The shoulder joint is capable of a wider and more varied range of motion than any other joint in the human body. This extraordinary flexibility has allowed human beings to do everything from pitch a baseball to paint the Sistine Chapel. Unfortunately, because the shoulder is so flexible, it also tends to be unstable. This instability contributes to a variety of problems, some of which can be treated with rest, and others may require the expertise of a licensed physical therapist.
Certain athletes (throwers, tennis players, swimmers) are at especially high risk for shoulder problems, though they can occur in anyone. And in most cases- even those requiring surgery- a physical therapist plays an integral role in the rehabilitation process. The physical therapist's expertise can help you recover function as quickly as possible and get you back in the swing.
The shoulder has three major joints: the glenohumeral (GH) joint, the acromioclavicular (AC) joint, and the scapulothoracic (ST) joint. Each joint can become dysfunctional and painful. The glenohumeral joint is a ball and socket joint. This joint has been compared to a golf ball sitting on a tee: the large, rounded end of the humerus (upper arm bone) moves within the shallow, scooped-out glenoid (golf tee). The anatomy of the glenohumeral joint permits the greatest flexibility and range of motion of any joint in the human body. However, because of the shoulders make up it can also become unstable.
The acromioclavicular joint, more commonly called the AC joint, joins the scapula (shoulder blade) to the clavicle. The AC joint can become separated; this commonly occurs in contact sports, such as when a football player falls on the tip of the shoulder.
The third shoulder joint is the scapulothoracic or ST joint, which is the scapula as it lies over the thorax (back of the rib cage). The ST joint is attached to the thorax by muscles and tendons. Neck and upper back posture directly affect the position of the ST joint on the rib cage. Postural abnormalities will affect the function of the shoulder. In addition to these three joints, an intricate system of muscles, tendons, ligaments, and bursa sacs work in precise harmony with each other to provide the amazing amount of mobility of the shoulder.
The rotator cuff is made up of four muscles that encircles the shoulder joint. This muscles are a major source of muscular stability in the shoulder. The rotator cuff can be prone to tears and weakening due to a number of causes, including strain and overuse. When the tendons become inflamed it is called tendonitis. Tendons are strong fibrous cords that attach muscles to bones. An additional structure essential to the shoulder is the bursa sac. Bursa sacs are fluid-filled membranes within and around the shoulder; they cushion the joints and help minimize friction. Inflammation of the bursae is known as bursitis.
There are several factors involved in shoulder disorders:
• the aging process, including disuse and atrophy;
• strain and overuse;
It's not unusual for many of the common shoulder problems described below to develop from a combination of these factors.
Whether you're 15 or 75, age has a profound impact on how the body responds to shoulder strain or trauma. As young people, the tissue around our shoulder joints is soft and resilient. Before age 30, if we "overdo it" through sports or physical labor, the most we're likely to suffer is a slight, short-lived soreness or stiffness in the tendons. This Tendonitis is the most common of all shoulder problems. It rarely requires treatment in young people. However, as a person grows older, the cumulative effects of having an ongoing problem of tendonitis can result in a more serious ailments. After the age of 30 our muscles and tendons begin to undergo a structural weakening because of the aging process. The simple tendonitis can degenerate into actual tearing of the muscle tissue.
Each episode of tendonitis weakens the muscles further. Therefore, the cumulative damage can lead to larger tears in the muscles and tendons. This is why conservative treatment of tendonitis at an early stage, along with education about the way the shoulder works and proper exercise, is crucial to preventing further injury.
Rotator Cuff Injuries
Tears in the rotator cuff can result from the progressive worsening of tendonitis, repetitive strain through overuse, or trauma- especially as a result of athletics. The gradual tearing of the rotator cuff is a process similar to a shirt wearing out- it gets more and more threadbare until the edges fray or a hole appears. This sort of rotator cuff injury can be difficult to repair surgically, and conservative treatment under the direction of a physical therapist is often the best course of action. A "clean" tear to the rotator cuff (due to trauma) can often be repaired surgically. Whether or not surgery is indicated, a physical therapist will almost certainly be involved in all stages of the recovery process. Researchers have found that rotator cuff tears occur more often in people who rarely exercise or who participate in sports only sporadically. People who keep in shape through regular exercise are more likely to maintain strong bones and rotator cuff strength, and to diminish the chance of future shoulder injury.
Bursitis goes hand-in-hand with tendonitis. Inflamed bursa sacs may become thickened and reduce the "free" space in the joint, thus restricting movement. In extreme cases some of the bursa sacs can be removed surgically; otherwise, the therapeutic approach to treating bursitis and tendonitis is similar.
Osteoarthritis is a condition in which the joint cartilage deteriorates and the joint becomes gritty and rough. It can be caused by a number of factors, including disease, trauma, and infection. Degenerative arthritis is often associated with wear-and-tear in the joints over a long period of time. The AC joint is particularly susceptible because it degenerates faster than any other joint in the body as we age. Arthritis in the glenohumeral joint usually appears somewhat later, and may be related to trauma earlier in life or rotator cuff problems.
Besides being painful, arthritis can lead to the inability to fully move the arm due to tightness in the joint; attempts at movement in the later stages of the condition are usually painful. In advanced cases of arthritis involving the glenohumeral joint, arthroplasty- surgical replacement of the joint- is an option that can bring pain relief and greater mobility. The rehabilitation period, however, is crucial, with both the patient and the physical therapist playing active roles.
Subluxation is a quick, spontaneous "pop-in/pop-out" or partial dislocation of the shoulder joint. Subluxations can occur while playing "overhead" (throwing, tennis, swimming) sports, though the activity need not be strenuous to cause an occurrence. Subluxations usually happen to people who are approximately 14 to 30 years of age. Although they may not be painful, subluxations may, over time, contribute to problems of wear and tear in the shoulder region.
A dislocation is far more serious, involving tissue damage, stretching, and tearing. Unlike a subluxation, the shoulder doesn't "pop back in." The first step in treating a dislocated shoulder is almost always a trip to the emergency department. People under 20 and over 50 are most prone to dislocations, with younger individuals more prone to experience further dislocations in the future.
Impingement refers to a condition, sometimes painful, in which the shoulder joint lacks enough room to function properly. Structural impingement is a "built-in" organic condition, e.g., a bone spur in the shoulder joint. This situation is usually the result of years of tendonitis, rotator cuff injuries, and wear-and-tear. Functional impingements often result from occupational situations (such as being hunched over a computer keyboard all day). Brief stretching and exercise breaks, along with proper posture, can help prevent and alleviate functional impingement.
Trauma comes in two varieties: microtrauma and macrotrauma:
Microtrauma is common in everyday life- it can occur while lugging an overstuffed suitcase, or straining to reach a can of spaghetti sauce on the top shelf. In both cases we're inflicting microscopic tears to the soft tissue around our shoulders. Although a single episode of microtrauma in itself is rarely serious, over time it can set the stage for shoulder ailments such as tendonitis, bursitis, and rotator cuff injuries.
Macrotrauma is the result of violent force, with falls and sports injuries being the most common causes. Depending on what position your arm is in when you fall or get hit, you can fracture your collarbone, dislocate your shoulder, or tear your rotator cuff.
An evaluation of the shoulder, neck, thoracic, and upper extremity will performed to determine what the cause or driving force of the shoulder pain. The evaluation will look at posture, joint mobility, strength and coordination. After a thorough evaluation is performed a treatment plan is developed to eliminate or decreased the causes of the shoulder problem.
The following tips may prevent shoulder problems or injuries.
• Stay in good overall physical shape. Strengthen your wrist, arm, shoulder, neck, and back muscles to help protect and decrease stress on your shoulder. Do stretching and range-of-motion (ROM) exercises for your arms and shoulders.
• Maintain good posture. Stand straight and relaxed, without slumping.
• Warm up well and stretch before any activity. Stretch after exercise to keep hot muscles from shortening and cramping.
• Avoid catching falling objects.
• Use a step stool. Do not stand on chairs or other unsteady objects.
• Use the correct body movements or positions during activities, such as lifting, so that you do not strain your shoulder. Do not lift objects that are too heavy for you.
• Avoid overusing your arm doing repeated movements that can injure your bursa or tendons. In daily routines or hobbies, think about the activities in which you make repeated arm movements. Try alternating hands during activities such as gardening, cooking, or playing musical instruments.
• Avoid keeping your arms out to the side or raised overhead for long periods of time, such as when painting a ceiling. If you must do these things, take frequent breaks, and use rest, ice, compression, and elevation (RICE) for home treatment.
• Make sure your child's backpack is the right size with good support. Carrying heavy backpacks may increase his or her risk of shoulder problems or injury.
• If you feel that activities at your workplace are causing pain or soreness from overuse, call your human resources department for information on alternative ways of doing your job or to discuss equipment modifications or other job assignments.