Shoulder pain is common not only in the general orthopedic population, but also in athletes. The shoulder, being one of the most mobile and complex joints in the body, is often susceptible to injury, especially in games that require repetitive overhead movements like baseball, tennis, swimming, gymnastics etc. making it prone to pain and dysfunction.
Shoulder Anatomy
The shoulder complex includes the coordinated movement between four bones: the arm bone/humerus, shoulder blade/scapula, breastbone/sternum and the collar bone/clavicle. While the majority of movement happens between the humerus and the scapula- the shoulder joint, there is also some movement between the joints formed by the other bones for a smooth coordinated motion of the arm which is referred to as scapulohumeral rhythm. The shoulder joint gets its support from the ligaments, capsule and the rotator cuff muscles. Any impairments in structure or function involving the above joints, can lead to shoulder pain and dysfunction.
Conditions affecting the shoulder
Here we will discuss the common conditions affecting the shoulder joint. The symptoms of pain and dysfunction, we will refer them to as impingement symptoms, rather than considering impingement as a pathological condition.
I. Rotator cuff related pain The Rotator cuff consists of four muscles namely, subscapularis, supraspinatus, infraspinatus and teres minor. These muscles form a cuff-like structure around the shoulder joint. They provide adequate stability of the shoulder as well as help in shoulder movements in different planes. The 2 types of rotator cuff-related problems are: a) cuff tendinopathy. Here the tendons are affected causing pain due to degenerative changes and ii. Cuff tears- can be partial or full-thickness. Here the muscles are affected with or without pain, but with definitive weakness.
ii. Scapular dyskinesis: here the shoulder blade does not move adequately, having mobility issues due to poor muscle performance or ii. It moves excessively due to stability issues.
iii. Instabilities: These can occur due to trauma as in contact/collision sports or from a fall causing anterior (most common) or posterior dislocation which are traumatic dislocations. There can be cases of atraumatic dislocations happening spontaneously without injury. In this case, one needs to check if the person has general laxity, meaning if other major joints are lax as well, or if it is just the shoulder that is unstable. There is also a possibility of minor joint instability in athletes playing specific sport due to tissue adaptation.
vi. Biceps related pathology: Here the biceps muscle could rupture while lifting a heavy load or may tear at its insertion point at the glenoid labrum causing either a SLAP or non-SLAP lesion. The biceps tendon can become unstable in its bicipital grove due to tear in the transverse humeral ligament.
v. GIRD: This stands for glenohumeral internal rotation deficit. As a result of tissue adaptation to a specific sport, as in baseball pitching, the posterior structures of the shoulder can become tight and contracture. This causes a reduced posterior glide of the humeral head and the subacromial space leading to impingement symptoms of pain and dysfunction.
Shoulder complex assessment
This includes good history-taking of the athlete’s nature of problem including any co-morbidity that may be present. This is followed by observation of the posture and possible guarding of the arm indicating severity of the problem. The neck needs to be screened as well, making sure that it is not contributing to the shoulder pathology. Range of motion, joint glide assessment, sensory (pain, numbness etc.), motor and reflex testing are completed to get more information on the patient condition. We can now move to the shoulder special tests. The following tests may be performed based on patient’s presenting problem:
1. Jobe’s, Hawkins and Neer’s test can be carried out for potential impingement of rotator cuff. Also look for painful arc in the range of 60-120 deg of abduction.
2. For dyskinesis, we look for any scapular prominence of the inferior angle, superior angle and the medial border.
3. For shoulder joint instability, quadrant test can be used, which is provocative in nature. Mere pain can be indicative of impingement. Whereas increased muscle guarding and apprehension preventing the completion of the test by the patient, or a dislocation of the joint may indicate gross instability. For capsular/ligamentous laxity, we can use laxity tests. The load and shift test for anterior joint laxity, sulcus sign for inferior laxity and a posterior force applied to a flexed and adducted arm is used to test for posterior joint laxity.
4. For biceps and labral related problem, we can use Speed’s test and O’Brien’s test.
5. For GIRD, we can compare internal rotation range of motion between the painful and non-painful shoulder. There should be no difference in deficits greater than twenty degrees. Also, cross-body adduction can be compared to make sure it is equal on both sides.
As always, to rule-in pathology it is always a good idea to compare results from a cluster of tests, rather than depending solely on a single test.
Shoulder Rehabilitation for the injured athlete
In the acute stage, following injury the goal is to minimize or prevent further damage to the injured tissues and control pain. Towards this end, rest and application of ice is warranted to control inflammation. If the athlete is not in a lot of pain and the tissues are not highly irritable, then activity modification can be a better choice over activity cessation. Isometric exercises can be performed to maintain strength and blood supply and prevent muscle atrophy.
During the intermediate phase, exercises can be progressed to isotonic exercises provided that the inflammation is absent. Depending on the nature of sport, as in baseball pitching, eccentric exercises can be given preference over concentric exercises. Balance exercises for the shoulder and plyometrics can be added to further challenge the cuff muscles. Exercises must be progressed from closed-chain exercises to open-chain exercises. Again, depending on the sport, the preference can be altered. Irrespective of the presence or absence of scapular dyskinesia, it is always to a good idea to pay attention to the scapular muscles. It should not be forgotten that the scapula is the link between the trunk and the upper extremity. Therefore, the scapula not only requires adequate mobility, but also stability for the proper transmission of forces from the lower extremity. The trunk and hip also need to have good rotational mobility as they help with power generation. Failing which, the burden would be borne by the shoulder muscles, leading to fatigue and over time, degenerative changes. In case of GIRD, stretching of the posterior capsule, improving posterior joint glide and strengthening of the external rotators should be the primary focus. In case of shoulder instabilities, the cuff muscles need to be strengthened and the deltoid activity minimized. In case of atraumatic multi-directional instability, the choice of exercises would be closed-chain over open-chain. In cases of impingement, stretching of pectoralis minor and levator scapulae muscles can help increase the subacromial space and thereby reducing/preventing external impingement.
During the advanced phase, the focus is on boosting the endurance and power of these shoulder muscles and promoting sports-specific movements.
The final phase is return to play making sure that the athlete is safe to play again in coordination with the other healthcare team, ensuring good physical and mental health.
Conclusion
One of the most important factors in successful shoulder rehabilitation is ensuring that the rehabilitation program is tailored to the individual’s needs. Depending on the type and severity of the injury, the rehabilitation program may include stretching, strengthening, balance, and/or functional exercises.
The patient’s doctor or physical therapist should be consulted to determine the best exercises for the patient’s particular needs. It is also important to remember to progress the exercises slowly, allowing the body time to adapt to the changes. Ultimately, proper and consistent shoulder rehabilitation can help improve an athlete’s quality of life by allowing them to move and use their shoulder with greater ease and comfort.