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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.

Eliminating Your Pain: Finding Your CONTROL – ALT – DELETE

control alt delete 28When 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.

Sidelined by the Shoulder [aafp.org]

Shoulder Injury (Photo: Leedman)

In the 2011 NFL  season so far one of the most common injury is the shoulder.  Numerous player’s are missing  games or playing time with this injury.  An example is Washington Redskins running back Tim Hightower who hurt his shoulder on the third play of the game.  Mike Shannon said he could tell a difference in Hightower’s play after the injury.

Why is this injury so common during the first quarter of this young NFL season?  Did the crazy “off-season” have any impact on the vulnerability of these shoulders?

Here are four daily exercises to keep your shoulders strong and healthy.

From aafp.org:
Remember that the exercises described on the next two pages, which help strengthen the muscles of your shoulder (especially the rotator cuff), should not cause you pain. If the exercise hurts, use a smaller weight and stop exercising when the pain begins.

Perform each exercise slowly: lift your arm to a slow count of three and lower your arm to a slow count of six.

Look at the pictures with each exercise so you can follow the right position. Warm up before adding weights: stretch your arms and shoulders and do pendulum exercises (bend from the waist, arms hanging down; keeping arm and shoulder muscles relaxed, move arms slowly back and forth).

Keep repeating each exercise until your arm is tired. Use a light enough weight that you don’t get tired until you’ve done the exercise about 20 to 30 times. Increase the weight a little each week (but never so much that the weight causes pain): start with 2 ounces the first week, move up to 4 ounces the second week, 8 ounces the next week, and so on.

If you do all four exercises three to five times a week, your rotator cuff muscles will become stronger and you’ll regain normal strength in your shoulder. Each time you finish doing all four exercises, put an ice pack on your shoulder for 20 minutes. It’s best to use a plastic bag with ice cubes in it, or a bag of frozen peas, not gel packs.

Exercise 1:

Start by lying on your stomach on a table or a bed. Put your left arm out at shoulder level with your elbow bent to 90 degrees and your hand down. Keep your elbow bent and slowly raise your left hand. Stop when your hand is level with your shoulder. Lower the hand slowly. Repeat the exercise until your arm is tired. Then repeat the whole exercise again with your right arm

Exercise 2:

Lie on your right side with a rolled-up towel under your right armpit. Stretch your right arm above your head. Keep your left arm at your side with your elbow bent to 90 degrees and the forearm resting against your chest, palm down. Roll your left shoulder out, raising the left forearm until it’s level with your shoulder. (Hint: this is like the backhand swing in tennis.) Lower the arm slowly. Repeat the exercise until your arm is tired. Then repeat the whole exercise again with your right arm.

Exercise 3:

Lie on your right side. Keep your left arm along the upper side of your body. Bend your right elbow to 90 degrees. Keep the right forearm resting on the table. Now roll your right shoulder in, raising your right forearm up to your chest. (Hint: this is like the forehand swing in tennis.) Lower the forearm slowly. Repeat the exercise until your arm is tired. Then repeat the whole exercise again with your other arm.

Exercise 4:

In a standing position, start with your right arm halfway between the front and the side of your body, thumb down. Raise your right arm until almost level (about a 45 degree angle). (Hint: this is like emptying a can.) Don’t lift beyond the point of pain. Slowly lower your arm. Repeat the exercise until your arm is tired. Then repeat the whole exercise again with your other arm.
Author Source: http//www.aafp.org/afp/980215ap/98021a.htl

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.

Tennis Shoulder: Impingement Syndrome of the 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

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.

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.

Avoiding Long-Term Problems with a Dislocated Shoulder

SHOULDER DISLOCATION - "HERE COMES THE PAIN"

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!

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.