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Shoulder Tendonitis

What is shoulder tendonitis/bursitis?

Shoulder bursitis and tendonitis are common causes of shoulder pain and stiffness. They indicate swelling (inflammation) of a particular area within the shoulder joint.

The shoulder joint is kept stable by a group of muscles called the rotator cuff as well as the bicipital tendon (the tendon that keeps the upper arm bone within the shoulder socket). When the rotator cuff tendon or the bicipital tendon becomes inflamed and irritated it is called rotator cuff tendonitis or bicipital tendonitis.

An area called the subacromial bursa lies in the space between the shoulder tendons. The bursa is what protects these tendons. Subacromial bursitis occurs when the bursa becomes inflamed.

Both conditions (shoulder bursitis and tendonitis) can cause pain and stiffness around the shoulder and may exist together.

What causes shoulder tendonitis/bursitis?

Tendonitis occurs as a result of sports injuries, by repetitive minor impact on the affected area, or from a sudden, more serious injury. For instance, professional baseball players, swimmers, tennis players, and golfers are susceptible to tendonitis in their shoulders, arms, and elbows. Improper technique in any sport is one of the primary causes of overload on tissues including tendons, which can contribute to tendonitis. But you don’t have to be a professional athlete to develop this condition. Anyone can get tendonitis, but it is more common in adults, especially those over 40 years of age. As tendons age, they tolerate less stress, are less elastic, and tear more easily.

Shoulder tendonitis/bursitis typically results from one or more of these factors:

  • Age: 40 and over
  • Frequent use of the arm in an overhead position or throwing motion, as in:
    • tennis or other racquet sports
    • swimming
    • baseball
  • Jobs such as overhead assembly work, butchering, or using an overhead pressing machine, heavy lifting
  • Direct blow to the shoulder area or falling on an outstretched arm
  • Other diseases or conditions that weaken shoulder muscles, such as rheumatoid arthritis, gout, psoriasis, or an unusual drug reaction
  • Infection (rare)

How is shoulder tendonitis/bursitis treated?

Treatment goals include reduction in pain and inflammation, as well as preserving mobility and preventing disability and recurrence.

The treatment recommendations may include a combination of rest, splints, heat and cold application. You may need more advanced treatments including:

  • Corticosteroid injections from your health care provider. They work quickly to decrease the inflammation and pain.
  • Physical therapy that includes range of motion exercises and splinting. This can be very beneficial.
  • Surgery, if you are not responding to other treatments.

When should you seek medical advice?

Most cases of tendonitis go away on their own over time. It may take weeks to months to recover, depending on the severity. See your doctor if you experience pain that interferes with your normal day-to-day activities, have soreness that doesn’t improve despite self-care measures, if you have recurrence, or if you have a fever and the area affected by tendonitis appears red or inflamed (swollen, warm). These signs and symptoms may indicate that you have an infection.

In addition, see your doctor if you have other medical conditions that may increase your risk of an infection, or if you take medications that increase your risk of infection, such as corticosteroids or immunosuppressants.

How can you prevent shoulder tendonitis/bursitis?

Because most cases of tendonitis are caused by overuse, the best treatment is prevention. It is important to avoid or modify the activities that cause the problem. Underlying conditions such as improper posture or poor technique in sports or work must be corrected.

Apply these basic rules when performing activities:

  • Take it slow at first and gradually build up your activity level.
  • Use limited force and limited repetitions.
  • Stop if unusual pain occurs.

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Patient Guide to Shoulder Pain and Shoulder Injury

Shoulder pain is very common in individuals who play ‘overhead’ sports such as baseball, tennis and volleyball. In this group of athletes injury may be the result of an isolated traumatic event such as a fall or through repeated sporting-use causing micro-trauma to the shoulder region.

The shallow anatomical design of the shoulder joint surface is what makes it inherently unstable and prone to these types of injuries. This lack of bony support increases the dependency on the muscles and other soft tissues for stability. Any alterations in how these tissues function will raise the risk of shoulder injuries.

Rotator Cuff Tendonitis

Rotator Cuff Tendonitis

Two common structural injuries in this group of athletes are the rotator cuff and the labrum.

  • The rotator cuff is a group of muscles which extend from the shoulder blade to the arm. It insures dynamic shoulder stability by maintaining the proper relationship between the arm and the shoulder blade.
  • The shoulder joint is comprised of a ball and socket. The labrum is a fibrous tissue at the edge of the shoulder blade which extends to cover the ball at the top of the arm bone. It functions to increase the shoulder’s stability by deepening the socket
  • Typically, you are more prone to injure the labrum at a younger age. This tearing injury is called a SLAP lesion which is an acronym, (Superior Labrum extending Anterior to Posterior), referring to the location of the injury. It is a fairly common diagnosis for overhead athletes complaining of shoulder pain. Some studies have found it to be present in 83% to 91% of these athletes who require shoulder surgery.
  • Injuries to the rotator cuff are more likely to happen as we get older. Repetitive micro-trauma to these tissues results in inflamed tendons (tendonitis) and tears.

Tightness in the tissues at the back of the shoulder and weakness in the shoulder blade muscles are factors that are known to increase your risk for these injuries. An assessment by a physiotherapist can be beneficial in determining which of these factors are present and designing a program to correct these imbalances before you have pain.

If you have discomfort and pain every time you cock your arm to throw or serve, or have experienced the sudden onset of sharp pain or a loss of strength and power, you may already have an injury. Ignoring these warning signs and continuing to play through the pain can cause damage. If you are experiencing symptoms a physiotherapist can determine whether a program of stretches for the back of the shoulder and exercises to strengthen your shoulder blade muscles will allow you to return to your sport with more power to serve or throw, lowering your chance of re-injury. The earlier you seek therapy the better will be the result.

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Shoulder Bankart Repair Surgery

What is a Bankart Repair?

The aim of a Bankart repair operation is to restore stability to the shoulder. The operation is suitable for people who have detached the labrum and ligaments at the front of the shoulder as a result of an original violent dislocation. Usually the shoulder has remained unstable and may have dislocated on a number of further occasions.

After the operation you should not suffer further dislocations and have much reduced pain.

bankart_repair1

What does Bankart Repair involve?

Bankart Repair surgery is performed under general anaesthetic and takes around an hour and a half.  Usually the nerves to the whole arm are also numbed with local anaesthetic which lasts for sixteen to twenty-four hours. This technique is called a regional block and is similar to the idea of an epidural anaesthetic frequently used in childbirth. This regional block not only means that a lighter general anaesthetic is required, reducing postoperative sickness and nausea, but also provides excellent pain relief afterwards.

The operation is carried out as a conventional open operation through an incision at the front of the shoulder, or telescopically through a number of small incisions around the shoulder.  The aim is to restore the labrum and ligaments to their original position on the edge of the socket and encouraged to heal there. The first step in the operation is to mobilise and re-position the labrum and ligaments and to create an environment in which healing can occur. Little harpoons or anchors are then inserted into the bone on the edge of the socket, which gain a good grip. Stitches on these anchors are then used to suture the labrum and ligaments back into place. The anchors and sutures then hold everything in the right place while natural healing occurs.

The incisions are closed with stitches and waterproof dressings are applied.

When will I recover?

The operation requires a one night stay in hospital and your stitches will come out at one to two weeks after the surgery. Your arm is placed into a special shoulder-immobilising sling and exercises and physiotherapy start on the day of surgery.  Your physiotherapist will teach you all you need to know for the first couple of weeks before your discharge from hospital.

As a general guideline your sling will be retained for a period of four weeks during which time you will be quite one-handed. At four weeks the sling generally goes and increased exercises and movement are encouraged. Most people can return to driving a car at around six weeks and will have regained good ordinary use of the shoulder by eight to ten weeks.

Physiotherapy and exercises continue for four to six months and sports that do not impose too much stress on the shoulder, such as running, can start again at around eight to ten weeks. Activities such as golf and swimming can be resumed at around three months. Contact sports, such rugby and football and other high demand sports such as surfing and climbing can be reintroduced at six months.

In addition to regular treatment with the physiotherapist, follow up is required with your surgeon. This is to monitor and guide progress and to look out for complications which are fortunately all rare.

What risks should I know about?

Bankart Repair is a very successful operation but there are some potential complications you should be aware of even though they are uncommon.

  • Infection can occur although it is rare and infection rates are at 1%.
  • Shoulder dislocation can occur although this risk is minimised by having the operation done very carefully and adhering to the physiotherapy regime.

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Prevent and Treat Shoulder Injuries

Advanced bodybuilders and weightlifters subject their bodies to tremendous amounts of stress. In many cases, the stress produced by training with extremely heavy weight leads to some type of injury, everything from mild muscle pulls and tendinitis to server sprains and tears.

Certain structures in the body are likelier to suffer damage under the assault of heavy training than others, and one of the areas most vulnerable to injury is the shoulder joint. The shoulder is the most complex and most mobile joint in the body, but this mobility is gained at the cost of instability and it is this inherent skeletal instability that renders the shoulder so susceptible to injury.

STRUCTRE OF THE SHOULDER

To understand why this is so, what sort of shoulder injuries bodybuilders are likely to encounter, how to prevent them and what to do about these injuries once they have occurred, let’s start by examining the anatomy of the shoulder. To begin with, the fundamental structure of the shoulder girdle includes the scapula, which is the large triangular shoulder blade situated on either side of the upper back, and the clavicle, the collarbone, which attaches at one end to the sternum, the upper part of the ribcage at the center of the body and at the outer end to a structure at the top of the scapula called the acromion, which forms the bony top or point of the shoulder.

To render the entire shoulder girdle mobile, as well as allowing the arm virtually 360 degrees of rotation at the shoulder, there is not one joint involved, but three joints, plus one “articulation.” These are:

1) The Glenohumeral Joint. This is the ball-and-socket joint that most people think of as the shoulder. The top of the humerus, the upper arm bone, fits into a shallow cavity or socket situated below the acromion called the glenoid.
2) The Acromioclavicular Joint. This is the point at which the outer end of the clavicle is joined to the acromion at the top of the shoulder.
3) The Sternoclavicular Joint. This is where the inner end of the clavicle attaches to the sternum.
4) The Scapula. The shoulder blade is attached to the thorax by a variety of muscles and other tissues that allow it movement in relationship to the trunk. It forms a joint with the arm at the glenohumeral joint and with the clavicle at the acromioclavicular joint.

Injuries can occur to any of these areas, but the most common problems encountered by bodybuilders and weightlifters involve the glenohumeral joint and the acromioclavicular joint.

INJURIES TO THE GLENOHUMERAL JOINT

The glenohumeral, ball-and-socket joint of the shoulder is very different from a ball-and-socket joint such as the hip in that, as described above, it has a tremendous amount of additional mobility It achieves its mobility from the fact that there is very little bony contact between the head of the humerus and the glenoid socket. At any given position, only about one quarter of the head of the humerus is in contact with the glenoid, which is what makes this joint so inherently unstable.

What stability it has comes from the surrounding ligamentous tissue that holds the joint together. Particularly the capsule, which is a fibrous envelope that attaches circumferentially around the glenoid, and is reinforced anteriorally by the glenohumeral ligaments.

Reinforcing the capsule and ligaments is the rotator cuff a musculotendinous support structure overlying and intimately attached to the capsule. The most important part of this structure in terms of frequency of injuries is the supraspinatus tendon.

Injuries to the glenohumeral joint almost always involve some damage to one or more of the ligaments, the associated tendons and muscles, or the glenoid labrum, a fibrocartilaginous structure at the rim of the glenoid cavity. The most frequent types of glenohumeral injuries are:

1) Damage to the capsule and ligaments, commonly where they attach to the rim of the glenoid. Tears or ruptures of these tissues result in pain and eventually in loss of mobility.
2) Damage resulting in anterior (meaning to the front) instability, in which sufficient stretching or tearing of the tissue allows the end of the humerus to come out of the glenoid cavity Subluxation is when the head of the humerus temporarily slips onto the rim of the glenoid and then spontaneously slips back into the socket; dislocation occurs when the head of the glenoid slips out over the glenoid rim and stays in this position.
3) Damage to the rotator cuff, usually as a result of impingement syndrome, a chronic, inflammatory process of the rotator cuff and the suhdeltoid hursa as these structures repeatedly impinge, are pressed and squeezed against the underside of the roof of the shoulder joint. Repetitive microtrauma and overuse of this nature may result in inflammation, partial tearing and thickening of the rotator cuff.
4) Bursitis, inflammation of a hursa, which is a sack that allows for the smooth gliding motion between the rotator cuff and the upper end of the humerus and the overlying deltoid muscle and the roof of the shoulder joint.

INJURIES TO THE ACROMIOCLAVICULAR JOINT

The most common injuries to bodybuilders and weightlifters in the area of the acromioclavicular joint involve damage to the ligamentous tissue surrounding and stabilizing the joint and arthritis degeneration of the joint itself.

A shoulder separation involves a situation in which some degree of subluxation or dislocation occurs between the clavicle and the acromion in the area of the AC joint. This type of injury, often caused by falling on the point of the shoulder, is more common to athletes like football players than to bodybuilders.

The two exercises that I see causing the greatest frequency of injuries to the AC joint in bodybuilders are heavy bench presses and dips. These movements frequently cause cumulative microtrauma to the distal or outer end of the clavicle, resulting in destruction of the bony tissue in this area leading to degeneration of the joint.

HOW SHOULDER INJURIES OCCUR

While the shoulder joint is a skeletally unstable structure, it is connected to some of the most powerful muscles of the body. For example, a main function of the pectorals is to pull the shoulder girdle forward, while muscles of the back such as the rhomboids, latissimus dorsi and trapezius work to pull the shoulder girdle up, down and to the rear.

The joints of the shoulder are involved in almost all upper body movements. Stress is put on the shoulder not only when you’re training the deltoids, but during chest, back and arm workouts as well. Therefore, one of the primary causes of shoulder problems is simply overuse. When you overuse an area of the body there is a resulting degree of microtrauma. This damage, although small, can be cumulative. If you keep training in spite of fatigue and mild pain, the damage is made worse and eventually leads to inflammation or more serious damage and the likelihood of chronic or incapacitating problems in the area.

Damage can also be done by a single incident of momentary overstress, such as lifting too heavy a weight or a multiplication of stress that comes from using poor technique. Faced with a sudden stress the shoulder is not prepared to deal with, the ligaments and musculotendinous structures of the shoulder can stretch, tear or rupture. However, it is possible that what may appear to be an injury resulting from a single incident of overstress may actually be the result, in part, of cumulative microtrauma in the injured area due to repeated overuse of which you were unaware.

Certain exercises are likelier to cause shoulder injuries than others. For example, a lot of bodybuilders I’ve treated have sustained glenohumeral injuries from doing heavy bench presses. Advanced bodybuilders, who have built up a great deal of strength, are capable of lifting enormous amounts of weight, 500 pounds and more in the bench press, and this puts enormous amounts of stress on the shoulder joint stress that the inherently unstable shoulder joint was not designed to cope with. If the bodybuilder attempts this kind of lift when the shoulder joint is already weakened by overuse, or when it has become overly fatigued during a workout, the glenohumeral joint and its surrounding tissue may not be able to bear up under the demands of that much weight and he or she may experience some degree of acute injury

Also, certain exercises appear to be more biomechanically unsound than others, which means they must be approached with a great deal of care. For example, while I’ve never had a patient with a shoulder injury that could be directly traced to doing behind-the-neck barbell presses, this movement does put a lot of stress on the shoulder while it’s in its least stable position. A conventional military or dumbbell press involves a combination of abduction and external rotation, which puts the head of the humerus against the weaker part of the shoulder joint, forcing it forward. Pressing behind the neck adds the element of extension, putting even more stress on the head of the humerus and causing it to bear large amounts of stress while in its relatively weakest and most vulnerable position.

But no matter what exercise you are performing, you are courting injury if you use poor technique or bad judgment. Bodybuilders who bounce too heavy a weight off their chest doing barbell bench presses, jerk the weight around and let it get out of control performing movements like barbell shoulder presses or dumbbell presses and flyes are simply asking for trouble. So are the ones who train too hard when they’re already tired, or who fail to adequately stretch and warm up before a heavy workout.

PREVENTION OF SHOULDER INJURIES

Prevention of shoulder injuries involves nothing more for the most part than avoiding the mistakes outlined in the previous section. This involves:

1) Proper stretching, keeping the structures flexible so that a sudden elongation due to pull of heavy weight will not create damage.
2) Proper warm-up to allow the structures maximum ability to deal with stress.
3) Using proper technique – controlling the weight, not letting stress become magnified by out-of-control inertial forces.
4) Avoiding overtraining – both short and long term. Short-term overtraining means that you are stressing a fatigued area; long-term overtraining means that you are in danger of “overuse syndrome.”
5) Avoiding pain. If you feel pain, avoid whatever movement is causing it. Try something else – incline instead of flat, for example, dumbbells instead of barbells. But don’t continue to do anything that causes you pain.
6) Avoid biomechanically unsound exercises. If a movement involves putting stress on the joints at an especially awkward angle or when they’re in an unstable position, the exercise should be approached with care.

Remember, when it comes to overuse and overtraining, that the shoulder is involved in virtually all upper body movements, not just deltoid training. While bench presses and behind-the-neck presses are the exercises most often associated with shoulder injuries, doing movements like heavy dumbbell flyes or laterals, weighted behind-neck chins or heavy pulldowns can also contribute to the wear and tear of the shoulder joints that can lead eventually to serious injury.

TREATMENT OF SHOULDER INJURIES

There are numerous specific programs of therapy appropriate to each of the various kinds of specific shoulder problems, such as bursitis, bicipital tendinitis, impingement syndrome, rotator cuff tears, labral tears, capsular disruption, or arthritic degeneration of the glenohumeral joint or the AC joint. However, while there are differences in how each of these conditions is treated, there are certain general therapeutic principles that apply to virtually all of them. These are:

1) Rest
2) Treatment of inflammation
3) Stretching and restoration of range of motion
4) Strengthening
5) Avoidance of reinjury

The first step in rehabilitation of any shoulder injury is rest and avoiding the particular activity that caused the problem in the first place. I can’t stress this enough. The idea of “training through the pain” is disastrous when it comes to physical injury. When a damaged structure is put under stress you only make the injury worse, prolong the period needed for recovery and possibly limit the degree of recovery you will ultimately be able to achieve.

In the event of inflammation caused by severe tendinitis or bursitis, the use of an oral anti-inflammatory drug may be indicated. But in cases where anti-inflammatory injections are administered, they must be used on a limited basis — once, twice or, at the most, three times spaced out over a period of time. If the anti-inflammatory injections are going to be effective, you usually expect to see a response in the first few days after their introduction. Repeat injections of anti-inflammatory drugs are not recommended, since they have a deleterious effect on collagen tissue.

Once the acute inflammation has subsided the next step is muscular and capsular stretching, a restoration of full flexibility in all the structures involved within the limits of pain. Stretching is important to avoid such problems as capsular adhesions. If range of motion is not restored, the result can be adhesive capsulitis, a severe restriction in the range of motion of the shoulder also called “frozen shoulder. However, in cases of glcnohumeral instability, you should avoid further capsular stretching in the same direction as the instability.

Following restoration of range of motion with problems such as interior instability, the next step is for strengthening such things as the internal rotators, the adductors, the anterior deltoid and the prime scapular stabilizers. Obviously, the specific exercises required for rehabilitation depend to a large degree on the nature of the injury itself. But whatever the particular therapy called for, the initial steps in strengthening involve very low weight, high-rep exercises, isolating the specific muscles you want to work — such as the subscapularis, the internal rotator of the shoulder or the anterior deltoid. Since extreme isolation of a given bodypart is often necessary, this is a situation in which a variety of specialized exercise machines is extremely valuable.

In the event of impingement syndrome and/or anterior instability, the restoration of strength is a particular priority. However, I recommend a substantial period of light, high-repetition rehabilitative exercise before going on to train with heavier weights — although in some cases the patient may never be able to regain pre-injury strength levels.

Dealing with most of my health-oriented patients, I have no great problem convincing them to go slowly and not to rush into heavy training too quickly. With bodybuilders, however, this is almost always a struggle. Bodybuilders and weightlifters are notorious for believing they know more than their doctors. Their instinct is to jump into heavy training at too early a stage, and they need to be constantly reminded that a few extra weeks of going slow will ultimately save them months or years in the rehabilitative process.

And when I say heavier resistance, I mean progressively heavier resistance. You don’t go in one day from light training to heavy, one-rep maximum repetitions. The area to be rehabilitated needs to be strengthened gradually over a period of time. Remember, not only are you trying to rehabilitate an injury, you are dealing with a structure that was inherently weak enough to be injured in the first place. So gradual and careful escalation of poundages is an absolute necessity to avoid re-injury.

One important factor in understanding the process of rehabilitation of shoulder injuries is that the healing process can take a considerable period of time, depending on the severity of the injury. Really serious conditions such as severe anterior instahlity or substantial damage to the rotator cuff may involve as much as six months, nine months or even a year. However, less serious conditions such as mild inflammation are reversible within a relatively short period of time.

SURGERY

Although most injuries respond to the kind of conservative treatment described above, there are times when surgical intervention is called for, especially for professional athletes and young people with complete tears.

For example, in the case of a young pitcher or tennis player with a complete rotator cuff tear, you’d want to go in there immediately. In the event of extreme shoulder separation, sometimes it’s necessary to go in and reattach the distal end of the clavicle to the acromion to restore the AC joint. In the case of arthritis of the AC joint, when conservative treatment is not sufficient, the surgical remedy is to cut away a small portion of the distal end of the clavicle.

Arthroscopic surgery, which is currently so widely used in knee injuries, has not as yet developed to the same degree in dealing with injuries to the shoulder. The arthroscope is used for diagnosis, and for procedures such as resecting torn portions of the lahrum, but not for rotator cuff repair. In terms of state-of-the-art orthopedics, there is nothing to replace standard open surgical procedures for rotator cuff tears.

THE LONG-TERM PROGNOSIS FOR SHOULDER TRAINING

The human body is not something that lasts forever. It is subject to cumulative damage from long-term wear and tear, and it eventually wears out. And when you subject the body to excessive amounts of stress, the degeneration and attrition are accelerated.

Bodybuilding for health and fitness can give you a body that is 10 or 20 years younger than that of a more sedentary person, given the variations inherent in individual heredity. But bodybuilding or weightlifting pursued as a serious sport takes a tremendous toll on the body, particularly on the joints. Especially the inherently unstable shoulder joint.

A race car, for example, can in a few hours wear out a set of tires that would last years on a regular car, and a high-performance dragster requires an engine rebuilding after every run. When you increase performance, you also increase stress, and the rate of wear and tear becomes vastly accelerated.

Most individuals don’t begin to experience the problems associated with physical attrition until middle or old age. Serious athletes, particularly bodybuilders, often experience these kinds of problems earlier on. In fact, virtually every competition bodybuilder and weightlifter I’ve treated, even if quite young, has already experienced some physical problems, limitations of motion or chronic damage to the musculotendinous structures, joints or ligaments that in some way limited their ability to do certain movements or bear up under particular kinds of stress.

Most good competitors learn to ‘train around” chronic problems. If it hurts them to do bench presses, they substitute dumbbell presses, or incline presses or something else. If a lower back problem prevents them from doing barbell rows, they switch to one-arm dumbbell rows or heavy cable rows, whatever it takes to work around the affected area.

When you’ve been training a considerable amount of time, training around a physical problem is usually possible because you already have gotten most of your growth and developed about the maximum amount of strength you’re capable of. And since it’s always easier to maintain a level of development than it was to achieve it in the first place, you may be able to get away with training around a considerable amount of damage and limitation.

But this is not always the case. Sometimes an injury to an area such as the shoulder is so great that you just have to quit heavy training. Stop completely, not for a rest, but forever. You only get to be a virgin once, and any time you sustain a serious injury, especially if surgery is required, no matter how much of your pre-injury physical ability you are able to regain, the injured area will never be “as good as new.” And areas that have been injured in the past usually degenerate at an accelerated rate over time compared to noninjured areas.

But the real lesson this implies, I believe, is that bodybuilders who do not have any competitive ambitions should avoid the kind the damaging, heavy training that would-be World and Mr. Olympia competitors have to put themselves through. There’s a physical price to be paid for pushing your body to its limits, and no reason to pay that price unless there is some commensurate reward to be gained for doing so.

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