Physical Therapy Series: Shoulder Pain
Shoulder pain is a common reason for visits to the orthopedic office. In active, middle aged patients it is almost expected to occur at some point. In this blog, we will discuss the various causes of shoulder pain, the importance of physical therapy, the design of the shoulder that makes it prone to injury, several shoulder exercises programs and finally my own history of shoulder pain.
The majority of patients experiencing shoulder pain typically have either shoulder impingement or rotator cuff syndrome. Basically, when you lift your arm the rotator cuff, the long head biceps tendon, and the bursal sac pinch between the humeral head and the acromion bone. Overtime, this can result in chronic inflammation of the bursal sac and the rotator cuff tendon. By middle age, many patients have partial rotator cuff tears and even full thickness rotator cuff tears. Many surgeons will proceed with surgery for full thickness rotator cuff tears but the majority of cases of bursitis, tendinitis, and partial tears will be treated with physical therapy. Often, medication or injections will be offered prior to starting therapy in order to manage the inflammation that may limit progress. The therapy during the “injured phase” will be directed at modalities to decrease pain and inflammation, and exercises to regain strength and mobility in the shoulder. Shoulder pain is so common I would recommend starting a simple rotator cuff program to increase stability in your shoulders long before you suffer any pain. This is the “prehab” form of treatment. A few exercises 2-3 days a week will make the shoulder resistant to injury. These same types of exercises are beneficial in the “recovery” phase. Whether your shoulder quickly recovered from medications or an injection or you required a surgical rotator cuff repair you should still consider the joint a problem area. This means it is best to continue a few exercises 2-3 days a week to keep your shoulders healthy.
Last week in “Physical Therapy Series: Low Back Pain”, I mentioned the term VOMIT- which means “victim of medical imaging technology”. This concept also applies to shoulders. In many cases, your MRI does not correlate to your pain. The abnormal findings may have been present for years when you were asymptomatic and are only aggravated now that you are in pain. I will often tell middle age patients that it is expected for the MRI reports to list several abnormalities. If you look down at the report’s impression you will likely see some combination of the following:
Mild to moderate acromioclavicular arthritis
Possible degenerative SLAP tear extending into the labrum
Inflammation and fluid in the bursal sac
Tendinosis of the infraspinatus and the supraspinatus tendon with partial thickness tear at the anterior aspect of the supraspinatus
Seeing the words “tear” and “degenerative” often concerns a lot of patients, but the reality is these findings are fairly normal and can be treated with physical therapy. Surgery is still an option, but is reserved for when physical therapy and other modalities fail.
The most common shoulder diagnosis, shoulder impingement is characterized by painful range of motion or even limited range of motion in the shoulder. Patients with shoulder impingement may have difficulty moving their shoulder on their own, but the physician can move the joint fully. In other patients, the physician can not move their shoulder due to more advanced stiffness. An x-ray will often confirm shoulder diagnosis. If the x-ray shows moderate to severe arthritic changes the diagnosis is likely arthritis. However, if the x-ray is normal the diagnosis is likely frozen shoulder which is also called adhesive capsulitis and involves tightening of the joint capsule. Again, physical therapy can be very beneficial to treating these issues. The early stages of arthritis can be significantly improved with a consistent therapy routine to maintain mobility and strength. The vast majority of frozen shoulder cases will resolve with physical therapy focused on stretching. Another common injury is labral or SLAP tears. These are tears of the thick cartilage around the glenoid (shoulder sockets) and where the bicep tendon attaches to the socket respectively. Throwing athletes like pitchers and quarterbacks will often proceed to surgery, but for the majority of the population surgery is only required if physical therapy fails.
Another group of patients are those that suffer from major shoulder trauma such as fractures, dislocations, and major acute rotator cuff tears. These patients often present to the emergency room and subsequently to the orthopedic office. A patient with a degenerative full thickness rotator cuff tear will usually be able to lift their arm with pain but an acute massive tear will not and will require surgery. A dislocation or fracture may require immobilization or surgery. They will all require therapy after the initial treatment and home exercises will be recommended in the “recovered” phase.
My message is aimed at middle aged and older patients but I do want to mention teenagers and young adults. The majority of shoulder pain in this group is due to instability. Naturally kids have loose joints that tend to tighten as they age. This increased joint motion can lead to inflammation and pain. We often see problems in throwers, overhead servers and swimmers. All these athletes would benefit from a shoulder program
Our shoulders' unique design combined with our modern lifestyle often results in shoulder pain.
A great video on the shoulder from an evolutionary biology standpoint. In the video the author admits the shoulder is not a bad design at all but problems come from our misuse of the joint. The shoulder is the least stable joint in the body. Rather than being restrained by bone the shoulder socket is shallow and needs the support of ligaments and tendons. The benefits of this decrease in stability is an increase in range of motion. We have evolved or adapted to throw which allowed our ancient ancestors to hunt with rocks and spears. Our shoulders are failing us now because we spend too much time sitting with poor posture(sitting is the new smoking) and slouching forward which puts a strain on the rotator cuff. While weight training is important, our gym/fitness culture is not beneficial. We tend to concentrate our exercises on the larger and more aesthetically pleasing muscle groups such as the biceps, pecs, and deltoids at the expense of the smaller shoulder stabilizers.
Another video on how our shoulders evolved to allow us to throw. It is a fascinating theory, but I will fully admit I was not there to witness the evolution. Our closest relatives, the chimpanzee can only throw 20 mph. The average little league pitcher is able to throw 60 mph and elite pitchers can throw 90-100 mph. Evidence shows humans started throwing to hunt about 2 million years ago. Hunting leads to getting more food and more calories, which leads to bigger bodies, bigger babies, and bigger brains. This would explain why humans evolved so quickly beyond our other primate cousins. As I stated in other blogs, reasonable people can disagree. My father was a hand surgeon who taught that the opposable thumb was what set humans apart. I will stay neutral and allow the hand surgeons and the shoulder surgeons to battle it out. We should keep in mind we throw more repetitively than our ancestors ever did. That is why we see injuries at such a high rate in throwing or overhand serving athletes.
This is a quick video on how our posture strains the rotator cuff and results in pain. I will also mention that some of our lifestyle choices such as poor nutrition, fitness, sleep, and stress control lead to higher levels of chronic inflammation. This chronic inflammation will settle in the shoulder and make previously asymptomatic wear and tear symptomatic.
The following are useful videos you can do at home in the “prehab” and “recovered’ phases of treatment. You can try them in the “injured” phase if tolerable but you should seek medical assistance if you are not improving. Remember a stiff and weak joint is a painful joint. If your job or fitness routine requires heavy lifting or repetitive overhead motion you will certainly need a shoulder program. I often say Tom Brady’s shoulder would fall off if he just showed up and threw. If your job requires prolonged sitting or your activities increase shoulder stiffness you need a shoulder program as well. There are many extensive videos on YouTube, but I prefer to keep it simple in the “prehab” and “recovery” phase. Any variant of a shoulder stretch into full flexion, full abduction, full internal and external rotation is adequate. Many patients simply need to do a few cycles of freestyle and backstroke per each arm. This is followed by three strengthening exercises:
Shoulder flexion
Shoulder abduction
Shoulder external rotation
These exercises are done with a light dumbbell 2-15 lbs or a band. I recommend 20 repetitions for each arm and repeat all three exercises twice. The weight should be heavy enough to feel tension but light enough to have perfect form.
For a more extensive program consider the following. It provides band and weight exercises and many variants of the above three exercises.
Hanging is a unique exercise form that is beneficial to help prevent and treat many shoulder issues. It was introduced by Dr. John Kirsch, an orthopedic surgeon who suffered shoulder pain himself. The concept is pretty straight forward, you hang from a pullup bar, jungle gym, swing set, or branch. This uses your body weight to stretch out your shoulder and theoretically increase the subacromial space (the space your rotator cuff tendon goes through). It also strengthens the shoulder stabilizers such as the rotator cuff and the scapular muscles. It's a great exercise for the “prehab” and the “recovered” phase of treatment. It can be used in the “injured phase” if the injury is minor. It is not a panacea for all shoulder injuries according to Dr. Krisch. An added benefit is it increases grip strength as well which is correlated with long term health.
My Shoulder Pain Story
Now for anyone interested, you can keep reading for my own shoulder pain story. For years my community had a softball game between married men and single men every Sunday in the summer. I started playing in the game when I was 16 years old. I was young and dumb and just showed up often after a late night and played without warming up. At 25 years old, I was in the outfield for the married team. In the first inning with a runner on second a one hopper came to me and I threw home as the runner rounded third. I felt a sharp pinching pain in my shoulder as the runner was tagged out(that's how it goes in my head but I honestly do not remember). Overnight, my shoulder stiffened and I had trouble lifting my arm over my head. I happened to be on my medical school radiology rotation and they needed a volunteer to test the new MRI machine. I volunteered and my MRI showed a partial thickness rotator cuff tear. My shoulder slowly healed on its own but it was intermittently painful whenever I threw or lifted objects including moving patients. My next episode was more severe. I was home from my Hand and Upper Extremity fellowship at age 32 and was throwing a heavy wet nerf football on the beach. The next day I woke up with excruciating shoulder pain and was unable to move. Over the next few days it slowly improved. It was tolerable except usually stiff and sore after I would play quarterback in a weekly flag football game. Finally, the day before my 40th birthday I was at a conference and the speaker was complaining about the aches and pains of middle age and said “ if you do not know what I am talking about, wait until you turn 40.” I thought he was being ridiculous because I felt great. On my 40th birthday I threw the football with my youngest son and once again had horrible shoulder pain for a few weeks. Three episodes and 15 years of intermittent shoulder pain and I never considered therapy. I just assumed I would get my rotator cuff repaired some time between 40 and 50. Finally I got sick and tired of being sick and tired. I started therapy at home 2-3 times a week doing stretches with flexion, abduction, and external rotation strength exercises. Now all of the functional strength programs I do incorporate these exercises in their upper body programs( shout out to P90x and Peloton strength training). I have now incorporated hanging when I remember and have been mostly pain free for the last 15 years. My footnote would be that when I eat a lot of sugar and processed carbs around the holidays I get a hint of discomfort in my shoulder which reminds me to clean up my diet.
Now, if you need a little inspiration to keep your shoulder healthy, just remember the ability to throw is one of the things that make you human. Playing catch with a parent, child, or grandchild is one of life’s simple pleasures.