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A Patient’s Guide to Cuff (Rotator) Tear Arthropathy

The rotator cuff is a unique structure in the shoulder that is formed by four tendons. These four tendons attach to four muscles that help keep the shoulder stabilized in the socket (or glenoid) and help rotate the upper arm inward and outward. If the rotator cuff is torn and is not repaired, a type of wear and tear arthritis of the shoulder can develop over time. This condition is sometimes called arthropathy and the term cuff tear arthropathy is used to describe this type of arthritis of the shoulder that develops when the rotator cuff is damaged. If you develop this condition, your shoulder will be painful. Movement and strength of the shoulder will be decreased. Moving the arm away from the body and raising it over your head can be especially difficult.

This guide will help you understand

  • what parts of the shoulder are involved
  • what causes this condition
  • how doctors diagnose the condition
  • what treatment options are available

Anatomy

What parts of the shoulder are involved?

The bones of the shoulder are the humerus (the upper arm bone), the scapula (the shoulder blade), and the clavicle (the collar bone). The roof of the shoulder is formed by a part of the scapula called the acromion. The shoulder joint is also called the glenohumeral joint. One of the bones of the glenohumeral joint is the humerus (the long bone of the upper arm). It has a ball, called the humeral head on the top end. The humeral head fits into a small, shallow cup called the glenoid fossa. It makes up the other part of the glenohumeral joint. The glenoid fossa is part of the shoulder blade. A large ligament runs from the front of the acromion to another part of the shoulder blade called the coracoid process. This ligament is called thecoracoacromial ligament. It adds stability to the front of the shoulder.

The rotator cuff is made up of tough, fibrous tissue. It forms a cuff (or capsule) covering the shoulder joint. There are four tendons that help form the rotator cuff. The muscles that form the tendons are the supraspinatusinfraspinatusteres minor, and subscapularis. These muscles rotate the shoulder outward and inward. Along with another muscle, the deltoid, they also help lift the arm away from the body.

The rotator cuff slides between the humeral head and the acromion as we raise our arm. As this sliding occurs over and over, the rotator cuff tendons will often be pinched as you use the shoulder everyday. This pinching is called impingement. Over time this pinching can lead to damage and weakening of the rotator cuff tendons.

Causes

What causes this condition?

Dr. Charles Neer actually described rotator cuff tear arthropathy (RCTA) in 1977. Today, doctors generally refer to this as simply cuff tear arthropathy. Cuff tear arthropathy is actually a type of wear and tear, or degenerative arthritis of the shoulder that develops over time after the rotator cuff is damaged.

Normally, when the rotator cuff muscles contract, they pull the head of the humerus tightly into the socket of the shoulder. This stabilizes the shoulder and allows the the large deltoid muscle to raise the arm over the head as it rotates the humeral head like a pulley. This motion needs the rotator cuff and deltoid muscles to work together – in balance. When the rotator cuff is torn, the shoulder becomes unbalanced. The deltoid muscle pulls the head of the humerus up into the acromion in a sliding motion. When the top of the humerus hits the underside of the acromion, the deltoid may be able to pull the arm part way up as it levers against the underside of the acromion. But, over time this abnormal sliding motion causes wear and tear on the joint surfaces. Arthritis develops and any motion becomes painful. The shoulder becomes weaker and weaker until you can no longer raise the arm above the head.

Rotator cuff tears are very common. Trauma, such as falls, lifting, and pulling forcefully can also cause a rotator cuff tear. When this happens, it is called an acute tear. Although the rotator cuff can be damaged from a single traumatic injury, damage to the rotator cuff usually occurs gradually. Age can be a factor. As we age, the tendons of the rotator cuff become weaker and more likely to be injured. The blood supply to the tendons diminishes with age. Rotator cuff tears are much more likely to occur after the age of 40.

Certain activities can increase the wear and tear on the rotator cuff. Repetitive overhead activity such as painting, plastering, racquetball, weightlifting, and swimming can cause wear and tear of the rotator cuff.

Surgeons generally will recommend surgery to repair a rotator cuff tear when it occurs. A successful surgical repair of a torn rotator cuff tear can make the development of cuff tear arthropathy much less likely. But, sometimes a rotator cuff tear cannot be repaired. The tissue is simply too damaged and cannot fixed. This is not an uncommon situation in older patients with rotator cuff tears. In other cases, the patient simply elects not to have surgery to repair a rotator cuff tear and chooses to simply live with the discomfort. Over several years, both of these situations can result in the later development of rotator cuff arthropathy.

Symptoms

What does this condition feel like?

The most common symptom of rotator cuff tear arthropathy is pain in and around the shoulder. The pain can also radiate into your neck, arm, even into your wrist or hand. The shoulder can be especially painful when trying to lift the arm, or rotate it outward. The pain is usually worse at night. It can interrupt your sleep, especially if you try to sleep on the affected shoulder. If untreated, the pain can be nearly continuous and can be severe.

Weakness of the shoulder makes it difficult, if not impossible to lift the arm overhead. Often, even starting this motion can be difficult. The tendency is to shrug the shoulder in order to lift the arm part of the way. With time, weakness of the rotator cuff muscles will worsen. Range of motion can be quite limited. You will often find it difficult to do routine things, like reaching behind your back, reaching into a cabinet, or combing your hair. You may notice a crackling or popping sensation. When there is arthritis of the glenohumeral joint, there is often a creaking or grating sound.

Diagnosis

How do doctors diagnose this condition?

Your doctor will want to do a history and physical examination. He will ask you about activities or trauma that could have injured your shoulder. He will want to know the level of your pain, and what limitations you have. A physical examination is done. Range of motion and strength of the shoulder muscles will be evaluated. Your doctor will want to look at your shoulder to see if there is bony deformity, or atrophy (shrinkage) of the muscles. With a complete rotator cuff tear, moving the arm away from the body can be nearly impossible. If your doctor lifts your arm for you, and you cannot hold it up, this is called a positive Drop Arm Test. This usually means the rotator cuff is torn.

Other areas such as the neck may also need evaluation. A pinched nerve in the neck can mimic a rotator cuff tear. A neurological examination to include checking reflexes and sensation may be included. Your doctor may want you to have anelectromyogram (EMG). This checks the function of the muscles of the shoulder. An EMG uses a small needle in the muscle being tested. It measures the electrical activity of the muscle at rest, and when tightened.

Your doctor will request X-rays of your shoulder. X-rays show the shape of the bones and joints. When the rotator cuff is torn, the shoulder will often ride high, meaning that it sits higher in the joint than it should. It can also show how much damage ahs occurred to the joint surfaces.

Magnetic resonance imaging (MRI) allows your doctor to look at slices of the area in question. The MRI machine uses magnetic waves, not X-rays to show the muscle, tendons, and ligaments of the shoulder. MRIs will show tears of the rotator cuff tendons. Atrophy of the muscles can also be evaluated with MRI. A computerized tomography (CT) scan shows slices of bone. Like X-rays, it uses radiation. A CT scan can help to more accurately determine the degree of damage of the glenohumeral joint. A CT scan is especially useful to plan surgery if an artificial shoulder replacement is considered for treatment.

Treatment

What treatment options are available?

Nonsurgical Treatment

Conservative care that includes physical therapy, ice, heat, and anti-inflammatories is tried first. The goal of treatment is to reduce pain, and increase range of motion and function. Corticosteroid injection into the shoulder joint is also sometimes helpful. Steroids are very powerful anti-inflammatory medications that can reduce pain temporarily. These injections will not heal the tear but may give pain relief for several weeks to months. If arthritis of the shoulder is advanced, and pain is continuous and severe, surgery may be the best option available.

Surgery

Cuff tear arthropathy is the result of long standing lack of rotator cuff function. In almost all cases, repair of the rotator cuff tear is no longer an option. Surgery for cuff tear arthropathy is done when pain and decreased motion continue after conservative care. The simplest surgical procedure to try and improve the situation is a debridement. During a debridement, the surgeon will surgically remove (debride) any inflammed tissue, bones spurs and loose flaps of tendon tissue that may be catching in the joint and causing pain. This procedure may reduce pain, however, it does not always improve range of motion, strength, or function of the shoulder.

Patients with this type of arthritis would seem to be good candidates for a shoulder replacement, but replacing the shoulder in the typical fashion has not been successful. Replacing the shoulder with a special type of artficial shoulder joint is becoming more popular. This procedure is called a reverse shoulder replacement.

The “normal” artificial shoulder was designed to copy our real shoulder. The glenoid component (the socket) was designed to replace our normal shoulder socket with a thin, shallow plastic cup. The humeral head component was designed to replace the ball of the humerus with a metal ball that sits on top of the glenoid. This situation has been compared to placing a ball on a shallow saucer. Without something to hold it in place, the metal ball simply slides around on the saucer. In the shoulder that something is the rotator cuff and the muscles that attach to the tendons. Without a rotator cuff to hold the metal ball centered in the plastic socket, the metal quickly wore out the plastic socket and the joint became painful once again. The answer to this dilemma was to rethink the mechanics of the shoulder joint and design an artificial shoulder that worked differently than the real shoulder joint. The solution was to reverse the socket and the ball, placing the ball portion of the shoulder where the socket use to be and the socket where the ball or humeral head use to be. This new design led to a much more stable shoulder joint that could function without a rotator cuff. The artificial joint itself provided more stability by creating a deeper socket that prevented the ball from sliding up and down as the shoulder was raised. The large deltoid muscle that covers the shoulder could be used to more effectively lift the arm, providing better function of the shoulder. The final result is a shoulder that functions better, is less painful and can last for years without loosening.

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

Your physical therapist will show you how to use ice or heat to help with pain. You will also be instructed in exercises to strengthen your shoulder girdle as much as possible. Showing you joint protection tips, or motion that you can expect to do safely without causing more harm to your shoulder is also important. The goal is to reduce pain, increase range of motion and function, and prevent further arthritis.

After Surgery

A physical or occupational therapist will see you the day after surgery to begin your rehabilitation program. Therapy treatments will gradually improve the movement in your shoulder. Your therapist will go over your exercises and make sure you are safe getting in and out of bed and moving about in your room.

When you go home, you may get home therapy visits. By visiting your home, your therapist can check to see that you are safe getting around in your home. Treatments will also be done to help improve your range of motion and strength. In some cases, you may require up to three visits at home before beginning outpatient therapy.

Out patient therapy at a facility can often more effective and is often preferred over home physical therapy. The first few outpatient treatments will focus on controlling pain and swelling. Ice and electrical stimulation treatments may help. Your therapist may also use massage and other types of hands-on treatments to ease muscle spasm and pain. Continue to use your shoulder sling as prescribed.

As the rehabilitation program evolves, more challenging exercises are chosen to safely advance the shoulder’s strength and function. Finally, a select group of exercises can be used to simulate day-to-day activities, like grooming your hair or getting dressed.

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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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Patient guide to Shoulder Pain

Understanding how your shoulder works

Your shoulder is a ball-and-socket joint. The ball portion of the joint consists of the rounded head of the upper arm bone (humerus), and the socket portion is made up of a depression (glenoid) in the shoulder blade. The humeral head (ball) fits into the glenoid (socket) creating the joint that allows you to move your shoulder. The joint is surrounded and lined by cartilage, muscles, and tendons that provide support and stability and make it easy for you to move.

It’s your shoulder joint that lets you rotate your arm in all directions. Your range of motion depends on the proper articulation of the humeral head upon the glenoid.

In a healthy shoulder joint, the surfaces of these bones where the ball and socket rub together are very smooth and covered with a tough protective tissue called cartilage. Arthritis causes damage to the bone surfaces and cartilage. These damaged surfaces eventually become painful as they rub together.

As you might expect, there are many different reasons why you could be feeling shoulder pain, including injury, infection, and arthritis.

Osteoarthritis (OA)

A common cause of shoulder pain is osteoarthritis, a degenerative joint disease that causes the cartilage in your shoulder joints to break down. When that layer of cartilage which is meant to cushion the joints and protect the surface of the bones is damaged or worn away, your shoulder bones come in direct contact to each other, and that contact hurtsYou can feel it when you’re lifting groceries, reaching for something, or simply raising your arms to brush your teeth or hair. It may even keep you up at night.

The factors leading to the development and progression of OA include aging, obesity, joint injuries, and a family history of arthritis (genetics). Although there is no cure, early diagnosis and treatment are crucial in slowing or preventing more damage to your joints.

Rheumatoid arthritis

In rheumatoid arthritis, the lining of the joint (synovium) becomes inflamed. The inflammation causes chemicals to be released that thicken the synovium and damage the cartilage and bone of the affected joint. This inflammation of the synovium causes pain and swelling.

Rotator-cuff Arthropathy

The rotator cuff is the group of muscles and tendons that hold your shoulder together to give you strength and stability. Rotator-cuff arthropathy is a combination of two types of damage—not only has the cartilage deteriorated, but the rotator-cuff tendon that connects the muscle to the bone has also been severely worn or torn. This causes pain and may significantly limit your shoulder’s range of motion, making it nearly impossible to perform many tasks requiring shoulder movement.

The good news about arthritis in the shoulder is that it can be treated. Arthritis is a disease that typically worsens over the years, so it is common for treatment to involve more than one approach and to change over time. For some people, nonsurgical treatments such as lifestyle changes, medications, and physical therapy help alleviate the pain. For others, shoulder replacement surgery may be a long-term solution. Together, you and your doctor can determine the best treatment options for you.

Stop the pain and get your Shoulder checked now. Call +65 6471 2744 / Email to: info@boneclinic.com.sg for Appointment

Shoulder AC Joint Injury

What is the Acromioclavicular Joint?

The AC joint is short for the acromioclavicular joint. Separation of the two bones forming this joint is caused by damage to the ligaments connecting them. It is sometimes also referred to as a shoulder separation injury.

The acromioclavicular joint is formed by the outer end of the clavicle (collar bone) and the acromion process of the scapular (shoulder blade). The acromion is a bony process which protrudes forwards from the upper part of the scapular. This joint forms the highest part of the shoulder.

The two bones are attached by the acromioclavicular (AC) ligament. There are several other ligaments which can be of importance in AC joint injuries, including the coracoclavicular (CC) ligament (divided into conoid and trapezoid sections) which joins the clavicle to the coracoid process, another forward protruding part of the scapula, slightly below and to the inside of the acromion.

A third ligament is the coracoacromial ligament which attaches the acromion process to the coracoid process, although it is rarely involved in this type of injury.The most common way of injuring the AC joint is by landing on the shoulder, elbow, or onto an outstretched hand.

Symptoms include:

  • Pain at the end of the collar bone
  • Pain may feel widespread throughout the shoulder until the initial pain resolves, following this it is more likely to be a very specific site of pain over the joint itself
  • Swelling often occurs
  • Depending on the extent of the injury a step-deformity may be visible. This is an obvious lump where the joint has been disrupted and is visible on more severe injuries
  • Pain on moving the shoulder, especially when trying to raise the arms above shoulder height

AC joint injuries are graded from 1-6 using the Rockwood scale which classifies injuries in relation to the extent of ligament damage and the space between the acromion and clavicle, as shown in the pictures opposite.

Grade 1 is a simple sprain to the AC joint, grade 2 involves rupture of the AC ligament and grade 3 rupture of both AC and CC ligaments which often results in a superior displacement. From this point onwards the scale and grade of injury depends on the degree of displacement of the clavicle.

Grade 4 involves posterior displacement and grade 5 superior displacement, to a greater degree than grade 3, with an increase in coracoclavicular space by 3-5 times the norm. A step deformity may be apparent with grade 3, 4 & 5 injuries. Grade 6 (not shown) involves full rupture of both AC and CC ligaments with the clavicle being displaced inferiorly.

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