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.

Eliminating Your Pain: Finding Your CONTROL – ALT – DELETE

When your computer locks up, what do you do?  The CONTROL – ALT – DELETE key combo is probably your go-to plan to put your computer back in business.  How cool would it be if you could quickly fix your body when unexpectedly pain locks you up?

I’m here to tell you that you can do just that!

Unwelcome Guests

We all get them so it shouldn’t come as a surprise to any of us.  Their disguises may vary while their locations tend to be a bit more consistent.  Meanwhile, they are rarely welcome and we never quite know when they plan on leaving.

Who are these mystery intruders?  They have many name such as aches, stiffness, joint catching, shooting pain, throbbing, spasms, stabbing tendon pain and/or deep-bone pain.  Do any of those different forms of pain sound all too familiar?

Onset of Pain

Some of these mild to moderate pains, although not enjoyable by any means, can be justified based on your history.  An old injury or surgery can add merit to why a joint is stiff or why a muscle is not as strong as its counterpart on the  other side of your body.

But what about the sudden stabbing pain in the front of the shoulder when you reach into the frig to grab the milk or when your kneecap catches as you bend down to pick up your shoes?  An injury is almost understandable when it occurs while you lift a heavy weight or run hard up a hill but “…how can I hurt my damn back just sitting at my desk?!”  Those are the pains that frustrate us; athletes and non-athletes alike.

Injury vs Pain

If you have a legitimate injury, get it checked out by a sports doctor, physical therapist or certified athletic trainer.  These quick fixes I’m about to tell you about don’t pertain to serious injuries.  If you’re dealing with a mild to moderate pain, as noted above, you may be able to eliminated it quickly and effectively.

Delving into a deep sports medicine diagnosing injury lesson is well beyond the scope of this article.  Keeping it simple: If your pain started without involving an accident of any sort, a significant change in your activity level and/or is not accompanied by swelling/redness and/or an increased warmth in the area of pain, you might be able to promptly improve your symptoms.

If you have any questions or concerns about your symptoms, see your doctor ASAP and get a firm handle on your injury.

Finding Your CONTROL – ALT – DELETE

When my shoulders hurt, somewhat common after many bike crashes, falls and a shoulder surgery, my Go To Fix-It move is: Pushups.  90% of my shoulder throbbing, stabbing and impingement pain will disappear after a quick set of 25 pushups.  I’m literally smiling as I type this because I love pushups!  They are my shoulder CONTROL – ALT – DELETE solution.

I personally have six (6) of these body pain eliminating routines in my personal toolbox which are awesome quick-fixes for my many orthopedic ailments.  They take no more than 5 minutes to complete and they keep me very active, almost pain-free and, as my wife will agree with, much easier to live with.

My question to you: What are your CONTROL – ALT – DELETE’s?

Tips to Finding Your CONTROL – ALT – DELETE’s

Go With What Works – what have you done in the past that helped you with this type of pain with this joint/body part?  Start with what has worked in the past and work on modifying your technique to improve it’s effectiveness and prolong its benefits.

Stop Looking for the Why – When in pain, the WHY is far less important than the HOW.  Eliminate your pain now and worry about your selfie-in-pain FB picture later.

Bilateral Movements – Your body likes balance.  Doing bilateral (both sides of your body) movements like twists, double arm stretches, bike riding, arm circles and crunches are typically the best moves to start with.

Slow Movements & Deep Breaths – Unless you’re a chiropractor, keep all you movements slow and methodical.  Slow and deep breathing relaxes your body and allows you to listen to the message your body is sending to you, be them good or bad.  Remember, you’re trying to “reset” your body to be balanced and pain-free so allowing for ample time in these new positions is crucial.

Posture, Posture, Posture – Poor posture is a very common source of pain in adults.  Viewing front, side and back photos of you standing and sitting will quickly show visual cues to problem areas in your body.  Focus on stretching stronger/short muscles and strengthening weaker/longer muscles.  Head and neck posture is a common problem in our sit-friendly society.

Examples of Simple Pain Eliminating Solutions

Shoulder Pain – Pushups, door stretches, resisted external rotations, ice massage, thumb-up dumbbell side raises, pool water movements, and seated rows.

Low Back Pain – Crunches, hamstring stretches, laying on hard floor with pillows under knees, hip flexor stretches, bike riding, groin stretches, rolling tennis ball into front/side of hip, Yoga downdog stretches and double arm pull-up bar hangs.

Knee Pain – Roller on front/side of quads, quad stretches, controlled quad strengthening, ice massage, hamstring stretches, massaging and mobilizing kneecap, hip flexor stretches, wall sits, Yoga downdog stretches and bike riding.

Ankle Pain/Heel Pain – Yoga down dog stretches, barefoot walking on soft surfaces, arch & calf massage, ice massage, duck walks on grass on heels only, resisted ankle motion: outward and upward, eliminate shoes with moderate to high heels, picking up marbles/rocks with toes and a heel lift if legs are not equal length.

Key Point to Remember

Your body does not want to be in pain.  Your objective for this endeavor is to put your symptomatic body part(s) in a position which is pain-free and strong to allow your body and mind to reprogram all your associated muscles, tendons, joint capsules and fascia to maintain this “happy place” allowing you to move with less resistance and less pain. Period.

I know this concept sounds very different from the all too common; “medicate to reduce pain” philosophy.  Personally, my physical therapy motto is simple:  Trust your body to know what it needs to do its job!

Being active and healthy is NOT a passive process.   There’s no better time than now to get busy eliminating your pain so you can get busy living.

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.

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!

AC Joint Separation Management

AC Joint Separation Management

Acromioclavicular (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 occurs when the ligaments that stabilize the collar bone (clavicle) and the shoulder blade (scapula) are damaged.

The acromioclavicular joint connects 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 that 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 due to a separated shoulder, there is a downward pull to the clavicle and AC joint.

What Causes a Sprained AC Joint?

Falls are a main 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 injury mechanisms are:

  • Landing on the lateral part of the shoulder, forcing the shoulder downward
  • Landing on an outstretched arm or elbow, forcing the shoulder joint upward into the undersurface of the acromioclavicular joint

Either of these situations noted above will disrupt the AC joint capsule and compromise the stabilizing ligaments.  The grade, or degree, of separation depends on the level of damage to both the ligaments and capsule.

Grades of Separation

Shoulder Separation, Grade I

Mild disruption of the AC joint capsule, resulting in minimal joint instability

Shoulder Separation, Grade II

Moderate disruption of both the AC joint capsule and stabilizing ligaments, resulting in moderate AC joint instability.  Partial tears of both the AC joint capsule and stabilizing ligaments are present.  Holding a weighted object with the injured arm at one’s side will present moderate AC joint laxity with visible elevation of the outer clavicle. The amount of elevation with a Grade II AC sprain is typically ½ to 1 inch, when compared bilaterally.

Shoulder Separation, Grade III

Significant disruption of both the AC joint capsule and stabilizing ligaments results in significant AC joint instability.  Complete tears of the AC joint capsule, and possibly complete tears of at least some of the stabilizing ligaments, are present. When the injured arm rests at the side of the body, there is visible laxity of the acromioclavicular joint and visible elevation of the outer clavicle.  When the arm reaches across the body toward the back of the other shoulder, abnormal lateral clavicle elevation increases.

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

Signs & Symptoms of an AC Joint Sprain

  • Pain and localized swelling on the top of the shoulder at the acromioclavicular joint
  • Swelling and/or bruising 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 when lifting the arm
  • With Grade II and Grade III AC joint sprains, a “clicking” or shifting felt in the AC joint with shoulder motion
  • Significant AC pain with active motion (personally moving the arm) or passive motion (someone else moving the arm), horizontally across the body toward the back of the other shoulder

Treating a Separated Shoulder

  • Ice the top and front of the shoulder with the elbow flexed to approximately 90 degrees and supported.
  • Use an arm sling if pain or clicking occur when walking.  This helps to support the weight of the arm while also restricting motion.
  • Once a fracture is ruled out, initiate early motion to reduce stiffness and pain.  Avoid horizontal adduction motion (horizontal movement of the arm across the midline of the body) until pain-free motion is achieved.
  • Perform easy pendulum swings to help regain motion of the shoulder.
  • Initiate a shoulder strengthening program early on with a Grade I & II sprain, if tolerable.  Start with rotational motions and progress with overhead lifts, continuing to avoid horizontal adduction as long as possible.

Ask the Right Questions Like a Pro

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

1. What grade is my shoulder separation?

2. Do you think I can successfully rehab this AC joint sprain and avoid surgery?

3. Are special padding, taping, or sports equipment alterations needed to reduce the chance of reinjuring my acromioclavicular joint?  Which specific lifts, activities, and motions should I avoid to help my AC joint separation heal quickly?

Sports Medicine Tips For an AC Joint Separation

  • No Need for the Knife – AC joint surgeries are not overly common unless instability is severe or complex limitations are present.
  • Sleep Well? – Plan to avoid 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, not the smartest thing that I’ve ever done, but it sure was fun…until I crashed!) in Vermont in 1994. I still can’t sleep on that side!
  • Prioritize Posture – Any position, movement or activity that rounds your shoulders will worsen the pain. It’s that simple.
  • Ice, Motion, Ice – Ice it, move it (in pain-free directions) and then ice it again. It’s a simple formula with fast results.
  • Exercise Efficiently – While sitting or standing tall, relax your arms while squeezing your shoulder blades (scapula) together and 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, most importantly, decompress your AC joint.