Shoulder Care for the Overhead Athlete
Throwing a baseball is one of the most physically demanding athletic motions. It places a tremendous amount of force on the shoulder and elbow, often leading to altered biomechanics and range of motion. The American Journal of Sports Medicine estimates 50% of youth pitchers will have shoulder and/or elbow pain at some point during the competitive season. Other baseball position players, softball players, football quarterbacks, and any other overhead athlete can also be affected.
The shoulder often becomes painful due to the repetitive nature of pitching and accumulation of force on the shoulder and elbow in the skeletally and structurally immature. The core and lower extremity also significantly contribute to throwing mechanics and stress placed on shoulder. Flexibility and strengthening in the hip and trunk motion in the sagittal and transverse plane are critical to leg drive resulting in optimal biomechanics, improved performance and reduction in injury risk.
Physical Therapy plays an important roll in reducing risk of injury of the pitcher (and other overhead athletes) and safely returning to play following a shoulder and elbow injury with reduction in risk or re-injury. Whether the pitcher has been injured or not, the throwers program will address warming-up / cool-down, specific stretches and strengthening exercises to address common deficits, and evaluation of throwing mechanics.
Physical Therapy can help reduce a pitcher’s risk of injury by evaluating mechanics, giving guidelines for pitch counting, improving Glenohumeral Internal Rotation Deficits (GIRD), improving muscular endurance, and even help to elevate performance.
Physical Therapy can also safely return a pitcher to his previous level of performance following an injury or surgery. The rehabilitation of the shoulder is not complete until a specific interval training program has been completed. Completing the rehabilitation process also helps to improve the psychological readiness of the athlete and confidence of the coach.
Impingement and Bursitis in the Shoulder
The bursa is a fluid filled cushion that lies in between bones, ligaments, muscles and tendons at points of friction to provide a smooth surface for them to glide. When repetitive compression is applied to a bursa, it can often become inflamed and swollen which leads to pain and disability in the affected joint, which in this case is the shoulder. The Subacromial Bursa lies in between the rotator cuffs attachment on the humeral head and the acromion. When an individual has an acromion that is more angled and hooked, it can cause increased compression of the rotator cuff tendons.
Impingement and Bursitis often occur simultaneously due to the above mentioned anatomic and biomechanical factors. Biomechanical factors include
- Narrowing of the subacromial space while lifting the arm in front or to the side
- Weakness in shoulder musculature can cause the head of the humerus to move forward of a normal position causing a reduction in sumacromial space
- Abnormal movement of the shoulder blade and abnormal resting position of the shoulder blade can also contribute.
- Increased kyphotic thoracic spine curve can also contribute to developing impingement of the shoulder.
There are 3 types of impingement that occur in the shoulder. Primary impingement creates substantial irritation of the bursa, rotator cuff tendons, and is progressive. When left unaddressed, rotator cuff tendonitis becomes rotator cuff tendionsis which then a partial tear or full thickness tear of rotator cuff tendons at their attachment on the humeral head. Secondary impingement occurs due to compression of shoulder tendons and tissue caused by instability of the humeral head. Instability can be caused by capsular instability or a labral tear. Internal impingement is caused by pinching of the rotator cuff in an overhead throwing position and is specific to athletes.
Evaluation of rotator cuff strength, endurance, scapular movement, posture and alignment can help reduce the anatomical and biomechanical forces contributing to impingement. Physical Therapy can correct deficits in muscle performance and stabilize the scapula to allow the humoral head to clear the acromion with forward and side movements of the arm. Addressing these dysfunctions alleviate stress to the bursa and impingement.
Rotator Cuff Lesions Non-Surgical and Surgical Repair
The rotator cuff is formed by a group of 4 muscles: the supraspinatus, infraspinatus, teres minor, and subscapularis. Most commonly, the supraspinatus is affected. Its main action is forward elevation. The infraspinatus primarily performs external rotation along with the terms minor. Lastly, the subscapularis performs internal rotation of the shoulder. Ultrasound studies have shown the supraspinatus can have areas of decreased blood flow after the age of 40 increasing the chance of pathology, however, blood flow can be improved with exercises.
The most common cause of tears and contributing factors to rotator cuff tear:
- Age is a contributing factor to tears, most commonly beginning at the average age of 48.7 years. Patients who have a painful tear in one shoulder after the age of 60 are 50% more likely to have a non-symptomatic tear in the opposite shoulder.
- Elevated BMI is associated with increased risk of rotator cuff tendinitis and tears
- Type 1 Diabetes
- Cigarette Smoking
- Degenerative changes of connective tissue, collagen and bone
- Microtrauma due to repetitive mechanical traumas
- Subacromial Impingement
- Fall on out stretched hand or dislocation of shoulder
Tears are classified as either partial-thickness or full-thickness. Tears are also classified as acute or chronic.
- Full-thickness tears extend from the top to the bottom of a rotator cuff muscle/tendon. Surgery is commonly indicated for patients with full thickness tears that cause pain and loss of function that is unacceptable to them. If the tear is due to trauma, surgery within the first 3-4 weeks has the most favorable outcome.
- Partial-thickness tears affect at least some portion of a rotator cuff muscle/tendon, but do not extend all the way through. Partial thickness tears often respond favorable to non-operative treatment. Research has shown that partial thickness tears can be progressive without treatment. The rate of progression is highly variable.
Physical Therapy can help non-operatively, pre-operatively or post-operatively. With a non-operative full or partial thickness tear. Treatment will include exercises to improve or maintain range of motion and strengthening of the remaining rotator cuff, scapular and deltoid muscles. Treatment will also recommend activity modification and capsular stretching. These same principles will be applied to a pre-operative program to allow for best outcome following surgery. Post-operative rehabilitation will be a staged program maximally protecting the repair while directing toward a safe return to certain activities over a period of months.
Frozen Shoulder is a term that is often overused and misapplied to patients with a painful stiff shoulder. Calcific tendonitis, bicipital tenosynovitis, arthritis, and rotator cuff tears can cause symptoms that mimic a frozen shoulder. Diagnosis of the specific condition needs to be obtained to correctly address the cause of pain.
True frozen shoulder is called adhesive capsulitis. Adhesive capsulitis affects more men than women and are usually between the age of 40 and 60. The non-dominant upper extremity is more frequently affected and commonly affects the controlteral side years after the first shoulder. Painful movements are often limited and mobility reduced. The capsule then begins to develop disuse contractors and scarring.
Adhesive capsulitis occurs in 4 stages.
- Stage 1 – Inflammation – typically lasts 3 months, pain is referred to the deltoid and is most predominate at night
- Stage 2 – Freezing – lasts 10 – 36 weeks. Pain at night and severe stiffness with shoulder flexion, abduction, internal and external rotation.
- Stage 3 – Maturation – Lasts 4 – 12 months. Severe limitation in range of motion with mechanical block of passive range of motion.
- Stage 4 – Thawing – lasts 5 – 26 months. Pain subsides and range of motion slowly returns.
Physical therapy initially will be aimed at pain control. The second phase will be aggressive range of motion. Strengthening will begin once range of motion improves. non-operative physical therapy is the most universally accepted first-line of treatment.
The shoulder has the greatest amount of mobility than any other joint which places it at a higher risk of dislocation. The relationship of the humoral head and how it sits in the glenoid (cup on the shoulder blade) is like a golf ball sitting on a tee. The labrum, mechanoreceptors, capsule and muscles function together to provide stability to this joint.
Instability occurs when the humoral head moves out of the cup that holds it (the glenoid) causing pain and apprehension to movement. If the translation is incomplete or partial and spontaneously moves back into place, it is called a subluxation. If the humoral head becomes completely displaced requiring a reduction, it is called a dislocation. Acute instability is a result of large trauma causing a specific injury. Chronic instability is the result of small traumas over time causing changes to the surrounding tissue.
Trauma and instability can cause damage to the glenoid fossa, the head of the humerus, and labrum.
Shoulder instability is often associated with a tear in the labrum of the shoulder. Research has shown that when the labrum is involved, most patients require surgery within 12 to 30 months as it does not usually respond well to non-operative treatment. Individuals at risk for a non-traumatic labral tear is repetitive overhead lifters and pitchers.
With operative or non-operative treatment, physical Therapy will address deficits incurred due to instability by increasing range of motion, performing strengthening exercises, improving joint awareness, retraining the muscles, and activity / sport specific training.
Fractures in the Shoulder
According to the Journal of Shoulder and Elbow Surgery, shoulder fractures account for 5% of all fractures. A fracture of the humoral head is the 3rd most common fracture in the elderly after the hip and wrist. The most common cause of a fracture in the shoulder is osteoporosis, a fall on an outstretched arm, or severe trauma. Associated injuries with a humoral fracture may include injury or the axillary or suprascapular nerve, axillary artery or vein and the surrounding soft tissue.
Treatment of a humoral fracture depends on the severity, location, and affected soft tissue in the shoulder. Some may be treated non-surgically with immobilization and others may require surgical repair. Surgical repairs may require internal fixation, a rod, or a replacement.
Operative and Non-Operative treatment of a humoral fracture will be individualized to the patient and severity of fracture. However, early, controlled, gentle passive motion that protects the healing of the fracture is very important for a successful outcome. Eventually, exercises will be gradually introduce. It is important that exercise and progression of strengthening is overseen by a physical therapist to avoid substitution and poor form.
Physical Therapy will provide a customized rehabilitation program with respect to the patient’s specific condition and considerations, response to treatment and progress during the recovery phase.
Total Shoulder Arthroplasty and Reverse Shoulder Arthroplasty
The indication for a shoulder replacement is normally Osteoarthritis, though other conditions can result in a replacement. A patient may be ready for a Total Shoulder Arthroplasty when they begin to notices their shoulder has lost significant motion, is very stiff, has pain with use of arm, has pain causing loss of sleep, and is unable to actively internally or externally rotate the shoulder. The patient may also experience a grinding sensation or audible popping / clunking of the shoulder that may be painful.
The purpose of a shoulder arthroplasty is to relieve pain, improve range of motion, and regain function of the affected arm.
The Total Shoulder Arthroplasty (TSA) is normally indicated in the older patient who has good rotator cuff integrity. With a TSA, the subscapularis tendon must be reattached and subsequently protected. The prosthesis closely resembles normal boney anatomy.
The Reverse Shoulder Arthroplasty (RSA) is normally indicated for the older patient that does not have a rotator cuff in tact. When a patient is deficient in the rotator cuff the RSA is the best option as it will give the patient overhead elevation where a TSA will not. The deltoid muscle becomes the prime mover and enables rotation in addition to elevation. The prosthesis places a ball on the shoulder blade and a cup where the humoral head was originally.
The Hemiarthroplasty is performed on younger patients due to rheumatoid arthritis, avascular necrosis, trauma or post-traumatic arthritis. The hemiarthroplasty only replaces the humoral head.
Physical Therapy following a shoulder replacement is essential to maintain stability of the prosthesis while safely advancing range of motion, strength and function of the arm. Rehabilitation is critical to a favorable outcome and to reduce the risk of failure of the prosthesis.
Acute Shoulder Strain
Strains to the shoulder generally are caused by specific positions that place strain on the muscles as opposed to a great amount of force. The strain will be graded as Grade I, Grade II, or Grade III. A grade I is over-stretched and inflamed. A grade II is partially torn but competent and a grade III is a complete rupture.
Physical Therapy can help to reduce inflammation and improve flexibility. You will also be given guidelines for recreation and work to avoid further or re-injury. A grade I and II should expect a fairly fast and full recovery.
Rotator cuff tendonitis or tendinopathy is a degenerative condition affecting of one or more of the rotator cuff tendons in the shoulder. It is one of the most common causes of shoulder pain. It usually comes on gradually over time or following a rotator cuff strain which has failed to heal properly. Tendonitis in the rotator cuff is commonly caused by repetitive micro trauma over a period of time. Poor posture can also contribute to its development. Shoulder tendonitis is a progressive disorder that often co-exists with shoulder bursitis or bicipital tendonitis and can deteriorate into calcific tendonitis or rotator cuff tears.
Rotator Cuff Tendonopathy symptoms usually come on gradually and radiate down the arm, but not past the elbow. Usually you do not have pain at rest, but experience a mild ache with use of the shoulder. Some movements can provoke severe pain, such as reaching overhead or behind you (like to grab a seatbelt). You may also experience weakness with lifting household items.
Conservative management usually will include a cortisone injection by an orthopedic, prescription of NSAIDS, and prescription for physical therapy.