Learning About Shoulder Injuries

Surf Physio Shoulder Exercise

The following review will explore current understanding in relation to shoulder injury, assessment and treatment. Shoulder injuries were sustained in 16% of surfers followed for a 12 month period and in New Zealand shoulder injuries for surfers resulted in 1.2million dollars of treatment costs for ACC in the year 2015-2016

 Shoulder injuries are the third most common injuries to present to primary care (Mitchell et al., 2015). 

If you have experienced a trauma during a wipe out and as a result you have difficulty lifting your arm up due to pain or weakness. Then it is advisable to have an examination with your local physiotherapist or medical professional.

 

What injury could I have sustained?

Potential diagnoses and factors be examined:

Trauma

  • Shoulder Strain

  • Shoulder dislocation

  • Rotator Cuff  / Bursitis / Subacromial Pain

  • Acromioclavicular (AC) joint injury

  • Sternoclavicular (SC) joint injury

  • Labral injury

  • Fracture of the humerus, clavicle or scapula

  • Biceps strain, tear or tendinopathy

  • Pectoralis major strain

  • Referral from structures in the neck and the nerves that supply the shoulder and arm

Non-Trauma

  • Medical red flags: Cancer, Vascular, Lung and Heart Disease

  • Frozen shoulder/Stiff Shoulder/Adhesive Capsulitis / Neurological guarding (severe loss of passive range of motion, 35-60 years)

  • Glenohumeral joint arthritis (least likely, >65 years, slow onset, severe loss of rotation range of motion)

As you can see there are a lot of potential diagnoses which is why it is best to have a physical examination by a physiotherapist or medical professional in your area. They will be able to discuss with you appropriate management and whether or not imaging would be necessary (MRI can only be requested by an orthopaedic surgeon in New Zealand).

If you are older than 40 years old, have no recent history of trauma and have developed a slow onset of pain in the shoulder with you could be experiencing Rotator cuff related pain. However it is important that appropriate screening of the cervical spine (neck) as 40% of patients with primary shoulder pain responded to repeated movements of the cervical spine. (Littlewood  

However, it is important to note that 50% of patients over the age of 60 although they had rotator cuff tears on imaging they also had no pain. (Hashimoto, Nobuhara, & Hamada, 2003). So a rotator cuff tear on imaging does not necessarily mean that it is the primary source of your pain. You may experience mild to moderate weakness and have difficulty with day to day tasks such as reaching into a cupboard, sleeping on that shoulder or getting dressed. People who also have diabetes or vascular issues also have a greater risk of rotator cuff related pain.

There is also some evidence that an inflamed sub-acromial bursa (SAB) could be the primary pain generator in rotator cuff disorders (Blaine et al., 2005).

What is Subacromial Pain?

Subacromial Pain is the most commonly diagnosed shoulder disorder, accounting for nearly half of all shoulder injuries. However, it is an umbrella term which covers a wide spectrum of injuries including: Rotator cuff tendonipathy, rotator cuff tears, subacromial bursitis. 

The name subacromial refers to structures that are under the acromion bone of the shoulderblade, as you will see in the diagram below: this includes the rotator cuff muscles and cuff tendons and sub acromial bursa (a fluid filled sac that is between the tendon and the bone and thus helps to prevent friction allowing for sliding and gliding of the tendons with movement), these structures become irritated or sensitised and nerves send danger signals up to your brain which produces pain as an output to protect you.

Shoulder anatomy

What does the rotator cuff do?

The rotator cuff (RC) is a group of four muscles (supraspinatus, infraspinatus, teres minor and subscapularis) responsible for stabilisation of the shoulder during active movement. The rotator cuff tendons are not isolated structures as they work together. It was also discovered by looking at the anatomy in cadavers that the tendons of supraspinatus, and infraspinatus  join to form a common insertion onto the humerus (Clark & Harryman, 1992). Thus, if there is significant trauma to the tendon it can affect multiple muscles in the shoulder.

RC_rotatorCuff

Keep in mind with a Clinical Examination..

The usefulness of pain provocation examination tests to accurately enable the clinician to arrive at a structurally specific diagnosis has been challenged (Lewis, 2009). Since the rotator cuff tendons are not isolated structures, it is extremely unlikely that an individual test can isolate a specific tendon during physical examination. Furthermore, due to the close relationship between the sub-acromial bursa and the tendons during movements and this can also reduce reliability of the test results. 

Some tests are more accurate than others

  • A positive painful arc test result (pain on lifting the arm up between 60°-120°and reduces after 120°) is sensitive to sub acromial pain, but does not tell you what specific structure 
  • A positive external rotation resistance test result is sensitive for detecting issues with the rotator cuff.
  • A positive lag test (external or internal rotation) result was most accurate for diagnosis of a full-thickness rotator cuff tear (Hermans et al., 2013).
  • A loss of passive range of motion can indicate stiffness in the shoulder resulting from Adhesive capsulitis or Arthritis.

Shoulder Dislocations

Shoulder dislocations are a risk for all surfers, solid conditions and big wave chargers have a bigger risk due to the greater forces of the wave and the height fallen during wipe outs.

If you know your shoulder has popped out of its socket and its your first time, the sooner it is relocated back into the joint the better.

If after a few failed attempts then seek a doctor, emergency department or somebody who is trained in how to safely relocate.

Risks with relocation include fractures to the humeral head “the ball” (Hil-sachs lesions) or glenoid and labrum “the socket” (Bankart lesions). Doctors will likely take an X-Ray post relocation to check that no further trauma was sustained.

If you are somewhere nowhere close to a hospital or medical attention, then attempt to relocate as able and get an X-ray post relocation to rule out fracture.

 

Imaging

MRI shoulder sub acromial

An X-ray is used to rule in or out a Fracture, Infection or suspected Malignancy. It is recommended post traumatic injury.

An ultrasound (US) scan allows assessment of the rotator cuff and is cost-effective relative to a magnetic resonance imaging (MRI) scan. However, it does depend on the ability of the operator usually a  radiographer.

A MRI scan can also be used to evaluate tear size and retraction of the tendon, but in addition the rotator cuff muscles can be assessed for muscle wasting and fat deposits which allows a better prediction of surgical outcomes after RC tendon repair.

Imaging can give information to your Doctor and Physiotherapist, however may people have findings on their scans that are considered normal age related changes, discuss further with your health practitioner. 

Management and Rehab is an excellent option as..

Conservative management of partial thickness rotator cuff tears is highly recommended prior to surgical treatment (Ainsworth & Lewis, 2007; Pegreffi et al., 2011). There is considerable evidence for the effectiveness of rehab exercises to improve outcomes in patients with rotator cuff disorders (Kuhn, 2009). It is superior to no treatment or placebo treatment in primary care (Lombardi, Magri, Fleury, Da Silva & Natour, 2008). A recent multi-centre randomised control trial has shown that nearly 75% of patients improved clinically and avoided surgical repair by performing rotator cuff strengthening, soft tissue mobilisation and joint mobilisation despite having full thickness tears (Kuhn et al., 2013).

A three phase rehabilitation programme has been recommended in the management of rotator cuff tears (Pegreffi, 2011) – see table below.

Goals
Phase One
1. To relieve pain, adjust activites
2. To restore normal range of motion – active and passive

Phase Two
1. To improve functional strength of the rotator cuff muscles
2. To restore the ability of the rotator cuff to dynamically stabilise the humeral head during active movements

Phase Three
1. Task-specific rehabilitation exercises
2. Facilitate integration of the kinetic chain


There are low recovery rates for degenerative rotator cuff tears, even three years after onset with considerable effect on health and basic activities of daily living (Winters, 1999). Degenerative rotator cuff tears tend to occur in older patients (over 50 years old) and commonly present with progressive shoulder pain with no obvious history of trauma (Clement, Nie & McBirnie, 2012). Four factors have been identified with successful outcome following conservative management (Tanaka et al., 2010). They are:

  • Preserved active range of motion in external rotation ( more than 52°)
  • Negative impingement signs
  • Little or no atrophy of the supraspinatus muscle
  • Preserved intramuscular tendon of the supraspinatus tendon

There was no additional benefits with inclusion of manual therapy with exercises from the findings of a systematic review (Ho, Sole, & Munn, 2009). There was only minor effect on pain intensity after 5 weeks.

Injections

Subacromial injection
Subacromial injection

If you do consider having a cortisone injections you shoulde be aware of the pros and cons before having one.  

Pros

Steroid injections give a short term pain relief (~3-6months).

In shoulders that don’t settle within 6-12 weeks of conservative management then a cortisone injection can be useful to reduce irritability and allow for exercises to be performed with decreased pain.

Cons

However the potential harmful effects such as reduction in tendon size and decreased tissue quality, and risk of future tear or rupture is greater (Pegreffi, Paladini, Campi, & Porcellini, 2011).

Should I have surgery?

This is ultimately your choice, its best to discuss your options with your doctor and orthopaedic surgeon.

My professional opinion is to always rehab your shoulder to the best of your ability first and use shoulder surgery as a last option.

There is good evidence to support an exercise program for 12 weeks of shoulder strengthening and mobility reduced pain and improved function equal to that of surgical outcomes.

Pros

  • Active 20 to 50 year old patients with an acute traumatic tear and severe functional deficit from a specific event are best treated with early surgery (Clement et al., 2012).
  • Patients who did not respond well to conservative management might benefit from surgical review. (Oh, Wolf, Hall, Levy, & Marx, 2007).

Cons

  • Complete restoration of muscle strength after surgery can take more than one year postoperatively to rehab.
  • This can mean considerable time off work, surf, life commitments!
  • Due to prolonged inactivity post surgery, the muscles decrease in size and strength which puts the tendon at risk of failure in the early stages of rehab
  • There is a risk of infection with surgery and other complications.

 

Factors associated with a better recovery post surgery

They include:

  • Greater pre-operative range of motion of the shoulder
  • Pre-existing rotator cuff integrity (size of tear, less retraction, less fatty tissue infiltration, number of tendons torn)
  • No previous surgery to shoulder i.e. biceps repair, AC joint
  • Healthy diet and nutrition
  • Absence of diabetes, obesity and other medical conditions that affect healing
  • Previous high level of sporting activity, good fitness

Conclusion

Shoulders are important to keep healthy for surfers, we need them for our paddle strength to get into waves and to generate the force in the pop up. Shoulder injuries are common and its best to get a physiotherapist, doctor or orthopaedic surgeon to take a look if shoulder especially if it is affecting your day to day tasks and limiting your surfing.

The good news is that there is strong evidence to support conservative management to improve strength and function for rotator cuff tears to get you back in the water and at your best.

 
References:

ACC Statistics. Active claims for shoulder injuries and surfing for the year 2015-2016  

Ainsworth, R. & Lewis, J.S. (2007). Exercise therapy for the conservative management of full thickness tears of the rotator cuff: a systematic review. British Journal of Sports Medicine, 41(4), 200–210.

Blaine, T. A., Kim, Y.S., Voloshin, I., Chen, D., Murakami, K., Chang, S., et al. (2005). The molecular pathophysiology of subacromial bursitis in rotator cuff disease. Journal of Shoulder and Elbow Surgery, 14(1), 84–89.

Clark, J. & Harryman, D. (1992). Tendons, ligaments and capsule of the rotator cuff. Gross and microscopic anatomy. The Journal of Bone & Joint Surgery, 74(5), 713–725.

Clement, N. D., Nie, Y. X. & McBirnie, J. M. (2012). Management of degenerative rotator cuff tears: a review and treatment strategy. Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology, 4(1), 48.

Hashimoto, T., Nobuhara, K. & Hamada, T. (2003). Pathologic evidence of degeneration as a primary cause of rotator cuff tear. Clinical Orthopaedics and Related Research, 415, 111–120.

Hermans, J., Luime, J. J., Meuffels, D. E., Reijman, M., Simel, D. L. & Bierma-Zeinstra, S. M. (2013). Does this patient with shoulder pain have rotator cuff disease?: The rational clinical examination systematic review. The Journal of the American Medical Association, 310(8), 837–847.

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Fermont et al., (2014). Prognostic Factors for successful recovery after arthroscopic rotator cuff repair: A Systematic Review. JOSPT, 44(3), 153- 162.

Kuhn, J. E. (2009). Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized evidence-based rehabilitation protocol. Journal of Shoulder and Elbow Surgery,18(1), 138–60.

Kuhn, J. E., Dunn, W. R., Sanders, R., An, Q., Baumgarten, K. M., Bishop, J. Y., et al. (2013). Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study. Journal of Shoulder and Elbow Surgery, 22(10), 1371–1379.

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Lombardi, I., Magri, A. G., Fleury, A. M., Da Silva, A. C. & Natour, J. (2008). Progressive resistance training in patients with shoulder impingement syndrome: a randomized controlled trial. Arthritis and Rheumatism, 59(5), 615–622.

Mathew, B. (2014). Rotator cuff disease. Retrieved from https://thesportsphysio.wordpress.com/2014/05/24/rotator-cuff-disease-a-guest-blog-by-benoy-mathew/

Mitchell, C., Adebajo, A., Hay, E., & Carr, A. (2005). Shoulder pain: diagnosis and management in primary care. BMJ : British Medical Journal, 331(7525), 1124–1128

Oh, L. S., Wolf, B. R., Hall, M. P., Levy, B. A. & Marx, R. G. (2007). Indications for rotator cuff repair: a systematic review. Clinical Orthopaedics and Related Research, 455, 52–63.

Pegreffi, F., Paladini, P., Campi, F. & Porcellini, G. (2011). Conservative management of rotator cuff tear. Sports Medicine and Arthroscopy Review, 19(4), 348–353.

Sher, J., Uribe, J., Posada, A., Murphy, B. & Zlatkin, M. (1995). Abnormal findings on magnetic resonance images of asymptomatic shoulders. The Journal of Bone & Joint Surgery, 77(1), 10–15.

Tanaka, M., Itoi, E., Sato, K., Hamada, J., Hitachi, S., & Tabata, S. (2010). Factors related to successful outcome of conservative treatment for rotator cuff tears. Upsala Journal of Medical Sciences, 115(3), 193–200.

Winters, J. (1999). The long-term course of shoulder complaints: a prospective study in general practice. Rheumatology, 38(2), 160–163.

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