How To Diagnose, Treat & Prevent Common Shoulder Injuries
The shoulder is complex. It involves multiple bones and joints that function together with an intricate network of muscles, to allow for the greatest mobility of any joint in the human body. While this provides us with impressive dexterity and power to perform complex tasks, the trade-off is an increased potential for instability and overuse injury.
Understanding The Anatomy Of The Shoulder
The 3 bones that make up the shoulder include the humerus (upper arm bone), scapula (shoulder blade) and clavicle (collar bone). They are connected to one another at the glenohumeral and acromioclavicular joints and connect to the rest of the torso at the sternoclavicular and thoracoscapular joints. Muscles have the complicated job of stabilising the humerus and scapula, while at the same time powering their coordinated movement. These muscles need to have adequate strength and control in order for the shoulder to function optimally and reduce the risk of injury.
Common Symptoms & Signs Associated With Shoulder Pain
Shoulder injury can present with a wide variety of symptoms depending on the type and severity of the injury. These are the most common indications of shoulder injury:
- Pain – might be localised (in a specific location) or more spread out in the shoulder region. Pain might also be present in the neck or shoulder blade area and can radiate/refer down into the upper arm, forearm and hand.
- Stiffness – resistance to movement (especially at end ranges) can develop when shoulder tissues are sensitive because of injury. Inflammation often contributes to the sensation of stiffness.
- Loss of range of motion – the motion of the shoulder can be structurally restricted because of severe injury or structural changes that develop over time (frozen shoulder, osteoarthritis etc).
- Swelling – can occur with traumatic injury (where an injury incident occurred), caused by inflammation of injured tissues. Overuse injuries don’t commonly cause visible swelling.
- Instability – an uneasy feeling in the shoulder, associated with a vulnerable state in certain positions, which puts the shoulder at greater risk of dislocation. This can be caused by a genetic ligament laxity or by acquiring laxity in the shoulder as a result of extreme use of the shoulder during overhead throwing or smashing activities. Major shoulder trauma can also result in shoulder instability by damaging the structures that provide the shoulder its stability.
How To Treat A Shoulder Injury
Because different shoulder injuries require different treatment plans, it is important to get an accurate diagnosis. This will determine the specifics of the rehab programme. However, generally speaking, once red flags (indicators of a serious condition like cancer or infection) have been ruled out, some general principles apply. The initial phase of rehabilitation usually involves reducing inflammation and restoring range of motion. Good rest and gentle activities of daily living that don’t flare up your symptoms are wise to start with. Anti-inflammatory medication and ice can be used if the pain is unmanageable and prevents you from getting good rest or doing the life tasks that are absolutely essential for you to do. The next phase involves gradually increasing the amount of load on your shoulder by doing more activities of daily living and adding specific rehab exercises that target your painful movements (as tolerated). If the goal is to return to sport then higher-level coordination, stability and power drills should be incorporated gradually and become increasingly specific to the demands of your sport.
Types Of Shoulder Injuries
Shoulder injuries can be classified into 3 main categories:
- Overuse
- Traumatic
- Other
1. Overuse Shoulder Injuries:
Overuse shoulder injury is often caused by a sudden increase in shoulder activity level over a period of time, beyond what the shoulder can tolerate. Examples include (but are not limited to):
- Rotator cuff tendinopathy
- Biceps tendinopathy
- Acquired sport-specific shoulder instability
2. Traumatic Shoulder Injuries:
Traumatic shoulder injury is caused by the shoulder being involved in an injury incident:
- – A fall onto an outstretched hand or the tip of the shoulder.
- – Direct contact in a car accident or opponent on the sports field etc.
Depending on severity, these injuries might require surgery. Examples include:
- Rotator cuff strain/tear
- Other shoulder related muscle strain/tear
- Shoulder dislocation or subluxation
- SLAP labral tear
- Fractures (scapula, humerus, clavicle)
3. Other Shoulder Injuries
Certain shoulder injuries do not have a well-established cause. Others are caused by genetic factors, and some originate from an injury or dysfunction in an area other than the shoulder (but cause pain in the shoulder). Examples include:
- Frozen shoulder
- Congenital shoulder instability
- Radiating/referred pain from the cervical spine (neck)
- Cancerous bone tumours (beyond the scope of this post)
- Visceral referred pain from E.g., diaphragm, gall bladder, heart, spleen, lungs (beyond the scope of this post)
8 Most Common Types of Shoulder Injuries
1. Rotator Cuff Tendinopathy/ Rotator Cuff Related Shoulder Pain/ Shoulder Impingement/ Subacromial Impingement Syndrome/ Swimmer’s Shoulder
(these are all the same injury that have been given different names)
The rotator cuff is a group of muscles and tendons that function to stabilise the shoulder during shoulder movement. They also generate force to create shoulder movement. The rotator cuff is therefore activated during most activities involving the shoulder. Excessive elevation (raising your arm in any direction) in combination with rotational movements are mostly the cause of rotator cuff tendinopathy. Heavy manual work, unaccustomed use of your shoulder during housework & gardening, or sports involving explosive overhead movements are often to blame.
Characterised by: Pain broadly over the upper arm and deltoid region, typically aggravated with reaching overhead or behind your back, or when lying on the painful shoulder. Weakness might also be experienced with shoulder elevation and rotation.
Treatment
Resistance exercises that improve the function of your rotator cuff muscles should be performed. This might take the form of exercises that are known to load the rotator cuff (including resisted rotation and elevation based movements) and exercises that resemble the tasks you struggle with. Gradual progression of these exercises, while making appropriate adjustments based on your pain response, can decrease pain and increase function over time.
2. Rotator Cuff Strain/Tear
Rotator cuff strain/tear can be caused by falling onto an outstretched hand, receiving an unexpected force when pushing or pulling, or as a result of a dislocation.
Characterised by: Pain broadly over the upper arm and deltoid region, typically aggravated with reaching overhead or behind your back, or with lying on the painful shoulder. Weakness might also be experienced with shoulder elevation and rotation.
Treatment
Depending on the severity of the tear, surgical repair might be required (especially in young athletes). Whether or not surgery is performed, in the early stages the aim is to decrease inflammation and restore range of motion. Resistance exercises that improve the function of your rotator cuff muscles should also be performed. This might take the form of exercises that are known to load the rotator cuff (including resisted rotation and elevation based movements) and exercises that resemble the tasks you struggle with. Gradual progression of these exercises, while making appropriate adjustments based on your pain response, can decrease pain and increase function.
3. Shoulder Dislocation or Subluxation
A shoulder dislocation occurs when the head of the humerus (upper arm bone) is forced out of the glenoid (shoulder socket) and remains that way for a period of time until it is put back in place with medical assistance or otherwise. A subluxation is an incomplete dislocation in that it slips back into place immediately after being forced out of position. Both are caused by the arm being forced into excessive abduction and external rotation (think an extreme above shoulder level throwing position) and results in damage to the surrounding shoulder structures. The vast majority of dislocations occur in the anterior (forward) direction.
Characterised by: The loss of normal shape of the deltoid muscle of the shoulder. The patient carries the arm slightly away from the body and rotated slightly outwards.
Treatment
The shoulder should be relocated as soon as possible by a physician. Surgery will be indicated in the case of severe structural damage or if a non-surgical approach has failed. The shoulder is placed in a sling for 3-4 weeks to allow symptoms to settle. Gentle shoulder mobilisations and resistance exercise of the rotator cuff muscles should be performed at this stage. From 6 weeks this can be progressed to more advanced mobility and strength exercises using resistance bands, dumbbells and other resistance equipment, as tolerated.
4. SLAP Lesion
A SLAP lesion is an injury to the upper portion of the glenoid labrum (a rim of cartilage that attaches around the edge of the shoulder socket), which serves as the attachment site for the tendon of the biceps muscle. A common cause of injury is a strong force from the biceps which pulls excessively on the labrum, such as when carrying or dropping and catching a heavy object. Other mechanisms of injury include a fall on an outstretched hand or excessive, repetitive throwing.
Characterised by: pain at the posterosuperior (upper and towards the back) portion of the joint, aggravated by overhead and behind the back arm movements. Popping, grinding or catching might also be present.
Treatment
The vast majority of SLAP lesions are treated without surgery. Exercise rehabilitation should focus on slowly progressing the load placed on the biceps muscle, as tolerated. This includes resisted elbow flexion, shoulder flexion and forearm supination movements. Heavy and explosive loads should be gradually applied to prepare for a return to sports involving overhead throwing.
5. Frozen shoulder/ Adhesive Capsulitis
Frozen shoulder is an inflammatory condition with an unknown cause, that results in the thickening and stiffening of the shoulder joint capsule. It occurs more commonly in women, people with diabetes and people between the ages of 40 and 60 years.
Characterised by: Severe pain in the deltoid muscle region initially and progressive loss of shoulder range of motion, especially into shoulder external rotation and elevation.
Treatment
Frozen shoulder is said to occur in 3 phases:
- Painful/freezing phase – more pain than stiffness
- Stiffening/frozen phase – more stiffness than pain
- Resolution/thawing phase – spontaneous progressive improvement in range of motion.
During the painful stage, corticosteroid injection is recommended as soon as possible. This might decrease pain, capsule thickening and stiffening. This becomes less effective as time passes. Painful activities should be mostly avoided. Antiinflammatories, hot packs, dry needling, electric stimulation, gentle physio mobilisation etc, can be used for short term relief from severe pain.
During the stiffening phase, pain-free shoulder mobility and resistance exercises along with physiotherapy hands-on mobilisations might improve shoulder range of motion or limit the progression of stiffening.
During the resolution phase, mobility and strength exercises can be intensified with the aim to restore pre-injury levels of shoulder function.
Frozen shoulder is a notoriously difficult condition to treat and much is still to be learnt about how best to manage it.
6. Acromioclavicular Joint Injuries
The acromioclavicular joint is formed by the connection between the acromion process of the scapula (shoulder blade) and the clavicle (collar bone). This joint is particularly vulnerable to injury in athletes participating in contact/collision sports. The common mechanism of injury is a direct impact to the tip of the shoulder, often from a fall or collision with an opponent. Injury can vary from a minor sprain of the joint ligaments, to a full tear and complete separation of the joint.
Characterised by: Pain on movement, especially horizontal adduction (pulling your arm across the body). In more severe cases a deformity at the joint might be visible.
Treatment
Surgery might be required for more severe injury. Non-surgical management is based on general treatment principles for ligament injuries. Ice and antiinflammatories to reduce inflammation followed by the use of a sling if necessary. This is followed by gentle range of motion and early strengthening. Strength is focused on the rotator cuff and scapula muscles, which all function to stabilise the acromioclavicular joint.
7. Shoulder Instability
Shoulder instability can be caused by a genetic ligament laxity or by acquiring laxity in the shoulder as a result of extreme use of the shoulder during overhead throwing or smashing activities. People with shoulder instability often experience pain and uneasiness in certain positions and are more prone to shoulder dislocation or subluxation events.
Characterised by: Pain and apprehension, along with loss of shoulder comfort and function, especially when the arm is overhead, out to the side and away from the body (the classic position in which most dislocations occur).
Treatment
Exercise based rehabilitation should be targeted at improving the strength of the stabiliser muscles of the shoulder. These include the scapula stabilisers which control the positioning of the scapula (shoulder blade) and the rotator cuff muscles which control the position of the humeral head (head of the upper arm) in the glenoid (shoulder socket). These muscles need to perform their individual functions well, in order for the shoulder as a whole to be stable. Initially, these exercises are performed with the hand supported on a surface to provide extra stability. These are progressed by removing the hand support to where the hand is free to move in space. Stretching is mostly avoided or performed only gently.
8. Shoulder Pain Radiating/referred From The Cervical Spine
It is possible for pain to be felt in the shoulder, but the origin of the pain be from the cervical spine (neck). This might be brought on by a cervical spine injury that results in nerve compression or other pathology, causing radiating/referred pain to the shoulder.
Characterised by: Pain radiating/referring from the neck into the shoulder, or pain in the shoulder alone, that is brought on by neck movements. Pain can also be present in the scapula region, arm or hand.
Treatment
If nerve compression is involved, we need to ensure that the arm, hand and finger sensation, reflexes and muscle strength is not progressively getting worse. If this is the case then surgery might be indicated to relieve that compression. If not, then an exercise based approach should be attempted to cautiously strengthen and mobilise the neck and nerves, while the cause of the nerve compression subsides or the body adapts to the compression.
Best Recommendations To Prevent Shoulder Injury
Education – get a better understanding of the mechanics of activities you take part in. This way you can identify the movements, positions and situations that potentially cause shoulder injury. Predicting these before they happen can help you effectively avoid injury.
Load management – Avoid big increases in frequency, intensity or duration of activities that load your shoulder. Progress slowly, especially after an extended break from activity.
Rest and recovery – Rest days are important, especially after a day of high-intensity activity. Improving sleep, nutrition and hydration while reducing stress, can have a profound effect on reducing your injury risk.
Exercises To Rehabilitate Your Shoulder
We recommend the following exercises to help rehabilitate your shoulder:
1. Resisted shoulder external rotation
This exercise strengthens the shoulder external rotators which are the rotator cuff muscles most often associated with rotator cuff injuries. The exercise can be performed in different starting positions (elbow next to your body or at shoulder level) based on your activity requirements.
2. ‘Y’ press
This exercise strengthens the muscles that move the scapula into position for efficient overhead movement. This important function allows the rotator cuff to perform its essential function.
3. Shoulder lateral raise
The combination of simplicity and effectiveness makes this a useful rehab exercise for many patients. It produces high levels of scapula and rotator cuff muscle activity and provides the much needed exposure to a movement that is so often painful and weak in the injured shoulder.
4. Push-up
The “classic” push up makes the list because, although traditionally used to build the pec and tricep muscles, it also produces high levels of activity in the posterior rotator cuff muscle.
5. Arnold press
Reaching overhead is often problematic for people with shoulder pain. Building up this capacity gradually is an important part of returning to normal shoulder function. This exercise provides this overhead stimulus in different planes of motion and at the same time is often more comfortable on the painful shoulder than the traditional overhead press.
Download our handy printable version of shoulder rehab exercises here.
Need To Rehabilitate Your Shoulder Injury?
Treating a shoulder injury can be tricky. If you are unsure of where to start or fear you might do more harm than good, get in touch with one of our friendly Biokineticists. We’ll asses your injury and put together a custom exercise-based plan to help you rehabilitate your shoulder. Book your assessment now at our Claremont or Green Point facilities.
Disclaimer: This content is not medical advice and is intended for general education purposes only. It should not be used to self-diagnose or self-treat any medical condition. Do not use this information to avoid going to your own healthcare professional or to replace the advice they give you. Dhansay and Roberts Biokineticists makes no representations about the accuracy or suitability of this content.