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Patient Guide to Frozen Shoulder

Frozen shoulder, also known as adhesive capsulitis, is a condition characterized by stiffness and pain in your shoulder joint. Signs and symptoms typically begin gradually, worsen over time and then resolve, usually within one or two years.

Your risk of developing frozen shoulder increases if you’re recovering from a medical condition or procedure that affects the mobility of your arm — such as a stroke or a mastectomy.

Treatment for frozen shoulder involves stretching exercises and, sometimes, the injection of corticosteroids and numbing medications into the joint capsule. In a small percentage of cases, surgery may be needed to loosen the joint capsule so that it can move more freely.

SYMPTOMS OF FROZEN SHOULDER

Frozen shoulder typically develops slowly, and in three stages. Each of these stages can last a number of months.

  • Painful stage. During this stage, pain occurs with any movement of your shoulder, and your shoulder’s range of motion starts to become limited.
  • Frozen stage. Pain may begin to diminish during this stage. However, your shoulder becomes stiffer, and your range of motion decreases notably.
  • Thawing stage. During the thawing stage, the range of motion in your shoulder begins to improve.

For some people, the pain worsens at night, sometimes disrupting normal sleep patterns.

CAUSES OF FROZEN SHOULDER

The bones, ligaments and tendons that make up your shoulder joint are encased in a capsule of connective tissue. Frozen shoulder occurs when this capsule thickens and tightens around the shoulder joint, restricting its movement.

Doctors aren’t sure why this happens to some people and not to others, although it’s more likely to occur in people who have recently experienced prolonged immobilization of their shoulder, such as after surgery or an arm fracture.

RISK FACTORS OF FROZEN SHOULDER

Although the exact cause is unknown, certain factors may increase your risk of developing frozen shoulder.

Age and sex
People 40 and older are more likely to experience frozen shoulder. Most of the people who develop the condition are women.

Immobility or reduced mobility
People who have experienced prolonged immobility or reduced mobility of their shoulder are at higher risk of developing frozen shoulder. Immobility may be the result of many factors, including:

  • Rotator cuff injury
  • Broken arm
  • Stroke
  • Recovery from surgery

Systemic diseases
People who have certain medical problems appear to be predisposed to develop frozen shoulder. Examples include:

  • Diabetes
  • Overactive thyroid (hyperthyroidism)
  • Underactive thyroid (hypothyroidism)
  • Cardiovascular disease
  • Tuberculosis
  • Parkinson’s disease

TESTS AND DIAGNOSIS:

During the physical exam, your doctor may ask you to perform certain actions, to check for pain and evaluate your range of motion. These may include:

  • Hands up. Raise both your hands straight up in the air, like a football referee calling a touchdown.
  • Opposite shoulder. Reach across your chest to touch your opposite shoulder.
  • Back scratch. Starting with the back of your hand against the small of your back, reach upward to touch your opposite shoulder blade.

Your doctor may also ask you to relax your muscles while he or she moves your arm for you. This test can help distinguish between frozen shoulder and a rotator cuff injury.

Frozen shoulder can usually be diagnosed from signs and symptoms alone. But your doctor may suggest imaging tests — such as X-rays or an MRI — to rule out other structural problems.

TREATMENTS AND DRUGS:

Most frozen shoulder treatment involves controlling shoulder pain and preserving as much range of motion in the shoulder as possible.

Medications
Over-the-counter pain relievers, such as aspirin and ibuprofen (Advil, Motrin, others), can help reduce pain and inflammation associated with frozen shoulder. In some cases, your doctor may prescribe stronger pain-relieving and anti-inflammatory drugs.

Therapy
A physical therapist can teach you stretching exercises to help maintain as much mobility in your shoulder as possible.

Surgical and other procedures
Most frozen shoulders get better on their own within 12 to 18 months. For persistent symptoms, your doctor may suggest:

  • Steroid injections. Injecting corticosteroids into your shoulder joint may help decrease pain and improve shoulder mobility.
  • Joint distension. Injecting sterile water into the joint capsule can help stretch the tissue and make it easier to move the joint.
  • Shoulder manipulation. In this procedure, you receive a general anesthetic so you’ll be unconscious and feel no pain. Then the doctor moves your shoulder joint in different directions, to help loosen the tightened tissue. Depending on the amount of force used, this procedure can cause bone fractures.
  • Surgery. If nothing else has helped, you may be a candidate for surgery to remove scar tissue and adhesions from inside your shoulder joint. Doctors usually perform this surgery arthroscopically, with lighted, tubular instruments inserted through small incisions around your joint.

PREVENTION OF FROZEN SHOULDER:

One of the most common causes of frozen shoulder is the immobility that may result during recovery from a shoulder injury, broken arm or a stroke. If you’ve had an injury that makes it difficult to move your shoulder, talk to your doctor about what exercises would be best to maintain the range of motion in your shoulder joint.

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Patient Guide to Shoulder Pain

Shoulder pain should not be ignored. Early treatment can prevent further injury and chronic shoulder problems. Pain in the shoulder may also be referred from other areas of the body, e.g. disc problems the neck.

The Shoulder Joint

The structure of the shoulder joint allows more range of motion than any other joint in the body.

The shoulder actually has several joints that work together to allow a wide range of motion. Most injuries occur at the “main” shoulder joint, where the head of the upper arm meets the shoulder blade; the term “shoulder joint” refers to this joint. The other smaller shoulder joints are referred to by their specific names.

The head of the upper arm bone sits on a very small and shallow socket in the shoulder blade. This allows for the shoulder’s wide range of motion but makes it susceptible to injury. Because there is little bony stability, the shoulder relies greatly on connective tissue (e.g. ligaments, tendons, muscles) to hold the bones of the joint together and to stabilize the joint.

Causes of Shoulder Pain

The Most Common Cause of shoulder joint pain is rotator cuff tendonitis – injury and inflammation of the tendons (rotator cuff tendons) that envelope the shoulder joint. The most common cause of rotator cuff tendonitis is overuse of the shoulder, though the rotator cuff tendons may be injured suddenly as a result of a fall or accident.

Muscle strain is common in the muscles that run over the shoulders to the neck . It is often the result of holding the shoulders in a raised position for long periods of time. The muscles between the shoulder blades are often strained from slouching from long periods of time. Muscle strain varies in severity.

Other painful shoulder conditions, such as frozen shoulder, may occur for no apparent reason. (The risk of frozen shoulder increases when the shoulder is not used enough after a painful injury). The cause of calcium deposits in the shoulder, which may trigger episodes of acute inflammation of the tendons, is also unclear. Arthritis sometimes occurs in a previously injured shoulder joint.

Slap Lesion

Slap Lesion

Risk Factors

WEAK ROTATOR CUFF MUSCLES

Weak or fatigued rotator cuff muscles can lead to soft tissue injury. If the muscles that stabilize the shoulder joint (mainly the rotator cuff muscles) are weak or fatigued, the muscles fail to fully stabilize the joint. If the head of the upper arm bone is not kept in place in its socket, abnormal force is placed upon tissue surrounding the shoulder joint and can lead to injury. Shoulder tendonitis and bursitis are common.

OVERUSE

Shoulder pain is frequently caused by chronic overuse of the shoulder. The shoulder may become injured suddenly from a blow or fall, but gradual injury from chronic overuse of the shoulder is more common. Repetitive lifting, pushing, pulling, throwing, and especially overhead activities may lead to injury. Pain may be mild and intermittent in the beginning and worsen over time. Combining repetitive overhead activities with force increases the risk of injury further (e.g. stacking heavy objects on a high shelf).

Repetitive overhead activities can be particularly damaging. When the arm is raised overhead, the head of the upper arm bone migrates upward on the shoulder socket somewhat and rotator cuff tendons come into contact with the roof of the shoulder blade. Repeated contact and friction of the rotator cuff tendons often leads to irritation and inflammation of the tendons (tendonitis).

A strong rotator cuff helps keep the head of the upper arm bone from riding up excessively but some contact between the rotator cuff and bones in the joint still occurs with overhead activity. The bursa that lies under the roof of the shoulder blade may also be affected and become inflamed (bursitis). Shoulder bursitis often occurs along with shoulder tendonitis.

AGING

Aging is a major factor in rotator cuff injuries Tendons lose elasticity with aging and they become more susceptible to injury. Muscle mass also decreases with age. Both the rotator cuff muscles and tendons can be strengthened with resistance exercises.

Prevention of Shoulder Pain

Overuse shoulder injuries often can be prevented.

Weak rotator cuff muscles may be unable to adequately stabilize the shoulder joint. Rotator Cuff Exercises can help. Building up strength of the rotator cuff through exercise helps to stabilize the shoulder joint to prevent abnormal pressure on the soft tissues surrounding the joint. The muscles that control the shoulder blade also play a role in stabilizing the shoulder joint.

Avoid repetitive overhead activities. If you are involved in activities that involve repetitive overhead movements, take frequent breaks. Fatigued rotator cuff muscles lose the ability to keep the shoulder stabilized.

Avoid doing too much too soon. If you are going to engage in any overhead activity you haven’t done for a long time, such as getting back into playing tennis, endurance must be built up slowly. Exercises to strengthen the muscles you will be using in an activity reduce the chance of injury.

Warm up before engaging in sports such as swimming, tennis or throwing sports that require overhead movement.

Proper form for your sport should be learned and practiced to prevent injury.

Maintain proper posture. Muscles over the shoulders become strained from holding the shoulders in a raised position for long periods of time. Muscles in the upper back, between the shoulder blades, become strained as a result of slouching.

Treatment of Shoulder Pain

Prevent major problems by treating minor problems early. If a minor injury is not given a chance to heal before it is subjected to the same activity, pain and inflammation may become chronic.

Treatment of shoulder pain depends on the cause – seek a proper diagnosis from a qualified physician. Most shoulder injuries heal with conservative treatment. Healing takes time. The time it takes to recover depends upon several factors, e.g. the severity of injury, the type of injury, how quickly one heals, how early one begins treatment.

Typical treatment of shoulder pain (for most conditions) involves a combination of rest (not complete rest), exercise, anti-inflammatory medication, applying cold or heat to the shoulder joint and, in some cases, an injection of steroids into the shoulder joint.

Doing activities that aggravate shoulder pain often cause further damage, delay healing, and may lead to long-term problems. However, not using the shoulder at all weakens the shoulder and leaves it more vulnerable to injury. Immobilizing the shoulder may also lead to frozen shoulder. Stretching exercises help prevent this condition.

Strengthening exercises for the muscles that support the shoulder, particularly the rotator cuff (the muscles and tendons that dynamically stabilize the main shoulder joint) are a major part of treatment for most shoulder injuries, but strength training before adequate healing has taken place may cause further pain and injury. A physician or physical therapist can determine when the shoulder is ready for strengthening exercises. Shoulder Exercises can prevent injury from recurring.

Massage therapy is also used to treat many soft tissue injuries. From muscle strain to tendonitis to frozen shoulder, massage therapy increases circulation, speeds healing, improves range of motion and relieves pain.

Most shoulder pain improves with conservative treatment; however, surgery may occasionally be required (depending upon the type of and severity of the injury). Surgery may be performed to tighten loose ligaments, repair a torn tendon, remove a calcium deposit, trim a damaged tendon, etc. when conservative treatment doesn’t adequately resolve symptoms.

Diagnosis of Shoulder Pain

Many shoulder conditions have similar symptoms and it may be difficult to diagnose the problem from symptoms alone. A physician, often an orthopedist, diagnoses the cause of shoulder pain by taking into consideration the patient’s symptoms and medical history, findings of a physical examination and sometimes diagnostic testing, such as x-rays, a CT scan, or an MRI.


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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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Frozen Shoulder

Frozen shoulder, also known as adhesive capsulitis, is a condition characterized by stiffness and pain in your shoulder joint. Signs and symptoms typically begin gradually, worsen over time and then resolve, usually within one or two years.

Your risk of developing frozen shoulder increases if you’re recovering from a medical condition or procedure that affects the mobility of your arm such as a stroke or a mastectomy.

Treatment for frozen shoulder involves stretching exercises and, sometimes, the injection of corticosteroids and numbing medications into the joint capsule. In a small percentage of cases, surgery may be needed to loosen the joint capsule so that it can move more freely.

Symptoms:

Frozen shoulder typically develops slowly, and in three stages. Each of these stages can last a number of months.

  • Painful stage. During this stage, pain occurs with any movement of your shoulder, and your shoulder’s range of motion starts to become limited.
  • Frozen stage. Pain may begin to diminish during this stage. However, your shoulder becomes stiffer, and your range of motion decreases notably.
  • Thawing stage. During the thawing stage, the range of motion in your shoulder begins to improve.

For some people, the pain worsens at night, sometimes disrupting normal sleep patterns.

Causes:

The bones, ligaments and tendons that make up your shoulder joint are encased in a capsule of connective tissue. Frozen shoulder occurs when this capsule thickens and tightens around the shoulder joint, restricting its movement.

Doctors aren’t sure why this happens to some people and not to others, although it’s more likely to occur in people who have recently experienced prolonged immobilization of their shoulder, such as after surgery or an arm fracture.

Risk Factors:

Although the exact cause is unknown, certain factors may increase your risk of developing frozen shoulder.

Age and sex
People 40 and older are more likely to experience frozen shoulder. Most of the people who develop the condition are women.

Immobility or reduced mobility
People who have experienced prolonged immobility or reduced mobility of their shoulder are at higher risk of developing frozen shoulder. Immobility may be the result of many factors, including:

  • Rotator cuff injury
  • Broken arm
  • Stroke
  • Recovery from surgery

Systemic diseases
People who have certain medical problems appear to be predisposed to develop frozen shoulder. Examples include:

  • Diabetes
  • Overactive thyroid (hyperthyroidism)
  • Underactive thyroid (hypothyroidism)
  • Cardiovascular disease
  • Tuberculosis
  • Parkinson’s disease

Diagnosis:

During the physical exam, your doctor may ask you to perform certain actions, to check for pain and evaluate your range of motion. These may include:

  • Hands up. Raise both your hands straight up in the air, like a football referee calling a touchdown.
  • Opposite shoulder. Reach across your chest to touch your opposite shoulder.
  • Back scratch. Starting with the back of your hand against the small of your back, reach upward to touch your opposite shoulder blade.

Your doctor may also ask you to relax your muscles while he or she moves your arm for you. This test can help distinguish between frozen shoulder and a rotator cuff injury.

Frozen shoulder can usually be diagnosed from signs and symptoms alone. But your doctor may suggest imaging tests such as X-rays or an MRI to rule out other structural problems.

Cure Your Frozen Shoulder Today. Call +65 6471 2744 or SMS to: +65 92357641 for Appointment

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.

Stop your Shoulder pain and Get it Checked. Call +65 6471 2744 (24 Hours) / Email: info@boneclinic.com.sg

Rotator Cuff Injury and Inflammation

Rotator cuff injury and inflammation is one of the most common causes of shoulder pain. There are three common conditions that can affect the rotator cuff: rotator cuff tendonitis, rotator cuff impingement syndrome and a rotator cuff tear. Most people with rotator cuff problems can be successfully treated by a combination of rest, painkillers, anti-inflammatories, physiotherapy and injections.

The shoulder joint

There are three bones in the shoulder region, the clavicle (collar bone), the scapula (shoulder blade) and the humerus (upper arm bone). The scapula is a triangular-shaped bone that has two important parts to it: the acromion and the glenoid. The three bones in the shoulder region form part of two main joints:

  • The acromioclavicular joint between the acromion of the scapula and the clavicle.
  • The glenohumeral joint between the glenoid of the scapula and the humerus.

There are also a number of muscles, ligaments and tendons around the shoulder. Ligaments are fibres that link bones together at a joint. Tendons are fibres that attach muscle to bone.

What is the rotator cuff?

The rotator cuff is a group of four muscles that are positioned around the shoulder joint. The muscles are named:

  • Supraspinatus
  • Infraspinatus
  • Subscapularis
  • Teres minor

The rotator cuff muscles work as a unit. They help to stabilise the shoulder joint and also help with shoulder joint movement. The four tendons of the rotator cuff muscles join together to form one larger tendon, called the rotator cuff tendon. This tendon attaches to the head of the humerus (the bony surface at the top of the upper arm bone). There is a space underneath the acromion of the scapula, called the subacromial space. The rotator cuff tendon passes through here.

What are the types of rotator cuff injury/inflammation?

There are a number of different problems that can affect the rotator cuff and lead to rotator cuff injury or inflammation. The most common problems include:

  • Rotator cuff tendonitis
  • Rotator cuff impingement syndrome
  • Rotator cuff tear

Rotator cuff tendonitis

Who gets rotator cuff tendonitis?

Rotator cuff tendonitis is the most common cause of shoulder pain.

What causes rotator cuff tendonitis?

Rotator cuff tendonitis is caused by irritation and inflammation of the tendons of the rotator cuff muscles. It tends to have an acute (sudden) onset. There is often a specific preceding injury. It can happen because of recent overuse of the shoulder. For example, it can occur in athletes, particularly those who participate in throwing sports. In non-athletes, there may be a history of recent heavy lifting or activities involving repetitive movements of the shoulder.

Sometimes the rotator cuff tendons can become ‘calcified’. This is when calcium is deposited in the tendons due to long-standing inflammation. This is called calcific tendonitis.

What are the symptoms of rotator cuff tendonitis?

The main symptoms are an acute (sudden) onset of pain and painful movement of the shoulder. Pain is worst when you use your arm for activities above your shoulder level. This means that the pain can affect your ability to lift your arm up – for example, to comb your hair or dress yourself. Swimming, basketball and painting can be painful but writing and typing can produce little in the way of pain. Pain may also affect sleep.

How is rotator cuff tendonitis diagnosed?

Our doctor is usually able to make the diagnosis just by talking to you and examining your shoulder. They usually start by asking questions about your shoulder. These questions may include when your shoulder problems started, whether you have had any specific injury and what aggravates your shoulder problem.

They may then perform an examination of your shoulder. This usually involves moving your shoulder in various positions. One of the tests that can help to diagnose rotator cuff tendonitis is called the ‘painful arc test’. Our doctor may ask you to start with your arm by your side and then lift your arm outwards from your side in an arc. In rotator cuff tendonitis, pain is usually felt at a maximum between 70 and 120° in this arc.

Occasionally, Our doctor may suggest an X-ray of your shoulder or they may refer you for more detailed investigations such as an ultrasound scan or an MRI scan.

What are the treatment options for rotator cuff tendonitis?

  • Rest: this is the main treatment for rotator cuff tendonitis. You should stop any aggravating activities that may have brought on the tendonitis. However, do not completely rest your shoulder. You should still try to keep your shoulder mobile.
  • Painkillers: painkillers such as paracetamol are usually helpful. Occasionally, stronger painkillers may be needed.
  • Anti-inflammatories: these are painkillers but they also reduce inflammation and are commonly prescribed. Side-effects sometimes occur with anti-inflammatories. Always read the leaflet that comes with the drug packet for a full list of cautions and possible side-effects.
  • Physiotherapy: your doctor may refer you to a physiotherapist for advice and exercises.
  • Injections: these can help reduce the inflammation in the rotator cuff tendons. Injections can be repeated if the initial response is good.

Calcific tendonitis is treated in the same way with rest, anti-inflammatory drugs, steroid injections and physiotherapy. Rarely, surgery is needed. An alternative to surgery is a procedure called lithotripsy. In lithotripsy, shock waves are generated and delivered by an external power source to the affected tendon(s) using a specialised machine known as a lithotripter. This helps to break up the deposits of calcium.

What is the prognosis (outlook) for rotator cuff tendonitis?

If rotator cuff tendonitis is adequately treated, there can be complete recovery.

If treatment of any rotator cuff problem is delayed or inadequate, it can lead to the affected person being cautious about moving their shoulder because of pain. This means that the shoulder can stiffen up and can lead to adhesive capsulitis (frozen shoulder). See separate leaflet called ‘Frozen Shoulder’.

Rotator cuff impingement syndrome

What causes rotator cuff impingement syndrome?

As discussed above, the rotator cuff tendon passes in the subacromial space (the space underneath the acromion part of the scapula, or shoulder blade). In impingement syndrome, the rotator cuff tendon gets ‘trapped’ in the subacromial space. The tendon is repeatedly ‘scraped’ against the shoulder blade which can eventually lead to fraying of the tendon. This means that the tendon weakens and is more likely to tear.

Impingement syndrome can occur because of long-standing ‘wear and tear’. It can also happen due to problems with the bone of the acromion. These can include arthritis and bony spurs (protrusions).

What are the symptoms of rotator cuff impingement syndrome

Rotator cuff impingement syndrome also causes shoulder pain. However, the pain tends to be more chronic (long-standing). The pain tends to be worse during activities when your arm is raised over your head. Pain can also be worse at night time.

How is rotator cuff impingement syndrome diagnosed?

Again, our doctor will usually diagnose rotator cuff impingement syndrome just by talking to you and examining your shoulder. You will experience the same painful arc as described above when your shoulder is moved.

Our doctor may also perform a special test when they examine your shoulder called the Neer Impingement Test. In this test they ask you to straighten your arm. They then raise your arm forward, keeping your palm pointing away from your body. If this test is painful, the test is positive and rotator cuff impingement syndrome is likely.

What are the treatment options for rotator cuff impingement syndrome?

The treatment for rotator cuff impingement syndrome is similar to that for rotator cuff tendonitis. You should rest from any activity that involves repetitive movement of the shoulder. This particularly includes overhead activity such as that performed by plasterers or painters and decorators. This may mean that you have to modify or change your work activities. However, be careful to keep your shoulder mobile so that it does not stiffen up. Painkillers, anti-inflammatories, physiotherapy and injections can help.

If these treatments do not work, some people with rotator cuff impingement syndrome need to have an operation to ‘widen’ the subacromial space. This is usually referred to as a ‘decompression’ operation.

What is the outlook (prognosis) for rotator cuff impingement syndrome?

If rotator cuff impingement syndrome is not recognised and treated promptly, it can lead to excessive wear and tear of the rotator cuff tendon. This in turn can lead to weakening of the tendon and the tendon can break, or rupture, causing a rotator cuff tear.

Some people do not have any symptoms from rotator cuff impingement syndrome and may not realise that they have it until they get a rotator cuff tear.

Rotator cuff tears

Who gets rotator cuff tears?

Rotator cuff tears are most common in people over the age of 40 years.

What causes a rotator cuff tear?

Rotator cuff tears are usually tears in the rotator cuff tendon rather than in the muscles themselves. In younger people, a rotator cuff tear normally happens as a result of trauma (injury) due to a fall or accident. In older people, they are often caused by rotator cuff impingement syndrome. In impingement syndrome, repeated damage to the ‘trapped’ tendon means that the tendon frays, weakens and is more likely to tear.

Rotator cuff tears can be minor/partial or full/complete depending on the degree of damage to the tendon.

What are the symptoms of a rotator cuff tear?

Pain is the most common symptom of a rotator cuff tear. The pain tends to be over the front and outer part of the shoulder. It is worse when your shoulder is moved in certain positions. For example, when your arm is moved above your head on dressing or combing your hair, or moved forwards to reach for something.

Your shoulder or arm can also feel weak and you may have reduced movement in your shoulder. Some people feel clicking or catching when they move their shoulder.

How is a rotator cuff tear diagnosed?

  • History and examination: again, our doctor will usually be able to diagnose a rotator cuff tear by talking to you and examining your shoulder.
  • The ‘drop arm test’: one of the tests that can help to diagnose a rotator cuff tear is called the ‘drop arm test’. If our doctor carries out this test they will ask you to stand with your arm by your side. They will lift your arm outwards from your side and up towards your head. They will then ask you to move your arm back down slowly towards your side. In a rotator cuff tear, you are usually able to lower your arm slowly to 90° but when you try to lower your arm below 90°, it drops quickly to your side because of the tear.
  • Other investigations: occasionally, our doctor may suggest an X-ray of your shoulder or they may refer you for more detailed investigations such as an ultrasound or MRI scan.
  • Referral to a specialist: if our doctor suspects a complete/full tear of your rotator cuff, they may suggest that they refer you to an orthopaedic surgeon (bone and joint specialist).

What are the treatment options for a rotator cuff tear?

  • Painkillers: painkillers such as paracetamol are usually helpful in rotator cuff tears. Occasionally, stronger painkillers may be needed.
  • Anti-inflammatories: our doctor may also suggest that you take regular anti-inflammatories. These are painkillers but they also reduce inflammation and are commonly prescribed. Side-effects sometimes occur with anti-inflammatories. Always read the leaflet that comes with the drug packet for a full list of cautions and possible side-effects.
  • Ice packs: these can also help to reduce pain. A bag of frozen peas is an easy ice pack to use in the home.
  • Physiotherapy: this may be helpful for people with minor rotator cuff tears. Our doctor may refer you to a physiotherapist for advice and shoulder exercises.
  • Injections: sometimes our doctor may suggest injections around your shoulder joint as a treatment for minor tears. The idea is that the injection may help to reduce any inflammation.
  • Surgery: this is sometimes needed in large/complete tears. Surgery usually involves decompression (widening) of the space underneath the acromion and may also include repair of the rotator cuff tendon. The surgery can be done using either a keyhole or an open method.

What is the prognosis (outlook) for rotator cuff tears?

About half of people with rotator cuff tears do well with just conservative treatment. That means the rotator cuff tears heal with treatment including rest, physiotherapy, painkillers, anti-inflammatories and injections. Surgery is needed in the other half in whom this conservative treatment does not work.

Stop your shoulder pain and get it checked. Call +65 6471 2744 (24 Hours) or Email to: info@boneclinic.com.sg

Rotator Cuff Injury

Rotator Cuff Injury

The rotator cuff is a group of four tendons that covers the humeral head and controls arm rotation and elevation. These muscles and their tendons work together with the deltoid muscle to provide motion and strength to the shoulder for all waist-level and shoulder-level or above activities.

Rotator cuff tendonitis is an inflammation of a group of muscles in the shoulder together with an inflammation of the lubrication mechanism called the BURSA. In fact, ‘bursitis’ should not be considered a diagnosis but rather a symptom of rotator cuff tendonitis.

This condition is often caused by or associated with repetitive overhead activities such as throwing, raking, washing cars or windows and many other types of highly repetitive motions. It may also occur as a result of an injury. Rotator cuff injuries are the most common cause of shoulder pain and limitation of activities in sports in all age groups. Rotator cuff tendonitis is the mildest form of rotator cuff injury.

The shoulder has a unique arrangement of muscle and bone. The rotator cuff (which is muscle) is sandwiched between two bones much like a sock lies between the heel and the edge of a shoe. In the same way that repeated walking eventually wears out the sock, the rotator cuff muscles fray with repeated rubbing on the bone. As the muscle begins to fray, it responds to the injury by becoming inflamed and painful. With continued fraying, like a rope, it may eventually tear.

What are the symptoms?

The classic symptoms include a ‘toothache’ like pain radiating from the outer arm to several inches below the top of the shoulder. Pain may also occur in the front and top of the shoulder. It may interfere with sleeping comfortably. It may even awaken people from a sound sleep with a nagging pain in the upper arm.

The symptoms are usually aggravated by raising the arms overhead or in activities that require reaching behind the body, such as retrieving an object from the back seat of a car. Furthermore, reaching behind the back to fasten underclothing or to pass a belt may aggravate the arm and shoulder pain.

A clicking in the shoulder may occur when raising the arm above the head.

What are my treatment options?

A thorough history and physical exam will nearly always lead to a correct diagnosis. X-rays will often show changes on the arm bone where the rotator cuff muscles attach, but an MRI provides the definitive diagnosis. This test clearly shows the muscles and indicates if the muscle is inflamed, injured or torn.

Medical

The following steps should be taken as a conservative approach to treating rotator cuff tendonitis:

  • Stop or markedly decrease the activity that required the use of the shoulder at or above shoulder level.
  • Apply ice to the affected area.
  • Take anti-inflammatory medication to reduce arm and shoulder pain.
  • Begin an exercise program to maintain flexibility.
  • Avoid carrying heavy objects with the affected arm or using shoulder-strap bags on the affected side.

In the early phases, over-the-counter anti-inflammatory medications may provide benefit. However, to allow the inflammation to resolve, it is vital to curtail any repetitive activity and it is equally important to try to keep the elbow below the shoulder level when using the arm.

Daily stretching while in a hot shower is also beneficial. If shoulder pain becomes more severe, prescription strength medication or a cortisone type injection may help.

Cortisone injections can be very effective in the treatment of the pain. When used, injections should be done in conjunction with a home exercise program for flexibility and strengthening, modification of activities and ice. Other pain controlling options include heat, ice, ultrasound and therapeutic message.

For a young patient under the age of 30 and with a first time episode of rotator cuff tendonitis that is treated immediately with the above protocol, the average length of time for rehabilitation is two to four weeks. For those with recurrent episodes of tendonitis and some risk factors, rotator cuff tendonitis may take months to heal and in rare cares may require surgery.

Surgical

If symptoms persist, surgery to remove a spur on the acromion can increase the space available for the inflamed tendon and may prevent further fraying or complete rupture. If an MRI shows a complete muscle injury, surgical repair may be required.

Surgery for recurrent rotator cuff tendonitis (bursitis) is occasionally performed to:

  • Remove a prominence or spur on the undersurface of the acromion.
  • Remove chronically inflamed, thickened and fibrotic bursal tissue.
  • Inspect the tendons and tidy up and sometimes repair a tear in the tendons.

These procedures are often done in combination. This can be done either through an open or an arthroscopic approach with the start of an early rehabilitation program one or two days after surgery and advancing to a more comprehensive program between two and five weeks after surgery. The initiation and progression of these exercises is dependent upon the patient’s findings at surgery, surgical procedure and rate of healing.

What do I need to do the day of surgery?

  • If you currently take any medications, take them the day of your surgery with just a sip of water.
  • Do not wear any jewelry, body piercing, makeup, nail polish, hairpins or contacts.
  • Leave valuables and money at home.
  • Wear loose-fitting, comfortable clothing.

How long is the recovery period after surgery?

The time for complete recovery is variable and can range from two to four weeks for a first-time mild episode treated properly to several weeks or months for chronic or recurrent cases or in people with more extensive surgery.

In most case, a sport specific program can begin four to six weeks after surgery, with a return to competition six to twelve weeks after surgery. This will need to be customized to your situation. Your doctor will tell you what is appropriate for your condition.

What is the rehab after surgery?

Although there is no one set protocol for rehabilitation for rotator cuff tendonitis several principles should be followed:

  1. Regain all passive range of motion first.
  2. Begin strengthening the rotator cuff with the arm by the side.
  3. Add deltoid and shoulder level strengthening when the shoulder is less painful.
  4. Be sure to strengthen the muscles that control the shoulder blade to regain normal smooth shoulder blade motion and strength when the arm is fully elevated overhead. The level of strengthening is dependent upon the individual needs of the person and the physical demands that he or she intends to place on the shoulder as well as the progress made in the initial program.

Before returning to sports, a sport-specific component to the rehabilitation program should be started that includes an initial return to a non-competitive level of sport participation. In the sport-specific rehabilitation, the athlete performs the activity for 25-50 percent effort (duration, frequency and intensity). If the athlete performs well at this level without pain over a few days then the activity can be increased over the next few days in intensity, frequency and duration.

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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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