last year that I helped him resolve so I’m taking it as a compliment that he came back to see me when the left shoulder caused him problems!

His medical case is quite typical and I think it will prove to be a helpful example of how to quickly manage acute Tennis Shoulder.

The Athlete:

  • Approximately 38 yrs old
  • Active military, excellent health, excellent overall strength and conditioning.
  • Right hand dominant although he plays tennis with the left arm with a Hx of impingement syndrome of the shoulder on the right.

The Symptoms:

  • Significant sharp shoulder pain on the left AC joint.
  • Approximately 50% strength loss with functional activities such as turning the steering wheel in car and holding anything away from his body.
  • Shoulder pain lifting arm and an inability to sleep on the left shoulder.

The History:

  • No falls, accidents or episodes that would create shoulder symptoms.
  • The athlete has a history of being a competitive tennis player in his youth and he has recently been playing a significant amount of tennis with his daughter.
  • Over the past 2 weeks, localized shoulder pain lifting arm has increased and point tenderness on the AC joint or tip of shoulder has become intense.

The Examination:

  • Point tenderness, approximately the size of a dime, was easily found at the end of the left collarbone on the front of the AC joint.
  • Intense pain with active motion with an attempt 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 the wrist pronated which maximizes the stretch on the longhead of the biceps brachii muscle.
  • Manual muscle tests to assess his shoulder strength for motions such as external rotation, flexion, abduction, supraspinatus elevation and extension demonstrated left shoulder strength of approximately 70% of the right shoulder.
  • Other tests to rule-out issues such as shoulder joint instability, an AC joint separation, nerve pathologies, and an SC joint sprain were normal and symptom-free.

The Diagnosis:

Acute Impingement Syndrome of shoulder or Tennis Shoulder

The Plan:

  • Discontinue tennis and all activities that create any shoulder symptoms for 2 weeks.
  • Consistent pendulum swings with light weight.
  • Implement an aggressive strengthening routine for external rotation (ER) for 1 week.
  • If strength of ER returns to approximately 90 in 1 week, return to painfree weight training while continuing to avoid all overhead lifting and any exercises involving the left arm acrossing the midline of the body.
  • Improving posture with painfree stretches of the chest and anterior shoulders.
  • Consistent massage of chest muscles immediately followed by exercising the upper-mid back with shoulder blade retraction or “pulling together” exercises.
  • Icing the shoulder 3-5 times per day.
  • Only if needed for pain, consuming an over the counter anti-inflammatory medicine for a short period of time.
  • Avoid sleeping on left shoulder for 2 weeks.
  • Determine 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 external rotators to help decelerate the arm during the follow-through phase of the tennis swing.

It was a pleasure working with this gentleman and I believe he will do very well with this action plan.   I expect him to be able to return to his normal activities as an active military specialist within 3 weeks.  He may need to permanently limit his overhead lifting and consistently focus on the strength of his external rotators bilaterally based on his history.

How to Survive a Rotator Cuff Tear

As I came up with the title of this article I actually laughed out loud.  With the amount of information on and diversity of options about rotator cuff injuries, “surviving” the information tsunami is quite appropriate.  Rotator cuff symptoms can vary based on the degree and location of the injury.  Meanwhile, I was secretly hoping my professional colleagues would read this article to share my humor before the title made them think that I was truly insane.

The rotator cuff is a group of four muscles, which function to dynamically stabilize the glenohumeral (shoulder) joint.  The four independent muscles bind to a cuff-like covering of the humerus (upper arm) bone to provide control and strength to the shoulder joint for both rotational and directional movements.

The four (4) rotator cuff muscles and their main function at the shoulder joint:

  • Supraspinatus Muscle – Lifting the arm out to the side (abduction) and slightly forward.
  • Infrspinatus Muscle – External rotation of the shoulder.
  • Subscapularis Muscle – Internal rotation of the shoulder.
  • Teres Minor Muscle – External rotation of the shoulder.

The most commonly rotator cuff injury is a strain or tear to the supraspinatus.  Due to the large amount overhead throwing and lifting activities for active individuals, excess strain and trauma is placed on the rotator cuff tissue.  In addition, the weakest motion of the shoulder is external rotation which contributes to the prevalence of an impingement mechanism upon the rotator cuff.

A rotator cuff injury can be 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 a sharp localized pain.
  • Common location of point tenderness is in the front of the shoulder that is more accessible when reaching behind the back along with lateral deltoid pain that is more general in nature with no associated point tenderness in that area of the shoulder.
  • Increased symptoms with raising and lowering of the arm especially in the horizontal or shoulder-level range of motion.
  • Noticeable weakness for most shoulder arm movements especially when lifting the arm overhead and with resisted external rotation.

Acute Rotator Cuff Tear Symptoms

  • Common mechanism of injury is a sudden fall on an outstretched arm or a rapid loading of the shoulder muscles such as from the ground or an opposing player.
  • Tearing sensation within the shoulder immediately followed by significant pain through shoulder girdle.
  • A degree of limitations with active shoulder movement secondary to pain and weakness.
  • Severe pain in a specific location followed by spasms and general shoulder joint stiffness.
  • Depending upon the degree of tendon/muscle disruption, the resulting weakness can range from minimal to severe enough to impair any active abduction (move the arm away from the side of the body) of the arm.

Chronic Rotator Cuff Tear Symptoms

Chronic rotator cuff injuries develop over a period of time.  Due to the excess impingement-type friction related to a more chronic pathology, the rotator cuff tear usually takes place at or near the tendon. Usually found on the dominant side

  • Ongoing symptoms with a gradual increase in both pain and weakness, both of which can get severe.
  • Increased symptoms with rest and while sleeping on the involved side.
  • Athletes with symptoms tend to be 35+ in age.
  • Depending upon the location and the severity of the rotator cuff injury, the limitations in range of motion and weakness will vary.

Treating a Rotator Cuff Injury

  • Getting a clean history of the trauma to the shoulder, neck, chest and upper arm will help address the treatment to the proper body part and type of tissue.
  • Thorough bilateral assessment will demonstrate the major limiting factors: weakness, range of motion, and/or pain.
  • Progressively regaining shoulder range of motion early is necessary.
  • Ice shoulder when an increase in shoulder joint warmth and soreness is demonstrated.  A contrast of warm/cold treatments will help increase blood flow for a chronic rotator cuff injury.
  • Increasing the strength of the rotator cuff without increasing the rotator cuff symptoms is probably the top priority when treating any type of a rotator cuff injury.  With strengthening program, special attention is addressed towards increasing the strength of the external rotators and caution is applied to all overhead exercises.
  • Soft tissue massage and manual therapy to the shoulder, upper back and neck will help normalize mechanics of the entire shoulder girdle.
  • Scapula (shoulder blade) stabilizing exercises are implemented early in the rehab plan.  The strength and endurance of the shoulder stabilizers are enhanced with activities such as planks, isometric arm holds and upper extremity weight bearing medicine ball rolls.
  • Distal extremity strength work such as hand-gripping, wrist curls and tricep extensions can help improve proximal shoulder strength.
  • Sports-specific activities can be included in treatment plan when shoulder strength has returned to at least 75% with extra caution given to all throwing and overhead activities.

Asking the Right Questions

A smart professional athlete with a rotator cuff injury who wants to safely return to his/her sport should ask his sports medicine specialist the following questions:

  1. Are my rotator cuff symptoms coming from an actual tear of my rotator cuff or is it related to a tendinopathy?
  2. Do I need to get an MRI or MRI Arthrogram to properly diagnose my injury?
  3. How would you grade my shoulder strength compared to the other side?
  4. Do you think that I will need surgery on my rotator cuff now or in the future?
  5. Who do you recommend as a physical therapist to coordinate my rotator cuff injury?

Sports Medicine Tips for Living With a Rotator Cuff Injury

Nerve Related? – Nerves can be funny things so make sure your sports medicine specialist evaluates your neck, nerves, muscles and shoulders to avoid missing some other reason for your weakness.

Hx Matters – That concussion last month or the pins & needles feeling you get when you sleep on that arm…those things do matter.  Tell your doctor all that you know and let him/her figure out what’s not important.

Living With It For Now – Don’t let the fact that you have a rotator cuff tear make you believe that you need surgery.  Weight the lifestyle factors with the limitations that you presently have along with the medical opinions of trusted resources before you “go under the knife”.

Long-Term Treatment – Surgery or not, if you have a rotator cuff injury you need to have a long-term treatment plan.  That plan will give you a clear roadmap of stretches and strengthening exercises that you WILL DO and vulnerable activities/exercises that you WILL NOT DO.  Knowing both is important for an active future.

Avoiding Long-Term Problems with a Dislocated Shoulder

Shoulder dislocation is an all too common an injury for many sports with both men and women.  Although it can happen in any direction, approximately 90% of these dislocations are in an anterior or forward direction.  With a shoulder dislocation, the head of the humerus (upper arm bone) is forced anterior from it’s shallow joint and the glenohumeral or shoulder joint is disrupted.

Typically this injury occurs when the arm is raised away from the side (abduction) at an angle greater than 70 degrees and externally rotated.  This is what is referred to as a throwing position.  When in this position, if your arm or hand is forced past the normal range of motion with a fall or comes in contact with an object or is struck by another person, the humeral head is dislocated from the joint and the stabilizing structures are damaged.

Dislocated shoulders are more common than similar injuries with other joints for two reasons.  First of all, the shoulder joint is very mobile which means it is not very stable.  As with any structure, the higher the mobility the lower the stability.  Secondly, a large percentage of sports require the athlete to put their arms in the throwing position of shoulder abduction and external rotation.

What is a Shoulder Subluxation?

A less severe disruption of the shoulder joint can occur where the humeral head starts to dislocate but it returns to the safety of the joint.  This is referred to as a shoulder subluxation or separation.  Some tissue damage can occur with this injury and it can predispose you to dislocating your shoulder in the future.

What Happens When You Have a Dislocated Shoulder?

When a shoulder dislocation takes place, tissue surrounding the shoulder girdle can be damaged.  The capsule, which surrounds the joint and holds the vital lubricating fluid known as synovial fluid, is stretched and damaged as the humeral head is relocated outside the joint.  Numerous ligaments reinforce the capsule, which gives stability to the shoulder joint.

Shoulder dislocations can also tear the glenoid labrum, which is 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 disruption of a joint can injure surrounding ligaments, bones, blood vessels, nerves and tendons.

This injury can often become a recurring problem. Due to the many stabilizing tissues surrounding the joint, damaged tissues will result in a highly unstable shoulder joint. A well-balanced rehabilitation program may decrease the likelihood of a chronically unstable glenohumeral joint but it cannot eliminate the change of additional shoulder dislocations.

Signs & Symptoms of a Shoulder Dislocation

  • An acute or sudden dislocation of the shoulder usually results in significant pain encompassing the front half and top of your shoulder.
  • A “pop” is often heard and a shifting of the upper arm, usually in an anterior and downward manner.
  • Difficulty in moving the arm due to pain and the inability to voluntarily contract the musculature surrounding the shoulder joint and upper arm.
  • Arm is most comfortably held slightly away from and in front of your body while you lean forward and towards that side with the arm supported by the uninjured arm.
  • The typical rounded appearance of your shoulder is replaced with a flatter and deformed-like appearance.
  • If blood vessel or nerve damage occurs, numbness and/or pins and needles may be present in your shoulder, arm and hand.

Treating a Dislocated Shoulder

Shoulder dislocations which require reduction (putting the joint back in place) is best when done by a trained medical specialist in a hospital setting.  Serious secondary injuries to nerves and blood vessels can easily occur when reducing a dislocated joint.

  • Once the shoulder is reduced, an x-ray and or MRI should be done to determine if there are any fractures, labral tears or extensive soft tissue damage.
  • A thorough evaluation by a shoulder-oriented orthopedic surgeon is extremely important.  Determining an exact diagnosis and a solid rehab protocol may very well be the most important initial steps that will determine if you fully recover from this injury or if you have a chronically unstable and painful shoulder for the rest of your life!
  • The application of ice helps decrease pain, spasms and swelling to the area.  Ideally ice should be applied every hour for 15 minutes with ice bags covering the front, top and back of your shoulder.
  • A sling is most often needed and helpful for the first 3 – 7 days after a dislocated shoulder. This helps to support the weight of the arm allowing for the arm to rest while restricting the motion of the injured tissue.
  • The specific protocol, which will include the timeframe for use of the sling, the range of motion (ROM) progression, the strengthening plan and the return to play procedures, must be directed by your physician and not by this article.  The purpose of the article is to inform you and to give a general overview of this injury.
  • If a fracture has been ruled out, easy range of motion (ROM) is initiated beginning with elbow motion and pendulum rotations.
  • A progressive strengthening program for the shoulder, arm and core is extremely important and should be started and monitored with the advice of your physician.
  • With your ROM exercises, strengthening program and activities of daily living, avoid any activities that place your arm in an “up and away” position, which is typically referred to as a throwing motion position.

Surgical Options for a Shoulder Dislocation

It is sometimes necessary to surgically repair a shoulder after dislocation.  The main objective for the surgery is usually to improve the stability of the joint and, hence, improve the function of the entire upper extremity.

The parameters for surgery and the types of surgeries for this type of injury are beyond the scope of this article.

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

  1. Amount of shoulder instability and secondary injuries.
  2. The sport(s) of interest.
  3. The projected lifestyle and quality of life.
  4. The ability of the athlete to put forth the necessary effort with the post-operative rehabilitation.

Many shoulder-stabilizing surgical procedures result in a permanent reduction in some shoulder motion such as external rotation.  This is an important factor that needs to be considered when determining the type of surgery and the rehabilitation protocol.

Asking The Right Questions

To ensure you receive the best possible care for your injured shoulder, ask questions like a smart professional athlete who wants to safely return to his/her sport as quickly as possible.  Here’s what a pro athlete would ask his sports medicine specialist:

  1. 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 I do, which type of surgery would you recommend and why?
  5. When can I get out of my sling, start my ROM drills and when can I start my strengthening exercises?
  6. Do you have a detailed rehab protocol for me to follow during my recovery?

Sports Medicine Tips for a Quick Recovery

  • The RC Rules – The shoulder joint stability is important but the rotator cuff drives that train.  You need to get that RC strong but in a smart manner so you avoid chronic issues with both.
  • Don’t Let the Labrum Scare You – Labral tears in the shoulder are much like small cartilage tears in the knee.  If your doctor finds a labral tear, don’t let it scare you because many of us have them and do just fine.
  • Be Honest With Yourself – Look at all the factors related to your shoulder and your lifestyle when considering surgery.  If your shoulder is unstable and your activity level is ambitious, having stability is a must.
  • The Big A Word – You want to minimize Arthritis or it’s cooler name of Degenerative Joint Disease (DJD).  Poor mechanics and a “sloppy” or loose shoulder for a very active athlete is the easiest way to accelerate DJD.
  • Rehab With Passion – As with any injury, physical therapy is key to your recovery and beyond.  Put your heart into getting your range of motion and your strength because you only have this opportunity one time.  Get it right now, get on a great maintenance program and get back into the game!