Shoulder Therapy Made Easy

"Look Maa, the Shoulder Therapy is Working!"

If you are experiencing general shoulder pain and want to return to exercising your shoulders or reduce your shoulder soreness, this article is written for you. Today I’m not going to address any one injury or diagnosis.  Instead I’m excited to share my general philosophies for shoulder treatment along with exercises that may save you thousands of dollars in medical bills.

With that being said, it’s very important to stress that I think you’re always better off when you utilize your health care providers before implementing any therapy program.  As I always point out, I do not want to replace nor do I want to discourage you from seeing your health care providers.  Quite the contrary:  I want to help you better utilize your many wonderful sports medicine specialists by enlightening you with tips and knowledge to help you ask better questions and grow your trust in their assistance with your shoulder treatment.

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

A smart starting point is to first understand your anatomy so you can get the best shoulder treatment possible.

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

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

The acromioclavicular (AC) joint is where the clavicle and the scapula come together.  This AC joint is located at the side or “tip” of the shoulder and it rests directly above the shoulder joint.  Commonly injured when someone lands on the side of his/her shoulder, the AC joint can be more painfully debilitating than 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.  The SC sprain is not common and rarely requires surgery.  However, when this injury occurs, it is not quick to heal. Plus limited motions typically remains with a little disability because of this impairment.

Do’s & Don’t for Shoulder Exercises

One of the goals of my position as a physical therapist is to make sure an athlete gets back on the field safely.  Of course the athletes I train also want to get back as quickly as possible too. The following tips are the rules I use with my professional athletes and will help you too—get back in the game quickly and safely.

The Do’s of Shoulder Therapy:

  • Perform a 5 to 10 minute warm-up of the four joints and countless muscles of the shoulder girdle before any exercise or shoulder treatment.
  • Focus on the strengthening the rotator cuff, especially if the injured side is not as strong as the other shoulder.
  • Listen to your shoulder and follow its lead.  If your shoulder exercises are telling you that a specific exercise makes your symptoms worse, discontinue or adjust the plan.   This may sound too simple but trust your instincts and your insight.  I always tell my athletes and myself: “Work with your body not against your body!”
  • Work hard to increase the pain-free range of motion of your shoulder joint and shoulder girdle.

The Don’ts of Shoulder Therapy:

  • Sleep on the injured shoulder.
  • Perform shoulder exercises with the thumb pointed downward, which have a tendency to create an impingement syndrome of the rotator cuff.
  • Perform high-intensity shoulder exercises above the shoulders unless it’s a functional position for the sports.  Comfortable stretching up there is great but aggressive strengthening up there is usually too risky.

Asking the Right Questions

Before you start exercising your shoulder, you’ll want to do like a professional athlete with shoulder pain. To ensure he can safely return to his sport, a pro athlete should ask his sports medicine specialist the following questions:

  1. Is my rotator cuff damaged and if torn, is it a partial thickness tear or a full thickness tear?
  2. With my shoulder therapy, what specific shoulder exercises or motions should I avoid?
  3. What can I expect with this injury for the next 2, 4 and 6 weeks?
  4. When you test my external rotation (ER) strength for both shoulders, what would you grade the percentage strength would you grade my external rotators on my injured side?
  5. Do you think I presently have or am I at risk of having an impingement syndrome?

Sports Medicine Tips To Get The Results You Want

  • Know Your Priorities – Ask yourself: “What do I really need from this shoulder?”  If it’s “less stiffness”, focus on stretching.  If it’s “better function”, focus on getting it stronger.  If your body tells you “less aching and pain”, prioritize the pain-free motion and icing.
  • Get Stable – Your shoulder is not a stable joint so avoid any position that risks injuring the shoulder and making the shoulder more unstable.
  • Ice is Your Friend – With the many ligament, bursas, muscles and stuff around the shoulder joint and shoulder girdle, ice is a very high priority.  Ice hurts but it’s exactly what you need for almost every shoulder injury.  The Pro’s will tell you that ice is their best teammate.  Stop complaining and do what you know you need….ICE and lots of it.
  • Put Your Hands on the Ground – Add a new wrinkle to your shoulder treatment that will open a new door to your stretches, your stability exercises and your 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 and it’s a fun change.  I know it’s kind of yoga-ish but that’s okay with me.
  • Lengthen the Front & Shorten the Back – For almost every shoulder therapy program, improving the resting position of the shoulder girdle is needed.  With today’s busy lifestyle that includes a large part of our day sitting in front of a computer, rounded shoulders is often a result. Lengthening the front of the shoulders (stretching the chest and internal rotators of the shoulders) while shortening the back of the shoulders (strengthening the upper and middle back and external rotators of the shoulders) should be addressed.

How To Treat Shoulder Pain Caused By AC Joint Separation

Location of Separated Shoulder Pain

Acromioclavicular joints or AC joints are easily injured and susceptible to secondary issues such as arthritis, laxity and shoulder pain.  Often referred to as a “separated shoulder”, an AC separation takes place when the ligaments that stabilize the collar bone (clavicle) and the shoulder blade (scapula) become damaged.

The acromioclavicular joint is the connection between the lateral end of the clavicle (collar bone) and the lateral end of the scapula (shoulder blade).  This bony section of the scapula is referred to as the acromion. The AC joint creates a stabilizing union between the front and back of the shoulder girdle.  It’s important to note that when healthy this joint has ample mobility, which allows for significant motion of the shoulder.  The AC joint forms an important archway that protects the rotator cuff and shoulder joint below.

Stabilized by a joint capsule, the acromioclavicular joint encompasses the ends of the clavicle and acromion along with several ligaments. Because ligaments attach bones to bones, when the AC joint ligaments, located under the clavicle, are damaged with a separated shoulder they create a downward pull to the clavicle and AC joint.

What Causes a Sprained AC Joint?

Falls are often the cause of separated shoulder injuries.  The AC joint is not overly stable and its location makes it quite vulnerable to injury.

The two most common reasons for injury are:

  1. Landing on the lateral part of the shoulder forcing the shoulder downward.
  2. Landing on an outstretched arm or elbow, which forces the shoulder joint upward in into the undersurface of the acromioclavicular joint.

With either of these, the AC joint capsule is disrupted and the stabilizing ligaments are compromised.  The grade or degree of separation depends upon the level of damage to both the ligaments and capsule.

Grades of Separation

Shoulder Separation, Grade I

A mild disruption of the AC joint capsule resulting in minimal instability of the joint.

Shoulder Separation, Grade II

A moderate disruption of both the AC joint capsule and stabilizing ligaments resulting in moderate instability of the AC joint.  Partial tears of both the AC joint capsule and the stabilizing ligaments are present.  You’ll notice moderate laxity of the AC joint with a visible elevation of the outer clavicle when holding a weighted object with the injured arm at your side. The amount of elevation with a Grade II AC sprain is typically ½ to 1 inch when compared bilaterally.

Shoulder Separation, Grade III

A significant disruption of both the AC joint capsule and stabilizing ligaments resulting in significant instability of the AC joint.  Complete tears of the AC joint capsule and possibly complete tears of at least some of the stabilizing ligaments are present.  There is visible laxity of your acromioclavicular joint with a visible elevation of the outer clavicle with the injured arm resting at the side of your body.  When your arm is reached across your body towards the back of the other shoulder, the abnormal lateral clavicle elevation increases.

AC Sprain Grade IV to VI’s are much more severe and are based on the hyper-mobility of the acromioclavicular joint.

Signs & Symptoms You Have an AC Joint Sprain

  • Pain and localized swelling on the top of the shoulder at the acromioclavicular joint.
  • Swelling and or bruising may be present on the top of the shoulder.
  • An obvious bony lump on the top of the shoulder, which is the end of the displaced collarbone.  The higher the grade of shoulder separation, the larger the elevation of the outer tip of the clavicle.
  • Limited range of motion (ROM) and pain with any lifting of the arm.
  • With a grade II and grade III AC joint sprains, a “clicking” or shifting can be felt in the AC joint with shoulder motion.
  • With active motion (when you move your arm) or passive motion (when someone else moves your arm) of the injured arm horizontally across the body towards the back of the other shoulder, significant AC pain will occur.

Treating a Separated Shoulder

  • Ice the top and front of your shoulder with the elbow flexed to approximately 90 degrees and supported.
  • Using an arm sling is helpful if having pain or clicking with walking.  This helps to support the weight of your arm while restricting motion.
  • Once a fracture is ruled out, early motion is started to reduce stiffness and pain.  No horizontal adduction motion (horizontal movement of the arm across the midline of the body) is allowed until you have full pain-free motion.
  • Easy pendulum swings to help regain motion of the shoulder.
  • A shoulder strengthening program can be started early with a Grade I & II sprain as tolerable.  Starting with rotational motions and progressing with overhead lifts as tolerable.  Continue to avoid horizontal adduction as long as possible.

Questions a Pro Athlete Would Ask To Heal Quickly and Safely

As always, my goal is to help you get back in the game as quickly as possible while ensuring you can return safely.  Ask the following questions—the same ones a smart professional athlete with a Separated Shoulder would ask his sports medicine specialist, so you too can recover quickly and safely:

  1. What grade is my shoulder separation?
  2. Do you think I can manage this AC joint sprain with rehab without needing surgery?
  3. Do I need any special padding, taping or altering of my sports equipment to minimize the chances to reinjuring this acromioclavicular joint?
  4. What specific lifts, activities and motions do I need to avoid to allow my AC joint separation to heal quickly?

Sports Medicine Tips For an AC Joint Separation

  • Little Need for a Knife – AC joint surgeries are not overly common unless the instability is severe or the limitations are complex.
  • Sleep Well? – Don’t plan on sleeping on the injured shoulder for a while.  I severely separated my right AC joint in a winter mountain bike race on a ski slalom course (I know, it’s not the smartest thing that I’ve ever done but it sure was a lot of fun…until I crashed!) in Vermont in 1994 and I still can’t sleep on that side!
  • Posture is a Factor – Any position, any movement or any activity that rounds your shoulders will worsen your pain. It’s that simple.
  • Ice, Motion, Ice – Ice it, move it in pain-free directions and then ice it again.  Simple formula with fast results.
  • Upper Back Squeezes – While sitting or standing tall, relax your arms while you squeeze your shoulder blades (scapula) together while exhaling hard.  Hold for 2 seconds and repeat 10 times.  Do this drill as much as possible to stretch out your chest muscles, strengthen your shoulder stabilizing muscle and, very importantly, decompress your AC joint.