COMMON SHOULDER INJURIES
AC joint separation
(acromio-clavicular joint)
 What is the acromio-clavicular joint?
This is where the clavicle (collar bone) meets the acromion process of the scapular. It is a bony bit on the top of the shoulder. This joint can be injured by falling onto the shoulder, elbow or an outstretched arm. It can range in severity from a little bit of pain to a complete rupture of the joint where you might get a lump where the collar bone sticks up out of the neck.
Symptoms include:
- Pain at the end of the collar bone.
- Pain when you move the shoulder joint especially with the arms above the shoulders. Possibly a bony lump where the collar bone sticks up depending on how bad the injury is.
What can the athlete do?
- Rest and apply ice in the early stages.
- As it gets less painful work on mobility exercises for the shoulder.
- See a sports physician or physiotherapist
What can a physiotherapist do?
- Tape the collar bone down into place so it heals properly. You will need to be strapped for 2 to 3 weeks.
- Apply ultrasound treatment to reduce pain and swelling.
- Educate you on a gradual rehabilitation program
- Tape your shoulder for further protection on return to sport
- Refer to a sports doctor if it is a total rupture.
WARNING - If this injury is neglected and allowed to heal out of place this could increase the wear and tear on your joint causing you problems in the future.
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Shoulder Dislocation
 Shoulder dislocation is a very common traumatic sports injury across a wide range of sports. In most cases, the humerus (upper arm bone) is forced forwards when the arm is turned outwards (externally rotated) and held out to the side (abducted).
Although some consider this to be a minor injury, most shoulder dislocations cause damage to the glenoid labrum - the ring of cartilage which deepens the glenoid fossa and acts as a cup, in which the humerus rests, forming the Glenohumeral (or shoulder) joint - which can cause an injury known as a Bankart Lesion, and may even cause a fracture to the attached bone (a Bony Bankart Lesion). There may also be damage to the surrounding ligaments, nerve or blood vessel damage, fractures of other bones, and in some cases tears of the labrum.
What causes it?
The injury is usually acute, caused by direct or indirect trauma with a sudden onset of severe pain, and often a feeling of the shoulder 'popping out'.
What are the symptoms of a dislocated shoulder?
The shoulder will often look obviously different to the other side, and if there is any nerve damage the sensation might also be altered. There is usually quite severe pain associated with a dislocation.
What should the athlete do about their dislocated shoulder?
- The dislocated shoulder should be relocated as soon as possible by a trained professional to prevent further complications which may arise due to nerve and/or blood vessel entrapment
- Ideally an X-Ray should be sought prior to reduction to rule out fractures. If this is not possible a post reduction X-Ray must always be sought.
What can the sports physician or physiotherapist do?
If you sustain a dislocation, it is vitally important to seek medical attention, even if the shoulder is reduced (put back into place). There is a strong likelihood that you will need some rehabilitation to help you regain both the function of the shoulder, and to prevent it from dislocating again. Some cases may even require surgery if the shoulder is regularly dislocating, or if there is an associated fracture, and if the reduction is difficult it may be necessary to conduct the procedure under anaesthetic.
You will probably have to rest the shoulder after reduction in a sling, to allow it time to recover and prevent further injury. Often pain killers are provided to ease the pain and then seeing a physiotherapist to reduce pain and inflammation in the early stages and also begin a graduated exercise program.
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Shoulder Instability
No single structure is responsible for providing stability at the shoulder joint. Instead, the bony structure of the joint surfaces, the ligaments and muscles are all key components in maintaining a stable shoulder joint yet permitting a large range of movement in several directions.
Instability is often associated with subluxation (partial dislocation of the shoulder joint), which may be associated with pain and / or dead arm sensation. Indeed this is often what prompts the athlete to seek medical attention. In some people, this is not actually painful but can be quite annoying and prevent them from taking part in daily activities or sports.
Instability of the shoulder joint can be in one direction for example, anterior instability, posterior instability (out the back) or in more than one direction. The most common form of instability seems to be anterior and is probably because the joint capsule is at its weakest at the front of the joint.
Causes of shoulder instability:
There are many reasons why a shoulder may become unstable. If the joint surfaces are shaped slightly differently - for example if the glenoid fossa is slightly flatter than usual, or the head of humerus is more of an oval shape - the joint may not be as stable compared with other people who have “normal” joint anatomy.
Other structures support the bony anatomy to help provide stability to the shoulder. These include:
- Glenoid Labrum - a ring of cartilage which deepens the glenoid fossa, making the “cup” of the socket deeper and hence improving stability
- Joint Capsule - a membrane which encompasses the entire joint, providing stability but also maintaining the joint complex and holding the lubricating (synovial) fluid in the correct place
- Ligaments - holding the bones together and providing stability by preventing them from moving when they shouldn’t be
- Muscles - Work alongside the ligaments in preventing unwanted movement, but also initiate and create movement of the joint.
Instability may be caused by:
- Trauma (traumatic instability)
- Usually due to a particular accident or injury which damages the structures that provide stability
- Sometimes due to an old injury - for example an injury which weakens the capsule may cause instability - known as ”post traumatic instability”
- Joint Laxity (atraumatic instability)
- May be due to
- anatomical abnormalities
- generalised laxity (known as hypermobility)
- muscle weakness
- certain conditions, including pregnancy
- “Acute on chronic” instability - a traumatic injury to an already lax joint
Treatment of shoulder instability
The physiotherapist will perform a range of tests to determine what type of instability the athlete is experiencing, and will take a detailed history to attempt to discover why this is occurring.
They will also assess whether you have a condition which has caused you to have lax ligaments throughout your body, known as hypermobility.
A strengthening programme to help you develop the muscles around the shoulder which are responsible for stabilizing the joint is usually recommended. Electrical stimulation may also be used in some cases when the athlete is unable to contract the desired muscles.
In some cases of instability (particularly traumatic instability) if conservative treatment with physiotherapy does not work, surgery may be an option. There are various techniques available to the surgeon to improve the joint laxity at the shoulder; however this will always be followed by intensive rehabilitation to ensure that you do not lose any movement at the joint.
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Shoulder Impingement
 Impingement Syndrome, which is sometimes called Swimmer’s shoulder or Thrower’s Shoulder, is caused by the tendons of the rotator cuff (supraspinatus, infraspinatus, teres minor and subscapularis muscles) becoming irritated and inflamed as they pass through a narrow bony space called the Subacromial Space - so called because it is under the arch of the acromion.
This can lead to thickening of the tendon which may cause further problems because there is very little free space, so as the tendons become larger, they are impinged further by the structures of the shoulder joint and the muscles themselves. This can lead to irritation of the small fat pad in the shoulder joint (bursa) leading to subacromial bursitis.
Impingement Syndrome in itself is not a diagnosis, it is a clinical sign. There are at least NINE different diagnoses which can cause impingement syndrome.
CAUSES:
- Is usually due to bony abnormalities in the shape of the acromial arch.
- Can sometimes be due to congenital abnormalities (known as os acromiale)
- Degenerative changes, where small spurs of bone grow out from the arch with age and impinge on the tendons.
- Usually due to poor scapular (shoulder blade) stabilisation which alters the physical position of the acromion, hence causing impingement on the tendons.
- Is often due to weak serratus anterior and tight pectoralis minor muscles
- Other causes can include weakening of the rotator cuff tendons due to overuse (e.g. throwing and swimming)
- Muscular imbalance with the deltoid muscle and rotator cuff muscles.
- Occurs predominantly in athletes where throwing is the main part of the sport (e.g. pitches in baseball)
- The under side of the rotator cuff tendons are impinged against the glenoid labrum - this tends to cause pain at the back of the shoulder joint as well as sometimes at the front.
TREATMENT
What can the athlete do?
- Rest
- Apply ice or cold therapy to the painful area for 10-15 minutes per 2 hour period. Remember to use an ice bag or a towel wrapped around the ice to protect against ice burn. A hot water bottle may also help if there is muscle spasm in the area
- Seek treatment and advice from a physiotherapist
- Return to sport gradually once the pain has eased
What can the doctor do?
- Carry out specific tests and/or order X-Rays to determine what is causing the impingement
- Prescribe anti-inflammatory medication such as Ibuprofen or other NSAID's (non steroidal anti inflammatory drugs).
- Discuss the option of directly injected steroids into the subacromial space to reduce inflammation and reduce inflammation in the local area
What can the physiotherapist do?
- Carry out specific tests and/or order X-Rays to determine what is causing the impingement
- Minimise pain and inflammation using massage electrotherapeutic modalities and mobilisation around the area
- Help to relieve aggravating muscle spasm and advice on activities to avoid.
- Advice on a graduated rehabilitation programmes to improve function and decrease pain and help with return to function and sport as able.
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Subacromial Bursitis
The supraspinatus muscle runs along the top of the shoulder blade and inserts via the tendon at the top of the arm (humerus bone). This muscle is used to lift the arm up sideways and is also important in throwing sports as it is the muscle that holds the arm in the shoulder when you release what you are throwing. There are massive forces involved in slowing the arm down after you have thrown something but few people bother to train these muscles. A heavy fall onto the shoulder can also result in injuring this muscle.
Over the tendon is a bursa (small sack of fluid used to help lubricate the moving tendon). This bursa can become trapped in the shoulder causing pain and inflammation.
The athlete is more prone to this injury if they overuse the shoulder particularly if the arm is at or above shoulder level. Or if the athlete has had a rupture of the supraspinatus tendon.
Symptoms include:
- Pain and weakness when the arm is lifted up sideways through a 60 degree arc.
- Pain when you press in at the inside front of the upper arm.
- If it is the tendon that is injured rather than the bursa there is likely to be more pain when the arm is lifted up sideways against resistance.
What can the athlete do?
- Rest from aggravating activity
- They must however continue pain free mobility exercises to keep the full range of movement in the shoulder and strengthen appropriate muscles.
- See a sports injury doctor and physiotherapist who can advise on rehabilitation.
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Rotator Cuff Problems
 The rotator cuff is a group of muscles which work together to provide the Glenohumeral (shoulder) joint with dynamic stability, helping to control the joint during rotation (hence the name). The rotator cuff muscles include:
- Supraspinatus
- Infraspinatus
- Teres Minor
- Subscapularis
Due to the function of these muscles, sports which involve a lot of shoulder rotation - for example, bowling in cricket, pitching in baseball, swimming, kayaking - often put the rotator cuff muscles under a lot of stress.
Problems with the rotator cuff muscles can be classed into two categories - Tears or inflammation of the tendons/muscles, and inflammation of structures in the joint.
Acute Tear
This tends to happen as a result of a sudden, powerful movement. This might include falling over onto an outstretched hand at speed, making a sudden thrust with the paddle in kayaking, or following a powerful pitch/throw.
The symptoms will usually include:
- Sudden, tearing feeling in the shoulder, followed by severe pain through the arm
- Limited movement of the shoulder due to pain or muscle spasm
- Severe pain for a few days (due to bleeding and muscle spasm) which usually resolves quickly
- Specific tenderness (“x marks the spot”) over the point of rupture/tear
- If there is a severe tear, you will not be able to abduct your arm (raise it out to the side) without assistance
Chronic Tear
- Usually found on the dominant side
- More often an affliction of the 40+ age group
- Pain is worse at night, and can affect sleeping
- Gradual worsening of pain, eventually some weakness
- Eventually unable to abduct arm (lift out to the side) without assistance or do any activities with the arm above the head
- Some limitations of other movements depending on the tendon affected
Inflammation
- More common in women aged 35-50
- Characteristic ache in the shoulder which feels like it is coming from “deep inside”
- Tenderness over particular areas, less specific than a tear
- Usually a gradual onset of pain, which “flares up” if using the arms over the head or out to the side
- Can sometimes lead to a chronic tear if untreated
When should I see a doctor or physiotherapist for my Rotator Cuff Injury?
- The pain persists for more than 2-3 days
- You are unable to work due to the pain/limitations
- You are unable to reach up or to the side with the affected arm after 2-3 days
- You are unable to move the shoulder and arm at all
- For any acute injury where you are unable to move the injured shoulder as well as the uninjured shoulder
What can I do to help my rotator cuff muscles recover?
- Rest the shoulder from aggravating activities
- Ice can be used at least 3 times a day and is useful for the first 5-7 days following an injury
- Apply ice for no more than 15-20 minutes ensuring you use an appropriate ice bag, or wrap the ice in a towel to prevent ice burn
- Warmth may be useful after the first few days to help with the pain
- Medication may be helpful to help control the pain – speak to your doctor if you think you require stronger than what you might usually take
- Visit your physiotherapist for pain relief techniques and advice on when to begin your rehabilitation.
How long will it take to get better?
Depending on several factors, conservative treatment has a 40-90% success rate at fixing the problem.
Surgery often has good results, with some studies citing a 94% satisfaction rate with the surgery, resulting in lasting pain relief and improved function. Very extensive tears often have a poor surgical outcome, however this injury is thankfully quite rare.
If you are older, it will take you longer to heal due to differences in your physiology.
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Referred Shoulder Pain
Referred pain occurs when pain is experienced in an area away from the actual injury or problem. It is actually quite common in the human body, and you probably already know of several types of referred pain – heart attacks can refer pain to the shoulder, arms and neck, throat problems can refer pain to the ear, and eating a very cold food can cause 'brain freeze' resulting in a bad headache due to chilling the vagus nerve. It is not certain why we experience referred pain, however some theories relate it to the way in which the nervous system develops at the foetal stage.
What causes referred pain?
Referred pain from the cervical and thoracic spine is usually due to compression of a nerve and/or nerve root. This can occur for many reasons, including problems with the vertebral discs, muscle spasms, osteo-arthritic changes, spinal fracture or tumour. For this reason, referred pain is more common amongst older adults except for that caused by trauma.
When the nerve is compressed, its ability to transport information to the areas which it serves becomes compromised. Some nerves carry sensory information, which can cause pins and needles, tingling and strange sensations if these are compressed, whereas other nerves carry “motor” information, which causes weakness of muscles and sometimes problems with co-ordination and movement. Sometimes the compression can affect both types of information.
What are the symptoms of referred pain from the Cervical and Thoracic Spine?
- Radiating pain into the arm, neck, chest, and/or shoulders
- Numbness or tingling in fingers or hands may also be present
- Muscle weakness
- Poor coordination, particularly in the hands.
Depending on what level the problem is occurring (meaning at which cervical vertebra), the pain and weakness will be experienced in different areas.
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Less Common Shoulder Injuries
Fracture of the neck of the humerus
A fracture to the neck of the humerus is often caused by falling onto an outstretched hand or direct impact to the shoulder. It is seen more often in young adults, adolescents and the elderly.
Frozen Shoulder / Adhesive capsulitis
A frozen shoulder (known also as adhesive capsulitis) is a condition that occasionally occurs in older athletes. It is this joint and the surrounding capsule that becomes inflammed and eventual there is a significant loss in mobility.
Inflammation of the long head of the biceps
Inflammation of this tendon is a fairly common complaint especially with swimmers, rowers, throwers, golfers and weight lifters.
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