By Dr Dan Laptoiu, MD, Bucharest, Romania
Overuse injuriees of the shoulder
Shoulder bursitis/tendinitis is a common overuse injury in sports where the arm is used in an overhead motion (e.g., swimming, baseball). Originally described (1872) as periarthritis scapulohumeralis its diagnosis and treatment were developed by Neer – 1972. The pain-usually felt at the tip of the shoulder and referred down the deltoid muscle into the upper arm-occurs when the arm is lifted overhead or twisted. He also described the diagnostic test “impingement test” by relievieng pain after injecting a local anesthetic in the subacromial space.
What is the mecanism?
The shoulder is a closely fitted joint. The humerus (upper arm bone), certain tendons of muscles that lift the arm, and associated bursa (fluid-filled sac that cushions to prevent friction) move back and forth through a very tight archway of bone and ligament called the coracoacromial arch. When the arm is raised, the archway becomes smaller, pinches the tendons, and makes the tissue prone to inflammation. The body may react by laying down scar tissue or calcific deposits.
Bursitis occurs when the bursa becomes inflamed and painful as surrounding muscles move over it.
Tendinitis occurs when the tendons or surrounding tissue becomes inflamed, swollen, and tender.
How does it feel?
The pain is on the lateral part of the shoulder, possibly referred below to the elbow.
The pain feels like sharp twinges “burning” felt on various movements, such as abduction, putting on jacket, or reaching above shoulder level
Onset of the pain - usually gradual with no known trauma. May be related to occupational or recreational overuse. May have been present for many months, or even years.
- Overuse is represented mainly by repetitive overhead motions.
- When the muscles are weak, more force is exerted on the tendons and bursa, causing inflammation and pain.
- Improper/inappropriate swimming or throwing techniques.
- Strenuous training. One hard throw may start the problem by promoting the initial strin/rupture of the tendons.
- Anatomy of the shoulder and more precisely of the acromion, which may be more “aggressive” creating a local impingement.
Treatment of overuse injuries
The degenerative lesions tend to be persistent, with little tendency toward spontaneous resolution. The combined effects of poor blood flow and continued stress to the tendon do not allow for adequate maturation of the healing tissue. It is not unusual for a patient to describe a history of several years of constant or intermittent problems with the shoulder. This should by no means suggest that such patients cannot be helped, since they do respond well, and often dramatically, to the program outlined below.
- Rest - Avoid doing things that hurt or make the pain worse the next day. Avoid the activity that started the problem. Your doctor may recommend a sling to immobilize the shoulder.
- Ice - Apply an ice bag over a towel (or a bag of frozen peas) to your shoulder at least twice a day for 30 to 60 minutes. Always apply ice for 15 minutes after any activity using your arm.
- Physical Therapy - Probably the key of the treatment. Your doctor may send you to a physical therapist for exercises or other therapy. Exercises to strengthen the shoulder may help to prevent a recurrence. Only after the failure of a well conducted treatment of 3 to 4 months, operative treatment can be indicated.
- Medication - Your doctor may prescribe anti-inflammatory/ analgesic medication to relieve pain and inflammation while your body's natural healing process goes on. An injection of cortisone into the shoulder may be recommended; it is usually a secondary treatment to supplement other therapy. After an injection, don't attempt vigorous activities with your arm for 2 weeks. It is better to be avoided in sportives because of the danger of weakening the tendon and increasing the risk of secondary ruptures.
Surgery may be required to treat shoulder bursitis/tendinitis if it becomes chronic.
Transverse friction massage is an essential component of the treatment program in chronic cases. The beneficial effects of friction massage in such cases are not well understood. However, it is proposed that an increase in the mobility of the developing, or developed, scar tissue takes place without stressing the tendon longitudinally.
Returning to sports
The younger person whose primary complaint is pain during recreational activities such as baseball or racquetball must be advised that temporary abstinence from certain activities is an essential remedial measure. Usually, resumption of activities will be accompanied by a recurrence of the previous symptoms because simply resting the shoulder does not insure the development of a mature, mobile scar tissue. This is also true for the older person, who may experience pain during normal daily activities. Although appropriate control of activities is usually necessary for resolution of the problem, it alone is usually not adequate. The use of friction massage and especially restrengthening exercises should not be excluded.
Throwing Sports - Throwing athletes represent a well documented and complex issue – and we are talking especially about baseball pitchers.
The shoulder pain in frequently related to impingement secondary to instability; some internal ligaments are more or less damaged.
Treatment should start as a prolonged rehabilitation effort and eventually arthroscopic evaluation. Initially, an underhand or sidearm throw will be easier than an overhand throw. Warm up well. Throw easily, and gradually increase to harder throwing. Try to maintain a smooth throwing motion that will make use of the overall strength of your body.
In severe cases all sports using the arm should be avoided. When you go back to your sport, go back slowly. Warm up well and do range-of-motion exercises. Avoid the football-throwing position and do not play for a long time. Slowly increase the intensity of your game. In some sports (e.g., tennis or squash) the overhead motions can be avoided. The therapist must, through a complete history, become aware of the patient's habitual daily activities. This is important because the patient often engages in activities that may contribute to the problem without actually realizing it. Such "fatigue" pathologies typically result from the cumulation of otherwise asymptomatic stresses. Activities that particularly need to be avoided are those involving repetitive elevation of the arm to shoulder level or above.
Other involved athletes are tennis, gmnasts, weight lifters and swimmers.
Back strokes and butterfly strokes put more strain on the shoulder. Do any hard swimming (sprints) early in your swimming workout after you are warmed up, but before you are fatigued. Try changing your swimming style by rolling your body to the side.
Range-of-motion exercises must be done twice daily to keep the joint loose. These exercises consist of moving the joint, carefully, as far as it can go in all directions. After pain has subsided, shoulder muscles must be strengthened to prevent bursitis/tendinitis from recurring.
Start with the "pendulum swing'." Support yourself with your good arm. Keeping your knees slightly bent, bend forward at the waist and let your bad arm hang down (or dangle off the bed). Then make circles with your arm three to five times in one direction, then the other. Start with small circles and gradually make them larger.
With palm out, place the hand of your injured arm behind your back and reach up as high as possible, as though you were going to scratch your back with your thumb.