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The Myths and Truths Inside a Painful Shoulder

Because it is one of the most mobile joints, the shoulder joint is also one of the most injured joints in the human body. This is because joint mobility and stability are inversely related.

Simply stated; The more motion a joint has the more instability of inherits.

Because of the high stress on the shoulder joint during a demanding and active lifestyle, it gets injured often.  A painful shoulder may have multiple sources of pain including tendons, muscles, bursas, labrums, loose bodies, rotator cuff or arthritis.

Learn the top 3 myths of shoulder pain and the simple solutions to manage your painful shoulder.  The recovery doesn’t have to be complicated.   During my past 30 years as a physical therapist, I’ve learned the patients with a simple plans and a consistent routine typically have the best outcome.

Click Here For My Spartan Race Article Titled: SHOULDER PAIN? 3 MYTHS & 3 SOLUTIONS

As the Sports Medicine Expert for Spartan Race, I write posts for fellow Spartan racers and SGX coaches related to helpful sports medicine topics.

How to Heat up a Frozen 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.

How to Survive a Rotator Cuff Tear

The Pitcher's Fear of the 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.