Shoulder Injury and Shoulder Pain Relief Guide

Impingement Syndrome

What is Shoulder Impingement?

Impingement refers to mechanical compression and/or wear of the rotator cuff tendons. The rotator cuff is actually a series of four muscles and tendons connecting the scapula (shoulder blade) to the humeral head (upper part of the arm bone). These muscles are located deep in the shoulder, beneath the deltoid muscle that gives your shoulder its contour. The rotator cuff is important in maintaining the humeral head within the socket during normal shoulder function and also contributes to shoulder strength during activity. Normally, the rotator cuff glides smoothly between the undersurface of the acromion (shoulder cap) and the humeral head.

How Does Shoulder Impingement Occur?

Any process, which compromises the normal gliding function of the rotator cuff, may lead to mechanical impingement. Common causes include weakening and degeneration within the tendon due to aging, the formation of bone spurs and/or inflammatory tissue within the space above the rotator cuff (subacromial space), and overuse injuries. Activities that can lead to impingement most commonly involve repetitive overhead motion. This is typically seen in such things as painting, carpentry, tennis, baseball, swimming, etc.

How is Shoulder Impingement Diagnosed?

The diagnosis of shoulder impingement can usually be made with a careful history and physical exam. Patients with impingement most commonly complain of pain, pinching, and stiffness in the shoulder, which is worse with overhead activity and sometimes severe enough to cause awakening at night. Manipulation of the shoulder in a specific way by your doctor will usually reproduce the symptoms and confirm the diagnosis. X-rays are also helpful in evaluating the presence of bone spurs and/or the narrowing of the subacromial space. MRI (magnetic resonance imaging), a test that allows visualization of the rotator cuff, may be used to rule out more serious diagnoses such as rotator cuff tears.

How is Shoulder Impingement Treated?

The first step in treating shoulder impingement is eliminating any identifiable cause or contributing factor. This may mean temporarily avoiding overhead activities like tennis, pitching or swimming. A non-steroidal anti-inflammatory medication, such as Advil or Motrin, is helpful in alleviating pain and swelling. The mainstay of treatment involves exercises to restore normal flexibility and strength to the shoulder girdle, including strengthening both the rotator cuff muscles and the muscles responsible for movement of the shoulder blade. This program of instruction and exercise demonstration may be initiated and carried out either by the doctor or a skilled physical therapist. An injection of cortisone into the subacromial space is often helpful in treating this condition.

Is Surgery Necessary?

Surgery is not necessary in most cases of shoulder impingement. If symptoms persist despite adequate non-operative treatment, surgical intervention may be beneficial. Surgery involves debriding, or surgically removing tissue that is irritating the rotator cuff. This is done on an outpatient basis with arthroscopic techniques that are minimally invasive.

After surgery patients use a sling for comfort, but may begin using the arm for everyday activities as soon as pain allows. Complete recovery may take 3 months. Outcome is favorable in about 90% of cases.

Rotator Cuff Tear

What is the Rotator Cuff?

The rotator cuff is a group of four muscles that assist in the stability and motion of the shoulder. These muscles attach from the back and underside of the shoulder blade (scapula) and combine to form a tendon that attaches to the "ball'"part of the shoulder. The muscles of the rotator cuff are the supraspinatus, infraspinatus, teres minor and the subscapularis.

Rotator Cuff Tears:

Rotator Cuff Tears can occur over a long period of time as the tendon becomes inflamed from overuse, aging, and repeated minor injuries. Activities requiring repeated overhead arm motion and/or heavy lifting may place excessive strain on the rotator cuff tendon. Tears may also occur suddenly as the result of a trauma such as falling on an outstretched hand or grabbing a heavy weight overhead.

Symptoms of a Rotator Cuff Tear:

Rotator Cuff tears may cause some or all of the following symptoms:

• Pain­ usually over the side and top of the shoulder. Pain is usually worse with overhead and "out-to-the-side" movements.
• Stiffness­ usually occurs as the pain increases.
• Weakness­ with movements overhead and `away-from-the-body'.
• Popping may be present with shoulder motion.
• Loss of Sleep due to pain from lying on the shoulder compressing the tendons.

Diagnosing a Rotator Cuff Tear:

A physical examination will usually give clues that there is a rotator cuff problem. Unfortunately, a rotator cuff that is severely irritated (but not torn) may have similar symptoms and physical examination findings as a rotator cuff that is torn. X-Rays will show evidence of arthritis and bone spurs, but will only show signs of a rotator cuff tear if it is a very large and has been present for a long time. Therefore an MRI may be ordered to better determine the extent of injury or damage.

Treatment for a Rotator Cuff Tear:

Rotator cuff tears do not usually `heal' on their own. However, many people do not have severe enough pain, weakness or limited function to warrant surgery. Conservative treatment is often very helpful in this group of patients.

Conservative treatment includes:

• Rest ­ from activities overhead and `away-from-the-body'.
• Ice ­ to help decrease inflammation and pain (especially after activities).
• Anti-inflammatory medications (i.e. Bextra, Celebrex, Ibuprofen, etc.) ­ to decrease inflammation and pain.
• Cortisone injections ­ may be used to help decrease pain and inflammation.
• Physical Therapy ­ to help restore normal motion, strength and function.

Surgical Options
Surgery is indicated for those patients with severe pain, weakness and loss of function who do not respond well to non-operative, conservative treatment. There are several surgical options to treat rotator cuff tears, depending on the size, depth, and location of the tear.

Arthroscopy is a `minimally invasive' surgical procedure in which miniature instruments are inserted through small incisions into the shoulder. Bone spurs scar tissue and most rotator cuff tears can be repaired using arthroscopic techniques.

Open-repair ­ is used for the most severe cases of rotator cuff tears. Usually an arthroscopy is performed to asses the size and severity of the tear. Bone spurs and scar tissue are removed, and then a small incision is made to allow for a proper repair to the torn rotator cuff.

These surgeries are all performed on an out-patient basis. Meaning you will go home the very same day. You will be given a prescription for pain medication to help control pain, and usually you will have a medication injected into you arm during surgery which will keep your arm numb and pain-free for up to several hours after surgery.

Regardless of the technique used to repair the tear, the recovery usually involves wearing a sling for 2-4 weeks after the surgery to protect the repair. Gentle motion is then allowed for the next few weeks, followed by a physical therapy program designed specifically to restore motion, then strength, and eventually function to the shoulder. The entire recovery may take as long as 6-8 months for full unrestricted activities.

Complications from arthroscopic and open rotator cuff surgery are rare, and may include bleeding, infection, blood clots, nerve or blood vessel injury, persistent pain and the need for further surgery. The most common complaint following successful rotator cuff surgery is mild pain and weakness with certain motions or arm positions.

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AC Joint Injuries

What is the AC Joint?

The AC (acromioclavicular) joint is a joint in the shoulder where the collarbone (clavicle) meets the shoulder blade (scapula). The specific part of the shoulder blade that meets the collar bone is called the acromion, therefore the name "AC joint". This is in contrast to the glenohumeral joint, which is considered the main "ball and socket" shoulder joint.

What Kinds of Problems Occur at the AC Joint?

The most common problems that occur at the AC joint are arthritis, fractures and "separations". Arthritis is a condition characterized by loss of cartilage in the joint. Like arthritis at other joints in the body, it is characterized by pain and swelling, especially with activity. Over time, the joint can wear out, leading to swelling and formation of spurs around the joint. These spurs are a symptom of the arthritis and not the primary cause of the pain. Motions that aggravate arthritis at the AC joint include reaching across the body toward the other arm. AC joint arthritis is common in weight lifters, especially with the bench press, and to a lesser extent military press. AC joint arthritis may also be present when there are rotator cuff problems.

How Do You Treat Arthritis of the AC Joint?

There is currently no way to replace the cartilage that is damaged by arthritis. As a result, the primary way to control the symptoms of arthritis is to modify your activities so as not to aggravate the condition. Application of ice to the joint helps decrease pain and inflammation. Medication including aspirin, Tylenol ®, and non-steroidal drugs anti-inflammatory drugs (NSAID's) may also be effective.

What Can Be Done if Those Treatments Do Not Work?

If rest, ice, medication, and modifying your activity do not work, then the next step is a cortisone shot. An injection of medication into the joint sometimes takes care of the pain and swelling permanently, although the effect is unpredictable and may only be for a short time.

If symptoms do not respond to conservative treatment, surgery may be an option. Since the pain is due to the ends of the bones making contact with each other, the treatment is removal of a portion of the end of the clavicle. This outpatient surgery can be performed through a small incision about one inch long or arthroscopically using several small incisions. Regardless of the technique utilized, the recovery and results are about the same. Most patients have full motion by six weeks and return to sports by 12 weeks.

What is an AC Separation?

When the AC joint is "separated" it means that the ligaments connecting the acromion and clavicle have been damaged, and the two structures no longer line up correctly. AC separations can be anywhere from mild to severe, and AC separations are "graded" depending upon which ligaments are torn and how badly they are torn.

What is the Treatment for AC Separations?

These can be very painful injuries, so the initial treatment is to decrease pain. This is best accomplished by immobilizing the arm in a sling, and placing an ice pack to the shoulder for 20-30 minutes every two hours as needed. NSAID's can also help the pain. As the pain starts to subside, it is important to begin moving the fingers, wrist, and elbow, and eventually the shoulder in order to prevent a stiff or "frozen" shoulder. Instruction on when and how much to move the shoulder should be provided by your physician, physical therapist, or trainer. The length of time needed to regain full motion and function depends on the severity or grade of the injury. Recovery from a Grade I AC separation usually takes ten to 14 days, whereas a Grade III may take six to eight weeks.

When is Surgery Indicated?

Grade I and II separations very rarely require surgery. Even Grade III injuries usually allow return to full activity with few restrictions. In some cases a painful lump may persist, necessitating partial clavicle excision in selected individuals such as high caliber throwing athletes. Surgery can be very successful in these cases, but as always, the benefits must be weighed against the potential risks.
Grade I Injury: the least damage is done, and the AC joint still lines up



Grade II Injury: damage to the ligaments, which reinforce the AC joint. In a grade II injury these ligaments are only stretched but not entirely forn. When stressed, the AC joint becomes painful and unstable.



< Grade III Injury: AC and secondary ligaments are completely torn and the collarbone is no longer tethered to the shoulder blade, resulting in a visible deformity.

Shoulder Arthroscopy

What is shoulder arthroscopy?

Shoulder arthroscopy is a surgical procedure used to visualize, diagnose, and treat various problems inside the shoulder joint and in the space surrounding the rotator cuff. This is done through small incisions that allow the insertion of specialized instruments. The arthroscope is a pencil-sized tool that contains magnifying lenses and a light source. This is attached to a small camera that projects a clear image of the joint on a TV monitor, allowing your surgeon to see all the structures inside your shoulder.

Understanding your shoulder.

Your shoulder is a very mobile joint. Because it is so mobile, it is prone to specific types of injuries. These injuries can develop slowly over time ­ usually from repeated overhead movements ­ or from a sudden injury.

The shoulder joint has three bones: the clavicle (collarbone), the scapula (shoulder blade), and the humerus (upper arm bone). The acromioclavicular (AC) joint is located between the acromion (part of the scapula that forms the `shoulder cap') and the clavicle. The glenohumeral joint, commonly called the shoulder joint, is a ball-and- socket type joint that allows a wide range of motion. The labrum is a rim of cartilage that helps deepen the shallow socket and helps with shoulder stability. The capsule is a soft but strong tissue envelope that surrounds the glenohumeral joint and helps stabilize the joint.

The rotator cuff is a group of muscles and tendons that provide strength and stability to the ball and socket.

Why do I need arthroscopic surgery?

Arthroscopic shoulder surgery is used to treat a variety of common shoulder problems, including bursitis, tendinitis, arthritis, impingement, rotator cuff tears, labral tears and shoulder instability. Usually patients who have shoulder arthroscopy have not responded well to other treatment options including rest, physical therapy, anti-inflammatory medications, and steroid injections.

How is arthroscopy performed?

Arthroscopy is typically performed in an outpatient surgery setting. The type of anesthesia used is up to the patient, surgeon, and anesthesiologist. Two or three small incisions, each the size of a dime, are needed to insert the scope and any necessary instruments. The joint is filled with sterile fluid to allow the surgeon to see more clearly. Most procedures take less than one hour to perform. Following surgery you may be in a sling or a special `shoulder immobilizer' depending on the type of surgery performed. You will be given specific instructions about whether or not you are allowed to move your arm immediately after the surgery.

Rest, icing, and anti-inflammatory medications will help decrease pain and swelling. The surgical area should be kept dry when showering for the first 3-5 days. After this, simply change the band-aids after bathing. Patients usually begin light exercise in 1 week.

Return to full activities may take several weeks to several months depending on the type of surgery performed.

What are the benefits of arthroscopic surgery?

Benefits of arthroscopic surgery compared with older open surgical techniques include:
1. Minimal scars.
2. No overnight hospital stay.
3. Decreased pain and swelling.
4. Improved motion.
5. Quicker functional recovery.
6. Fewer risks and complications.

Risks and complications.
Complications from arthroscopic surgery are rare, and may include bleeding, infection, blood clots, nerve or blood vessel injury, persistent pain and the need for further surgery. The most common reason patients experience continuing pain after arthroscopic surgery is from underlying damage to the articular or lining cartilage of the joint (early arthritis).

Shoulder Exercises

The following contains a variety of simple exercises that will aid in strengthening the muscles surrounding your shoulder. These exercises, when done consistently and properly, will help you rehabilitate your shoulder and speed your recovery. By diligently following this conservative home program, you and your physician can more effectively communicate about your injury and further your road to recovery.

Remember to perform exercises slowly and carefully; perform exercises only as directed by your Healthcare Professional; and consult your Health Care Professional if you experience any unusual pain or an increase in discomfort as a result of performing these exercises.

MOTION EXERCISES

1. Shoulder Pendulum ­ See/Saw
Assume the position shown (1), using either a chair or table to provide support. Allow your affected arm to hang, relaxed. Sway your body slowly to move the arm forward and backward (2) (See/ Saw). Repeat this motion side to side and eventually to a circular motion (Pendulum). Perform this circular exercise in both clockwise and counter-clockwise direction. Allow 1-2 minutes for this exercise.
Do this exercise 3 times per day


2. Abduction - Assisted
Stand with elbows bent to 90 degrees, holding the exercise rod in front of you (1). Using rod for assistance, gently raise your affected arm out to the side by pushing the rod with your good arm (2). Hold for 5-10 seconds.
Perform 10 repetitions of this exercise 3 times per day.


3. Abduction - Assisted For advanced stager of rehabs
Stand holding the exercise rod as shown (1), with hand of the affected arm grasping the end cap. Using the rod for assistance, push with your good arm up and overhead to stretch your affected arm out to the side and overhead (2), keeping your affected arm as straight as possible during this motion. Hold in the upright position for 5-10 seconds. Slowly lower your affected arm. Repeat.
Perform 10 repetitions of this exercise 3 times per day.


4. Flexion - Assisted
Stand as shown (1), with affected hand at the top of the exercise rod. Using the rod for assistance, stretch our arm higher overhead, directly out in front of you. (2). Maintain your affected arm as straight as possible during this motion. Hold extended for 5-10 seconds. Lower slowly. Repeat.
Perform 10 repetitions of this exercise 3 times per day.


5. Flexion - Supine
Lie on your back as shown (1), holding exercise rod with both hands directly out in front of your. Raise both hands in unison overhead until they are as fully extended as is comfortable (2). For those with a weak back, raise your knees to provide support to your lower back during the exercise motion. Hold the end position for a few seconds and slowly return to the starting position. Repeat.
Do 15 repetitions of this exercise 3 times per day.


6. Wall Crawls - Spider
Stand facing near a wall as shown (1) slowly "walk" your fingers up the wall, moving up and down as well as side to side. Support your hand with the wrist as you extend farther up the wall. Perform this exercise for approximately 1 minute, covering as much of the wall surface as possible from a single standing position as is comfortable.
Do this exercise 3 times per day.


7. Extended Wall Crawl
Stand near a wall as shown, with your affected side towards the wall (1). Slowly "walk" your fingers up and down, then from side with your arm outstretched. Perform this exercise for approximately 1 minute, covering as much wall surface as possible from a single standing position.
Do this exercise 3 times per day.


8. Horizontal - Rows
Anchor tubing to door jam or doorknob. Hold tubing by handle with your arm extended (1). With tension on the tubing, pull back on the handle until your elbow is along your side, as shown (2). Hold position for 3-5 seconds, slowly exited your arm to the original starting position.
This exercise may be performed with your palm facing downward on the handle or palm facing upward on the handle.


9. Flexion/Adduction
Anchor tubing to door jam or doorknob. Hold tubing by handle with your thumb facing upward (1). Raise your arm up and across your body as shown, arm straight and extended (2). Hold for 3-5 seconds, slowly lower your arm to the original starting position. Repeat.
Perform 10-15 repetitions of this exercise 3 times per day.


10. External Rotation
Anchor tubing to door jam or doorknob. Grasp handle with your thumb, stand with your unaffected side towards the door (1). Rotated arm outward unless is uncomfortable keeping elbow bent and as close to your side as is comfortable (2). Hold end position for 3-5 seconds and slowly relax. Repeat.
Perform 10-15 repetitions of this exercise 3 times per day.


11.Internal Rotation
Anchor tubing to door jam or doorknob. Stand with affected side towards the door, grasping the handle with your thumb up (1). Rotate the arm inward, keeping the elbow bent and as close to your side as is comfortable (2). Hold end position for 3-5 seconds and slowly relax. Repeat.
Perform 10-15 repetitions of this exercise 3 times per day.


12. Extension
Anchor tubing to door jam at shoulder height, stand holding stretch band extended out in front of you, arm straight at shoulder length (A). Pull arm down and backward as shown until your hand is at your side (B). Hold end position for 3-5 seconds and slowly relax, return to start position. Repeat.
Perform 10-15 repetitions of this exercise 3 times per day.


13. Diagonal Pull - For advanced stages of rehab
Anchor tubing to top of door jam; grasp tubing with thumb facing upward, arm straight, up and away from the body as shown (A). Start with affected side facing towards the door. Pull arm inward and downward, letting your head follow the movement. Allow your elbow to bend slightly but stay consistent as you move through the downward motion. Notice that the hand rotates as it crosses the body, ending with the thumb facing towards your at the endpoint (B). Hold the endpoint for 3-5 seconds, slowly relax and return to the start position. Repeat.
Perform 10-15 repetitions of this exercise 3 times per day.


14. Diagonal Pull - part 2
Anchor tubing to 6top of door jam; grasp tubing with thumb facing upward, arm straight, up and towards the body as shown (A). Start with unaffected side facing towards the door. Pull affected arm outward and downward, letting your head follow the movement. Allow your elbow to bend slightly but remain consistent as you move through the downward motion (B). Hold the endpoint for 3-5 seconds, slowly relax and return to the start position. Repeat.
Perform 10-15 repetitions of this exercise 3 times per day.


15. Abduction
Anchor tubing under your foot (A). While standing against a wall with your arm relaxd agaist your thigh, Extend the arm up and outward in front of you approximately 45 degrees from the wall until shoulder heighth is reached. Try not to compensate with back or thigh mucles. Hold the end position for 3-5 seconds and slowly return to the rest posotion. Repeat.
Perform 10 repetitions of this exercise 3 times per day.


16. Shoulder Flexion
Anchor tubing under your foot (A). Stand holding tubing along your side. Raise arm up until it is directly out in front of you at shoulder heighth (B). Hold the end position for 3-5 seconds then slowly return to the starting position. Repeat.
Perform this excersise 3 times per day.