Good shoulder function is essential for many popular sports, particularly repetitive sporting movements, such as racquet (i.e. tennis serve, golf swing) or ball sports (i.e. throwing in baseball / cricket).
The shoulder joint is a unique design, consisting of a ‘shallow’ ball and socket formation between the humerus (ball) and scapula (socket). This structure provides incredible mobility, however this also means that the stability is compromised, resulting in it being frequently injured in sporting and occupational activities. The shoulder joint relies on its static constraints (the glenohumeral ligaments, glenoid labrum and capsule) and dynamic stabilisers (the rotator cuff muscles) to provide additional stability, beyond the bony structure.
Any injury or disruption to the co-ordination of the rotator cuff muscles leads to dysfunction of the complex, causing the potential for further pathology or injury. Hence, if it does become sore and/or injured, it is a great advantage to correctly diagnose and rehabilitate the shoulder from the onset of injury, to reduce recovery time and prevent re-occurrences in the future.
Diagnosis of shoulder pain requires a thorough assessment by a physiotherapist, including pre-disposing factors such as abnormal biomechanics, stiffness of the lower cervical / upper thoracic vertebra and habitual postures, during activities of work and / or home. Investigations, such as x-rays, ultrasounds, computed tomography (CT) and magnetic resonance imaging (MRI) can all be used to assist in the diagnosis of shoulder abnormalities.
The commonly seen injuries in athlete’s shoulders are impingement, rotator cuff dysfunction (including tendonitis), shoulder instability and dislocations.
1. Shoulder Impingement
In all movements of the shoulder, particularly those above shoulder height, the deltoid muscle contracts to raise the arm, and in doing so, forces the head of the humerus upwards into the socket. The rotator cuff muscles (supraspinatus, infraspinatus, teres minor, and subscapularis) counteract this action, by preventing the head of humerus moving upwards.
Impingement occurs when the space between the humerus and shoulder socket is narrowed, causing pain, swelling and bruising of the rotator cuff tendons. This can lead to bursitis and tearing of the tendons, and maybe caused by: i) degenerative changes of the bones (i.e. spurs on the humerus or acromion). ii) inflammation of the rotator cuff tendons (i.e. tendonitis), due to overuse or overload.iii) excessive upward movement of the humerus, due to muscle imbalance between the deltoid and rotator cuff muscles.
The tendons become inflamed and lead to further imbalance of stability. Treatment can include ice application, anti-inflammatory medication and specific exercises to regain strength and coordination of the rotator cuff muscle activity.
If you have rotator cuff impingement, you need to avoid the following activities:
- using the arm in overhead positions
- heavy lifting or repetitive arm movement such as painting or washing your car
- sleeping on the affected arm
- hanging your arm down for prolonged periods.
To help your injury resolve as fast as possible:
- avoid or modify activities and positions, which cause your pain. Recovery is easier if you stop irritating the shoulder.
- rest your arm on a pillow when sitting for prolonged periods
- use ice packs for 15 – 20 minutes regularly
- hug a pillow or rest your arm on a pillow during the night.
2. Rotator Cuff Muscle Dysfunction (including Tendonitis)
The athlete with rotator cuff tendonitis complains of pain with overhead activity such as throwing, swimming and overhead shots in racquet sports, and there is often tenderness on the outside of the shoulder. Activities performed at less than shoulder height are usually pain-free.
Physiotherapy management involves avoidance of the aggravating activities, local daily application of ice (15 minutes) and soft tissue muscle releases. The use of anti-inflammatories, either topical (i.e. Voltaren gel) or medication (i.e. as prescribed by your local doctor) will improve the healing rate of the tendons. For effective and long lasting relief of symptoms, the rotator cuff muscles need to be strengthened and the underlying muscle imbalances needs to be corrected. These exercises need to be specifically designed for you by a physiotherapist and will involve the use of theraband and weights. Strengthening these muscles can take several weeks to achieve and will need to be an ongoing part of your daily routine. Prior to you returning to your preferred sport, any biomechanical abnormalities or training faults will be corrected, to minimise the risk of your symptoms returning in the future.
3. Shoulder Instability / Dislocation
Shoulder instability occurs when during daily or sporting activities, the body is unable to ensure that the humerus bone (upper arm) stays tightly within the shoulder glenoid (socket). If there is excessive movement of the humerus, rotator cuff muscle fatigue and pain may occur, that leads to the development of shoulder impingement and tendonitis (as discussed above). This instability can be either:
- Occurs when the body’s protective mechanism (i.e. joint capsule, ligaments and rotator cuff muscles) become progressively stretched.
- This can be genetic, where some individuals have greater ligament elasticity throughout the body (i.e. hypermobility), or it can be developed over time, due to repeated ‘stretching’ of the joint in extremes of movement. This is particularly common in sports requiring repetitive activities i.e. baseball pitchers, javelin throwers, swimming / water polo and tennis players.
- Occurs as a result of a fall on an outstretched arm or if the arm is pulled backwards, while above the athletes’ head, such as during a tackle.
- Results in the shoulder dislocating, where the ball (humerus bone) and socket (scapula bone and glenoid labrum) become temporarily separated. The patient may describe a feeling of the shoulder ‘popping out’.
- Is classified into either an ‘anterior’ (forwards) dislocation, that is very common, or a ‘posterior’ (backwards) dislocation, that’s far less common.
- Dislocations need to be ‘relocated’ as soon as practically possible (returning the humerus to its natural position). This is done by an experienced physiotherapist or sports physician. If neither professional is available, this patient must be made comfortable and taken immediately to hospital.
- You should ice the sore area 3-4 times a day, for 15 minutes, for the first 72 hours, to reduce pain and inflammation. Sometimes dislocations may tear ligaments or tendons in your shoulder, or occasionally, it may damage your nerves.
- Following relocation, the shoulder should be investigated, as most dislocations will result in damage to the labrum and / or fracture of the humerus. This will include specialist x-rays / CT / MRI scans.
- The athlete may be placed in a sling for 1-3 weeks (less for older patients) for pain relief, with physiotherapy commencing immediately.
- Physiotherapy rehabilitation is essential for all episodes of instability, in particular with atraumatic instability, as this condition leaves an athlete susceptible to a traumatic episode in the future.
- Rehabilitation commences immediately to improve the general movement of the shoulder, and then progress to an intensive scapular and rotator cuff strengthening program, using theraband, cable and free weights exercises.
- The program usually takes approximately 6-8 weeks to complete, and will require the athlete to continue these exercises, for long term maintenance and stability of their shoulder.
- Shoulder dislocations in athletes have a high chance of re-occurring, potentially leading to chronic shoulder instability. An appropriate physiotherapy shoulder strengthening program will minimise the risk of this developing.
- If at the conclusion of this rehabilitation program, the athlete is still having symptoms of instability, then a review with a shoulder orthopaedic surgeon is recommended, as surgical intervention may be required