“I have some shoulder pain and was wondering what is the difference between a regular injury and sports injury? Do I see a regular physiotherapist or a sports physiotherapist?”

- Joel

Hi Joel,

The terminology used by physiotherapists can ben confusing sometimes. Body parts other than the main body trunk such as your spine and hips are referred to a peripherals by physiotherapists. So a shoulder injury such as yours is a peripheral injury.

Regular peripheral and sports injuries over-lap significantly. You can get knee ACL injury from incidents that are not sports related even though ACL injuries are common seen in athletes.

The main difference in approach in treating regular injuries and sports injuries are

• the speed of recovery
• the intensity of the treatment

Speed of Recovery

The pace of sports therapy is generally much quicker and more aggressive. This is due to the demands of the sports. The longer the athlete is down and out from training, the harder and longer it is for them to return to peak performance as their conditioning can deteriorate quite quickly. So treatment sessions tend to closer together and more frequently, several times a day in some cases.

Regular therapy would be spread out over a longer period of time to allow the body to heal more gradually.

Intensity of Treatment

Also, the demands of the sports can place a lots of stress on the injuries body part. As such the treatment such as strength and conditioning are generally more intensive to build up support – stronger muscular balance and finer motor control to prevent re-injury.

Such treatments is generally not called for with regular injuries as high-stress is not expected to the placed on the injured body part.

What is the difference regular injuries and sports injuries? is a post from: Musculoskeletal Consumer Review

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What is the rotator cuff?

The rotator cuff is a layman term given to a group of 4 muscles and their tendons that connects the humerus and scapula. They essentially work to pull the humerus head into the glenoid cavity, providing integrity to the shoulder joint through its entire movement range.

The four muscles are the Supraspinatus muscle, Infraspinatus muscle, Teres minor muscle and Subscapularis muscle.

Rotator-Cuff-Muscles
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The rotator cuff muscles are relatively smaller than the ‘big’ shoulder muscles such as the deltoids, trapezius. While their role in the large movements of the arm are smaller in terms of ‘force’ exerted, they play a crucial role in enabling those movements. They keep the glenohumeral joint stable allowing the bigger muscles to work more effectively. As you can see from the diagram above, the four muscles are arrange to almost around all the point of the humeral head. This allows at least one of the four muscles to be able to ‘pull-in’ the humeral head into the glenoid cavity.

Why is stability of the joint important in terms of effective movement?

A key principle that the body employs is the lever and fulcrum principle. This allows us to move large objects with a smaller amount of force. And one of the key efficiency factor is the stability of the fulcrum. The lever principle depends on a firm and stable fulcrum to rest the lever of one through the movement. So how does the rotator cuff contribute towards the shoulder joint stability?

Humeral-Head-Riding-Up
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Take for a example when we raise our arm up from the side. This movement is primarily driven by our bigger deltoid shoulder muscle. However, given the shape and the angle of the glenoid cavity, this movement pulls the humeral head upwards out of the gleniod cavity. So without the rotator cuff muscles, the shoulder joint would ‘slip’ upwards and outwards a little from the glenoid cavity, changing the fulcrum position, resulting a poor performance of the deltoid muscles in raising the arm.

Take a look at our previous article to discover how to best strengthen your rotator cuff muscles: The rotator cuff stability

Rotator Cuff – The Shoulder Stabilisers is a post from: Musculoskeletal Consumer Review

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Anatomy: Image from Orthoinfo.aaos.org
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Injuries
Ac joint dysfunction is a result of a sprain, dislocation, fracture or osteoarthritis at this joint

Dislocation and sprain
The Ac joint is usually injured by a direct fall onto the top of the shoulder, cycling injuries, or associated with over head throwing (Javelin) athletes. The shoulder blade (scapula) is forced downwards and the clavicle (collarbone) appears prominent. The degree of injury at the joint is classified by the separation of the joint and damage to ligaments supporting it. A sprain suggests ligament injury whereas a dislocation refers to the clavicle moving upwards and backwards out of its normal alignment. The degree of this separation between the clavicle and acromion is graded on a 6 point scale, with grade 3-4 or higher requiring surgery.

The altered position of the clavicle, disrupts the normal rotation action of thr clavicle that is required to achieve end range forward flexion (overhead ROM). Pain will occur as a result of over stretched/ ruptured ligamemts (depending on the severity) and a stretched joint capsule. As a protective mechanism, pain tends to lead to altered postures which may comtribute to neck pain and altered muscles activity of muscles that attach to the clavicle; such as the pecs, trapezius and  sternocleidomastoid.

Fracture
The fracture may occur at the distal end of the clavicle following contact sports injuries, bicycle and car accidents.

Arthritis
The incidence of arthritis at this joint has been shown to be about 50% in MRI studies of elderly populations, however these people may be asymptomatic.
Just like any arthritis this refers to degeneration of the cartilage at the ends of the clavicle and acromion. Normal day-to-day activities that require repetitive arm motion can cause cartilage loss (primary osteoarthritis). In addition arthritis may be due to cartilage degeneration after an injury to the joint (post traumatic arthritis). Regardless of the cause, predominately the normally smooth cartilage, as well as the meniscus between the bones breakdown leading to pain, due to increased friction and thus creating an inflammatory response at the joint.

Signs and Symptoms
Arthritis
Pain and stiffness of the joint is a common symptoms as is catching and “clicking” at the shoulder. Usually, these complaints are worst with overhead activity or with positioning the arm across the body. These are both common positions of the arm- from daily activities such as brushing your hair or reaching your back pocket, putting a shirt on, to sports activities such as a golf swing.

Dislocation and sprain
Pain initially may be widespread throughout the shoulder until the acute phase resolves, following this stage the person will demonstrate specific tenderness at the site of the end of the clavicle. Swelling and depending on the the extent of the injury a step-deformity may be visible. This is an obvious lump where the joint has been disrupted (as in the case of a dislocation) and is seen in more severe injuries. Similar to arthhiritis the individual will report pain on moving the shoulder, especially with overhead activities and across your body motion.

Treatment
Acute injuries will respond to ice therapy, anti-inflammatory medications and a sling is often used.
Electrotherapy could be utilised to prevent the formation of scar tissue in the ligament and promote healing and decrease swelling.

Exercise therapy to restore strength and range of motion of both the neck and shoulder is vital. Strengthening exercises include lateral rotator work, as well as shoulder blade pinching exercises.

Taping can be applied to offload and realign the Ac joint.

Mobilisation of the Ac joint (clavicle) at painful ranges is also a common intervention used by physiotherapist to restore normal and pain free alignment.

If your not too sure whats causing your shoulder to hurt- book in to see a therapist for a shoulder assessment and treatment.

Another source for shoulder pain: Could it be the AC joint? is a post from: Musculoskeletal Consumer Review

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The Shoulder Joint

shoulder_joint
click for larger view

Two things about the shoulder joint that is different from the other big joints are

1. The groove that the head of the humerus bone sits (glenoid cavity) in is extremely shallow (compared to say the hip joint).
2. And compared to other joints, the joint is not held together by a set of ligaments found in other joint like the knee joint (anterior-cruciate and posterior-cruciate ligaments and the medial and lateral collateral ligaments). If the shoulder joint was held together by this

If the groove is very shallow and the joint is not bound by a set of strong tough ligaments, what holds up the shoulder joint that bears a lot of physical stress daily?

The answer is suction power.

The glenoid-labrum (a fibrous cartilage-like material) and joint fluid work together to create a suction-cup holding effect on the humerus head. The gleniod-labrum essentially deepens the sockets by acting like a skirting around the shallower glenoid cavity. The joint fluid through adhesive-and-cohesive forces holds the joint together even under great stress. This is akin to ‘wetting’ the suction-cup hook to stick better to a wall. (Watch the video).

Source: University of Washington, School of Medicine

Why is it different?

All this leads to the question, why is this joint different from the hip or knee joint? Why do it differently in the first place?

The answer is the degree of free the shoulder enjoys and the roles that freedom plays in the activities we do daily. If the glenoid cavity was deeper or the joint was held together with a set of strong ligaments, the amount of freedom of movement we now enjoyed would be severely limited.

Suction Power – The Glenoid Labrum is a post from: Musculoskeletal Consumer Review

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The effects of over developing one muscle group i.e. your chest muscles (pectorals) in the gym, whilst neglecting your back muscles, often affect your posture resulting in neck, back, and shoulder pain

To understand why this occurs, you must be familiar with the notion that most joints in our body have two or more separate and opposing sets of muscles acting on the joint. Take the elbow as an example.

When the biceps contracts and shortens, it bends the elbow joint. As the elbow bends, the opposing triceps, must relax and lengthen to allow this movement to occur. And vice-versa, for the elbow to straighten; the triceps contracts and shortens and the biceps must relax and lengthen.

To gain a well rounded physique you must consider strengthening more than just one, if not all the muscle groups. An over developed muscle (group) will create more tension on one side of the joint. Over developed muscles are also often tighter (shorter) than normal.  The balance between muscles at the joint is lost, pulling the joint away from its mid-line and changes the angle of rotation at the joint.

Muscle balance at a joint
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Muscle imbalance at a joint
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The Shoulder

The shoulder is a more complicated joint, however the same principles apply.

From personal experience as a physiotherapist, one of the most common mistakes in the gym is over-training the chest muscles.  This causes an imbalance between the muscles at the front of the body and those at the back. The shoulders with time are pulled forwards as the chest muscles get stronger, bigger and shorter, making the posture more rounded, creating pain and potential pathology.
Lateral postural Picture

Rounded posture with over-developed Pecs
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Why is a rounded posture problematic?

Rounded postures place the shoulder joint in a unbalanced position away from the ideal centred position. This unbalanced position leads to increased compression at the shoulder, resulting in pain and reduced function:

• Compression of muscles and other structures at the front of the shoulder joint, may cause pain in the neck, and or down the front of the shoulder and side of the arm. Pain is usually worse with overhead activities. If the compression of the tendons continues for long enough, tears of the tendons (rotator cuff) may occur.
• Rounded postures often lead to neck pain. A large number of muscle that attach to the shoulder also attach to the neck at the other end. If these muscles are affected (lengthened and weakened by the pull of the shoulders) the neck often tends to rest into a head forward ‘chin-poke’ position. This increases the pressure on the neck joints and also other pain sensitive structures around the neck that can cause symptoms (Szeto, 2005).
• The shoulder’s range of movement is significantly reduced as a result of having less space for the joint to move. (Bullock et al, 2005)

Additional contributing factors leading to rounded shoulders

Modern Lifestyles
Think about all your daily activities; washing your face and hair, driving, sitting at the computer.  People are becoming chair-shaped, and this keeps the shoulder in a rounded position.

Pain Response
Your body’s response to pain is another factor.  When you have neck and shoulder pain we often adapt a rounded posture.  This initially is good protective mechanism to prevent further damage for the first few days post-injury, however in the long term this posture keeps the shoulder in a poor/compressed position and will hinder healing.

How to correct your rounded posture?

As a guide, when looking from a side view your shoulders should be fairly central compared to the trunk, and the head should be central on the shoulders.  A ‘plumb line’ from the centre of the ear should fall through the centre of the shoulder.

Correct posture in sitting
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To get into this position roll your shoulders all the way forwards, then all the way back (your shoulder blades should touch), then find the mid-point between these two position.  When you have this, gently tuck your chin in, so that your head is positioned on top of your shoulders.

Workout program to prevent the over-training

Weight-training:
If you work the chest 2 x weekly, doing 6-9 sets of 12 repetitions, then do the same amount of work, at the same load and intensity for the opposing muscle groups – the upper back muscles.  Most chest exercises involve pushing – therefore to balance this and work the upper back you must include pulling type activity.  Some ideas are provided below.

• Lat pull down
• 45 degree angle lat-pull down
• Seated row
• Bent over row
• Pull ups
• Shoulder external rotation

Stretching
As well as strengthening (which contracts and thereby shortens muscles), you should ALWAYS stretch all the muscles you have trained (lengthen the shortened muscles ) at the beginning and end of your workout to reduce tightness of these muscles. In this scenario it is therefore strongly recommended to stretch both the pecs and back muscles.

Pec stretch
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• Hold 30 seconds
• rest 30 seconds
• repeat x 3 (4 x daily)

References:

1. Brukner and Khan. Sports Medicine
2. Bullock, M., Foster, N., Wright, C., (2005). Shoulder impingement: the effect of sitting posture on shoulder pain and range of motion. Manual Therapy 10, 28–37
3. Kwok Tung Lau, Ka Yuen Cheung, kwok Bun Chan, Man Him Chan, King Yuen Lo, Thomas Tai Wing Chiu (2010). Relationships between sagittal postures of thoracic and cervical spine, presence of neck pain, neck pain severity and disability. Manual Therapy 15 . p457-462
4. Szeto, G., Straker, L., O’Sullivan, P., (2005). A comparison of symptomatic and asymptomatic office workers performing monotonous keyboard work—2: Neck and shoulder kinematics. Manual Therapy. Vol 10. p 281–291

Gym Users – Are you OVER-working the PECS? is a post from: Musculoskeletal Consumer Review

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A deskbound worker's posture are the main factors that will give rise to such shoulder problem. These factors are similar to those predisposing factors of shoulder pain in overhead activity athletes.
 

The image below demonstrates a slouched sitting posture with a forward head posture typical of someone who spends long hours at their desk. A few factors to notice in someone with a shoulder pain, is the position of the shoulder blade, rounding of the shoulder, and poking of the chin.

Image 1. slouch desk posture
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Narrowing of shoulder joint space from a slouched position

Try slouching your upper body and raising up your arm as high as you can, compare this to sitting or standing upright and reaching high up. You will find that it takes more effort in the former scenerio and you may feel a pinch or a block in the shoulder as you go towards the end of range. This is because the shoulder joint space (subacromial joint) is narrower in a slouched position.

Muscle Imbalance

In slouched sitting, the shoulder blade is rested on the rib cage in a forward tilt orientation. Overtime, this develop into a muscle imbalance where the muscles in front (pectoralis minor) are tightened, and the muscles at the bottom of the shoulder blade (lower trapezius) are stretched and thus weakened. As the lower trapezius is one of the vital muscles to stabilise the shoulder blade, weakness will increase instability and poor control of the shoulder joint leading to overuse of the rotator cuff muscles to compensate for the instability.

Long hours in the slouched position also develop stiffness in the joints of the upper back. This means that even if you get away from the desk, the upper back is so stiff that it's "stuck" in this slouched posture, coupled with the muscle imbalance, a person will find it increasingly more difficult to correct their posture even when in an upright standing stance, further increasing the risk of shoulder pain.

Rounded shoulder makes muscles inefficient

In a rounded shoulder, the ball of the shoulder joint will not be able sit well in the socket of the shoulder as there will be a inward rotation of the ball in the socket. Imagine a golf ball balancing on a tee, when the ball joint is not sitting well in the socket, muscles around it will have to work a lot harder to pull the ball into the socket to maintain stability. The excessive efforts from the muscles makes it tires and wears it down faster.

Shoulder pain in office workers is a post from: Musculoskeletal Consumer Review

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Understanding Shoulder Injuries sustained from Sports (Video) is a post from: Musculoskeletal Consumer Review

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photo(4) click for larger view	Lie on your side, Place your shoulder and elbow at 90 degree as shown in the picture. Slowly lower your forearm towards the bed till you feel a comfortable stretch at the back of the shoulder joint Hold the stretch for 15 seconds and repeat 10 times.
photo(6) click for larger view	In standing or sitting position, Bring your shoulder diagonally across the body with the elbow turned in. Feel the comfortable stretch at the back of the shoulder joint Hold the stretch with your opposite hand for 15 seconds and repeat for 10 times.
photo(3) click for larger view	In standing or sitting, Bring the elbow across the body horizontally Hold the stretch with your opposite hand placed at the elbow Feel the comfortable stretch at the back of the shoulder joint Hold the stretch for 15 seconds and repeat 10 times.

Posterior Capsule stretches is a post from: Musculoskeletal Consumer Review

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“Dead Arm” is a common term used in the athletes in sports requiring precision throwing like baseball. The term “Dead Arm” is defined as any pathological shoulder condition in which the thrower is unable to throw with pre-injury velocity and control due to pain. Dead arm usually occurs during the acceleration phase when the arm is moving forward and the athlete suddenly feel s pain, and the am goes “dead” and is no longer able to throw the ball with his usual velocity.

click for larger view

What are the causes?

The “Dead Arm” phenomenon is characterized as a disorder with various causes. Some of the causes postulated include psychological factors, calcification in the ball and socket joint, bone spurs in the acromion, impingement of the shoulder ligaments, rotator cuff problems, bicep tendonitis, micro-instability, internal impingement and SLAP lesion.

What happens in the “Dead Arm”?

In the painful shoulders of throwing athletes, because of the repetitive arm position being turned out backwards as far as possible (external rotation)to create potential energy in the wind up phase prior to the forward acceleration phase, it has been previously postulated that the pain is due to the shoulder capsule in the front being over stretched. This excessively stretched capsule then allows the shift of the “ball” of the shoulder forward, creating an impingement of the structures in the front of the shoulder joint, hence resulting in pain and the inability to throw.

However, this theory is now being challenged. Some researchers have found that “Dead Arm” syndrome to be most commonly associated with type 2 SLAP lesion. SLAP (Superior labral tear anterior -posterior) lesion is a tear in the top part of the labrum (which is like the meniscus of the knee). It is now postulated that the type 2 SLAP lesion occurs because of tight capsule posterior capsule, which is the capsule at the back of the shoulder joint. It is because of this tight capsule which forced the ball of the shoulder upwards and backwards into the shoulder joint resulting in a tear in the labrum. The outward sign of this capsular tightness is the loss of forward rotation (internal rotation) of the shoulder joint.

How do I know if I have a "Dead Arm"?

Assessment for Internal Rotation Range click for larger view

A test that can be performed to assess the range of forward rotation in to lie down and have your arm placed at 90 relative to your trunk and with the elbow held in 90’. Keeping the shoulder stable without allowing the shoulder blade to slide up, allow the forearm to drop forward as possible. Ideally, you should get about 90’ forward movement. Everyone is different, the best way to assess for loss of range is to compare with the non painful/good arm and use that as a guide. A study found those who had the loss of range and did stretching to the capsule had a 38% decrease in the incidence of shoulder problems when compared to the non-stretched group. Researchers have defined an acceptable loss of forward rotation range as 20 degrees or less than 10% of the total rotation seen in the non throwing shoulder.

Reference:

Burkhart S. S, Morgan CD and Kibler WB. The Disabled throwing shoulder: Spectrum of pathology Part 1: Pathoanatomy and biomechanics. The Journal of ARthoscopic and related Surgery, vol19, no4 (April),2003:pp404-420

The disabled throwing shoulder- The “Dead Arm” is a post from: Musculoskeletal Consumer Review

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Recently, one of our physiotherapists, Chng Chye Tuan was interviewed by Style:Men on the common musculoskeletal injuries face by swimmers in the July's issue. Do read on to find out what he has to share.

swim-1
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What are the common problems competitive/regular swimmers face?

The most common swimming injury is the rotator cuff impingement / tendonitis.

• Ball joint of the shoulder compress the tendon against the roof of the socket (acromion) in 2 phases of freestyle – the pullthrough and recovery phase.
• Pull-through phase in the freestyle stroke involves the arm pulling against the resistance of the water. The outstretched arm with internal rotation of the shoulder stresses the tendon and pinched it against the acromion. The pinching can irritate the tendons and give a sudden catching kind of pain.
• The recovery phase involves a body roll and raising the elbow up and out to allow the upper limb to recover out of water efficiently otherwise the shoulder will be working harder at an awkward position to pull the hand out of water.
• Repeated pinching will give rise to inflammation and fraying of the soft tissues.

What are the usual causes?

The usual contributing factors are mainly due to over training, poor technique, poor core muscles and unilateral breathing.

• Over training – when muscles are fatigued, the stabilising component from the rotator cuff muscles becomes compromised thus increasing the chances of the humeral head translating upwards and impinging the rotator cuff tendons. The ball component has to be centralised within the socket of the shoulder to optimise stability and muscle function.
• Technique – the freestyle and backstroke requires the swimmer to roll their trunk such that the drag is minimise and the propulsion force can be maximised. Too much drag will increase the resistence, tiring out the shoulder muscles sooner.
• Strong core muscles and truck control enable the swimmer to do a body roll along the longitudinal axis so that it is easier for the shoulder to pull the upper limb out of water.
• Unilateral breathing can develop a muscle imbalance leading to improper muscle activation and overuse.

What kind of treatments do you recommend?

An assessment of the shoulder girdle, spine and core strength will be performed to be able to properly manage a swimmer’s shoulder.

A key treatment to approach the swimming shoulder is to rehabilitate the rotator cuff muscles to be able to centralise the humerus at different shoulder positions.

Exercises will be prescribed to specifically target these rotator cuff muscles, correcting any imbalances. These exercises include strengthening the weak muscles to improve dynamic support and also stretching exercises to the tight muscles pulling the joint out of position.

As most competitive swimmers will not be able to cease training completely, kinesiotaping complements the rehabilitation therapy by improving the rotator cuff’s ability to stabilise the shoulder joint via better joint awareness from the corrective

Are there preventive measures that swimmers can take to minimise such problems?

Regular stretching exercises, core stability training and work on the techniques. During the early stage of feeling the impingement (catching or pinching) pain, seek help from a sports physician or physiotherapist as soon as possible.

For Swimmers : Common Injuries, Treatment and Prevention tips is a post from: Musculoskeletal Consumer Review

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