Shoulder injuries

Fastmikie,

Shoulder pain as we age is fairly common, and can certainly be related to arthritis, changing posture, repetitive over head activities over the years. I can not tell you exactly what is wrong in your shoulders without personally evaluating them, however the most common issue would be that of RTC impingement. The cause could be from a number of different things going on in your shoulder area that throw off the normal biomechanics, and generally has symptoms of pain with any overhead movements, especially to the side or pain when reaching behind your back or when putting a coat on. People will often but not always have pain when reaching acrossed their body.

During normal biomechanics of the shoulder, when you raise your arm upwards, at around 60 degrees of elevation, the humeral head (the ball in the socket) has to start moving downwards into the joint capsule (a group of ligaments that mesh together to help hold the arm in the socket) into a small fold that allows the downward movement. Above the humeral head are your supraspintus muscle (90% of all RTC injuries are to this muscle), and the acromion above that. The humeral head moves downward as your hand moves upward to avoid pinching the supraspinatus muscle between itself and the acromion, and to stabilize the bone into the socket. The RTC muscles are responsible for creating this downward movement. Their line of pull pulls the humeral head down and into the socket to stabilize the humeral head with all overhead movements. This also occurs in conjunction with a number of counter forces from other muscles that occur to create normal movement, but are not pertinent to this discussion. Anything that inhibits the normal mechanics will cause the humeral head to rise up into the acromion and impinge the supraspinatus muscle. This becomes a viscious circle, as the RTC now weakens due to the impingement, causing less and less control of the humeral head to occur. There are a number of reasons why this can occur, but it would be difficult to explain them all here. Either way, the more the supraspinatus gets pinched, the weaker and more inflammed it gets (as well as frayed and possibly torn from the constant rubbing). Cortizone is a powerful antiinflammatory. It removes the imflammation from the muscle/tendon and allows it work better, as well as creates a larger area between it and the acromion to decrease the chances of impingement. If you simply inflammed the supraspinatus muscle or tendon, a cotizone shot can get get rid of the inflammation and allow you to return to normal biomechanics. If there is one of a number of other possible issues going on, the cortizone will only temporarily remove the inflammation, until the muscle becomes impinged enough again to start giving out pain signals. Usually the RTC and shoulder blade muscles (they play a big role in normal shoulder biomechanics) need to be correctly worked, and the capsule often needs to be stretched to allow the humeral head to travel to its correct positioning again. If a cortizone shot only gave temporary relief, it is usually time to go to the next step. I would see an ortho shoulder doc. They will usually prescribe PT, and possibly do an MRI/MRA if they suspect a tear. Cortizone can degreade a tear more quickly if one is present. If one is not, you can have up to 3 a yr.

Remeber, the above is regarding the condition of RTC impingement. That is, however, by far the most common ailment of the shoulder. It is generally the cause of it that differs. A RTC tear would of course cause this, or this could be the cause of the tear from the constant rubbing over time. Again, feel free to PM me with any other questions.
 
Last edited:
Mantis99... Many thanks for taking the time for such an excellent reply. I'll definitely be taking your advice and checking with an ortho shoulder doc. Bonus points to you!
 
FastMikie said:
Mantis99... Many thanks for taking the time for such an excellent reply. I'll definitely be taking your advice and checking with an ortho shoulder doc. Bonus points to you!
Click to expand...

Fast Mike,

Puleeeze, don't tell me that is your actual personal pool room view on your blog. Puleeeze, I hope you're going to tell me, "No, it's just a Photoshop creation.". Lie to me, man, just flat out lie to me. I'd rather hear a lie than for you to say, "No Joey, that's really the view from my pool room, in my house on the beach in ***fill in the blank *****.

Don't anyone go to Fast Mike's Blog and look at the view from his pool table. If that isn't bad enough, he's friends with Samm, you know the one, half Windsor knot and all. :)

JoeyA
 
mantis99 said:
Fastmikie,

Shoulder pain as we age is fairly common, and can certainly be related to arthritis, changing posture, repetitive over head activities over the years. I can not tell you exactly what is wrong in your shoulders without personally evaluating them, however the most common issue would be that of RTC impingement. The cause could be from a number of different things going on in your shoulder area that throw off the normal biomechanics, and generally has symptoms of pain with any overhead movements, especially to the side or pain when reaching behind your back or when putting a coat on. People will often but not always have pain when reaching acrossed their body.

During normal biomechanics of the shoulder, when you raise your arm upwards, at around 60 degrees of elevation, the humeral head (the ball in the socket) has to start moving downwards into the joint capsule (a group of ligaments that mesh together to help hold the arm in the socket) into a small fold that allows the downward movement. Above the humeral head are your supraspintus muscle (90% of all RTC injuries are to this muscle), and the acromion above that. The humeral head moves downward as your hand moves upward to avoid pinching the supraspinatus muscle between itself and the acromion, and to stabilize the bone into the socket. The RTC muscles are responsible for creating this downward movement. Their line of pull pulls the humeral head down and into the socket to stabilize the humeral head with all overhead movements. This also occurs in conjunction with a number of counter forces from other muscles that occur to create normal movement, but are not pertinent to this discussion. Anything that inhibits the normal mechanics will cause the humeral head to rise up into the acromion and impinge the supraspinatus muscle. This becomes a viscious circle, as the RTC now weakens due to the impingement, causing less and less control of the humeral head to occur. There are a number of reasons why this can occur, but it would be difficult to explain them all here. Either way, the more the supraspinatus gets pinched, the weaker and more inflammed it gets (as well as frayed and possibly torn from the constant rubbing). Cortizone is a powerful antiinflammatory. It removes the imflammation from the muscle/tendon and allows it work better, as well as creates a larger area between it and the acromion to decrease the chances of impingement. If you simply inflammed the supraspinatus muscle or tendon, a cotizone shot can get get rid of the inflammation and allow you to return to normal biomechanics. If there is one of a number of other possible issues going on, the cortizone will only temporarily remove the inflammation, until the muscle becomes impinged enough again to start giving out pain signals. Usually the RTC and shoulder blade muscles (they play a big role in normal shoulder biomechanics) need to be correctly worked, and the capsule often needs to be stretched to allow the humeral head to travel to its correct positioning again. If a cortizone shot only gave temporary relief, it is usually time to go to the next step. I would see an ortho shoulder doc. They will usually prescribe PT, and possibly do an MRI/MRA if they suspect a tear. Cortizone can degreade a tear more quickly if one is present. If one is not, you can have up to 3 a yr.

Remeber, the above is regarding the condition of RTC impingement. That is, however, by far the most common ailment of the shoulder. It is generally the cause of it that differs. A RTC tear would of course cause this, or this could be the cause of the tear from the constant rubbing over time. Again, feel free to PM me with any other questions.
Click to expand...

http://http://www.caringmedical.com/therapies/prolotherapy.asp

This is a link to prolotherapy information. Is this just bogus? Aren't anti-inflammatory medications actually harmful? Doesn't surgery cause scar tissue? Is C. Edward Koop who recommends this treatment a quack? Thanks for your help. It's hard to get good information. An actual moving shoulder model online would be a great help, but I can't find any.

IMO anyone who gets a shoulder operation without going to a chiropractor to at least get a neck adjustment is really uninformed about what's going on...

unknownpro
 
Last edited:
Your link did nor come up when I tried to go there. However, prolotherapy is used to create scar tissue in areas of laxity (being too loose). I have seen it be some what successfully used for SI joint problems, althoug the vast majority of attempts with it have failed. I have never seen it be recommended by any shoulder surgeon for a RTC injury. The scar tissue that you add is not that selective in where it lays down, so I would think it would cause a lot of problems in the shoulder. I have seen its creators make a lot of claims, but in my personal experience, it has been only very marginally successful.

Anti-inflammatories used for very prolonged periods of time, or in people with certain other medical conditions can be harmful, but in general are safe. In my profession we do not advise people on meds, so I will not get too specific. They are however, used by millions of people without trouble. Your physician should be able to tell you whether or not they would be safe for you. Of course many chiropractors claim them to be unsafe. That may be because it is not legal for them to prescribe meds. They instead give out mass amounts of vitamins and supplements.

Any time you cut the skin, scar tissue will be developed. In general, most shoulder surgeries today are performed arthroscopically, significantly decreasing scar tissue development. PT is an important part in the avoidance of scar tissue development that will impedede your function.

Your comment about the neck adjustment thing can be looked at from many different angles. I never do a shoulder evaluation without clearing the cervical spine before I move to the shoulder. The neck can definately be a major cause, or contributing cause to shoulder pain. However, if you have a RTC tear, whether or not you have neck issues, it will need to be fixed if it is large enough. Your ortho doc should also consider the origin of your pain before deciding to go ahead with any shoulder treatment. I certainly would not say that you need to see a chiropractor for the neck eval. I have nothing against them (although their theory and the rest of the medical communities theory of healing are different). PT's in general are also well qualified to treat neck vs shoulder injuries. I have personally taken many different advanced spine courses, and am well trained in treating the area. Good chiropractors may help you a lot if the problem is in your neck, bad ones may have you being adjusted once a month for the rest of your life (which may be okay with you if you agree with their theories on aligning the spine). Please understand that I do not mean anything negative towards them, just that they are not the only ones that can successfully look at the problem related to your neck or shoulder. Other options would be a physiatrist (rehab Dr.) or a PT.
 
Last edited:
Mantis99,
Wow man, kickass replies. Really, really good stuff and thanks so much for taking the time to write detailed replies. You gave me so much good info man, thanks thanks THANKS!

I have been working out since June pretty regularly but I go sparingly with military and lateral raises. I cant do free weights with my shoulder, I have been using the machines and using embarrasingly low weight. Like 20lbs shoulder press with ten pound sets to warm up. Do you recommend I just quit doing shoulder exercises like military press, lateral extentions and upright rows altogether. Also should I be benching , flies and doing lat pull downs? All of those I find to be uncomfortable but not painful and if I do some warmup sets with really light weights the discomfort fades.

Another guy at the gym recommended one alleve after workout to reduce inflammation as well as calcium supplements to help lube the joints some. I have both of those in my medicine cabinet and wonder if aleeve in particular is hard on the liver if you take it daily.
 
I am glad you have found the info informative. I really enjoy what I do, so writing about it is actually kind of fun.

With any type of RTC injury, any ovrehead pressing would be strongly contraindicated. I would definately avoid the military press, incline bench press, lateral raises, upright rows, and behind the neck pull downs. Flies put a lot of pressure on your shoulder also, and should be avoided. Lat pulldowns to the chest can be situational. They mainly work the lats, which pull the humeral head down into the socket, which can be beneficial, and are incorporated later in rehab. They are questionable to start though. Because you are starting overhead, you may be impinging the tendon. I would avoid them if you notice any pain. As far as bench press and other ex's go, I would go with the old addage if it hurts, don't do it. Working through pain with this is counter productive. You are either straining an already damaged muscle, or actually impinging it more. Those things will never be beneficial in this case. The RTC actually functions to hold the humeral head in the socket when any pressure is put on the arm. Because of this, strong loading of the shoulder with movements such as bench press can tend to over use the muscles in a case like this. I would usually advise people to avoid bench press until the pain subsides. I know how hard it can be to gain muscle and strength, and how frustrating it can be to have to lose it. If you have to do it, use lighter weights, and go slowly with increased reps to get the same burn. Do NOT continue if it is painful during or after the ex though. Bi's and Tri's can often be done with this as long as you are not going overhead. The biceps long head is actually a 2ndary stabilizer of the shoulder. When the RTC isn't working well, it can get over worked trying to pick up the extra load. Biceps tendonitis is the most common complication with this injury, so be careful, and again, stop if it hurts during or after the ex. If your shoulder presents with any of your painful symptoms after ex, you are doing something you should not.

Regarding the Alleve. My profession does not advise on meds. That being said, if it were my shoulder, I would definately use something like alleve or ibuprofen in an antiiflammatory doseage while I was doing stuff to correct the problem. I probably would not use it as a long term solution though. I would really recommend having that monitored by your treating physician. Inflammation is a big part of this injury though. The more inflammed the tendon, the less space there is under the acromion, making it easier to impinge the shoulder. Most docs would give you an antiinflammatory, or tell you to take aleve or ibuprofen. I would definately ice the shoulder also. 2-3 times a day for 15-20 minutes, and definately after ex.

There isn't any research that I know of that suggests that calcium will be beneficial here. Calcium plays an important role in muscular contraction and bone density, but I have not heard of it lubing the joints.
 
Last edited:
http://orthoinfo.aaos.org/topic.cfm?topic=A00032&return_link=0
This site explains impingement fairly well with some pictures. Realize that the surgery they are talking about is an acromioplasty, not a RTC repair. The latter generally requires a longer rehab.

http://www.orthogate.org/patient-education/shoulder/impingement-syndrome.html
This one is even better. If you click on the terms such as "rotator cuff", some nice pictures showing the structures well pop up.

One other thing these sites mention that I have not addressed is the possibility of a bone spur coming off of the acromion into the area beneath it where the supraspinatus lies. This can create more impingement on the muscle, and may need to be shaved off if it is too large.
 
mantis99 said:
http://orthoinfo.aaos.org/topic.cfm?topic=A00032&return_link=0
This site explains impingement fairly well with some pictures. Realize that the surgery they are talking about is an acromioplasty, not a RTC repair. The latter generally requires a longer rehab.

http://www.orthogate.org/patient-education/shoulder/impingement-syndrome.html
This one is even better. If you click on the terms such as "rotator cuff", some nice pictures showing the structures well pop up.

One other thing these sites mention that I have not addressed is the possibility of a bone spur coming off of the acromion into the area beneath it where the supraspinatus lies. This can create more impingement on the muscle, and may need to be shaved off if it is too large.
Click to expand...

Thank you so much for all your replies to this thread. As far as anti-inflammatories go I was meaning that the prolotherapy practitioners (and common sense) tell me that inflammation is the healing mechanism of the body and that ice and anti-inflammatory drugs reduce the amount of fluid going into the joints and prevent healing. As I understand it the whole idea of prolotherapy is to swell the joint so it will heal, since the joints do not have direct blood supply and must draw in fluid through movement.

I am doing gymnastic type exercises with a total gym along with rotator cuff exercises with light weights. On the total gym you can do light weight pull ups with your palms parallel which works better for me than using a bar. I don't do over head lifts except an overhead triceps extension holding my arm up as vertially as I can.

I also do high reps with a ten pound weight of several movements at different angles near the opposite of my pool stroke. And I do heavy weights very carefully now for my biceps.

I have been to chiropractors so many times that I have learned to do their tricks through exercise and stretching. Back exercises to me are the foundation of any fitness program. If you can't lie flat and lift your leg straight up above you with the knee straight without tension you have a problem that is affecting you all the way to your shoulder and neck.

Thanks again for your help.

unknownpro
 
Terry Ardeno said:
Dave,
I had a full tear in my left rotator cuff and waited 15 days before I saw a Dr. He did surgery the next day and my left shoulder is probably the strongest part of my body. It never hurts and I hit my heavybag almost every day and have never had any problem.
Pool wise, I could not bridge with my left arm, so I played left handed for about 6 weeks until my left arm got out of the sling. I never missed a day on the table and now look at it as a blessing because I'm so comfortable shooting southpaw.

If it needs fixed, get it fixed and over with. It probably won't heal on its own. Doc said mine looked shredded, like the bottom of frayed blue jean pants legs. But now, it's perfect. Never hurts at all.

Best of luck to you David.
Click to expand...

I'm the other example. I tore my anterior labrum ligament in my left shoulder and I had no clue how I did it. I think playing pool made it worse and I got to the point where I couldn't extend my bridge hand out and lean down to sight the shots.

This was twenty years ago and I was playing "A" class pool and dreaming about being a pro. The MRI showed the tear but I had no insurance, so the doctor recommended I let it heal on it's own since I worked with my Hands (chef) and I would be out of work for at least three months.

It took a good 10 years for my shoulder to almost completely heal and I experience pain for years and I couldn't play pool much for a couple years. If you have the means to get the surgery, I would highly recommend it.

The one thing that I did do was physical therapy and it made a world of difference.
 
efirkey said:
The one thing that I did do was physical therapy and it made a world of difference.
Click to expand...

That really was the key w/ my recovery. I was as diligent with the physical therapy as a person could have been. I never missed a session, did not slop thru the exercises, but rather concentrated on each rep. I stretched a lot and did extra stuff at home.

I was also lucky in that since I injured it at work (in a training scenario where we were supposed to "tap" when it started hurting too much, and I never did, being a dummy :eek: ) and had great insurance, I was on Worker's comp and something we have in Pennsylvania called "Heart & Lung" which means in certain jobs, if you're hurt at work, you get full pay with no useage of your accumulated sick days! That was a nice benefit to have for sure. Again, I got a lot of good rolls thru the whole thing.
Good luck!
 
unknownpro said:
Thank you so much for all your replies to this thread. As far as anti-inflammatories go I was meaning that the prolotherapy practitioners (and common sense) tell me that inflammation is the healing mechanism of the body and that ice and anti-inflammatory drugs reduce the amount of fluid going into the joints and prevent healing. As I understand it the whole idea of prolotherapy is to swell the joint so it will heal, since the joints do not have direct blood supply and must draw in fluid through movement. QUOTE

The inflammatory process is the bodies way of healing itself. Unfortunately, it is not perfect though. In general, when a significant injury occurs, the body responds with too much vigor, and sends an excess of blood to the area. This is bad anywhere, but particularly bad in a few areas. The shoulder is certainly one of them. When there is too much inflammation pressing on a tendon/muscle, that muscle decreases its ability to contract. Because the supraspinatus needs to contract to help pull the humeral head down, this becomes very bad. Also, the more inflammation in the area, the less room there will be for the humeral head to move without impinging the supraspinatus. Inflammation is very much the enemy with this type of injury. I prefer that any patient be on an antiiflammatory as soon as they know they are injured, and that they ice 2-3 x daily with this type of injury. Anyone who suggests inflammation is good with this type of injury is seeling something you do not want to buy.
Click to expand...
 
Efirkey,
I don't mean to be nit picky, but the labrum is actually cartilidge, not a ligament. It sits around the socket that the humeral head sits in to create a deeper socket for increased stability. The long head of the biceps attaches to the top, front portion of the labrum, so any strong contraction of this with the arm reaching back, or with overhead movements such as pitching can tear it. Sometimes it is from repetitive strain instead of a one time event, so it may not have been any one thing that necessarily did it. Again, the stronger the RTC is, the more it will help with stability, and the more it will decrease the stress on the labrum.

I am very glad to hear that you guys had good experiences with P.T. I believe what we do can make a big difference in someones return to function.
 
mantis99 said:
unknownpro said:
Thank you so much for all your replies to this thread. As far as anti-inflammatories go I was meaning that the prolotherapy practitioners (and common sense) tell me that inflammation is the healing mechanism of the body and that ice and anti-inflammatory drugs reduce the amount of fluid going into the joints and prevent healing. As I understand it the whole idea of prolotherapy is to swell the joint so it will heal, since the joints do not have direct blood supply and must draw in fluid through movement. QUOTE

The inflammatory process is the bodies way of healing itself. Unfortunately, it is not perfect though. In general, when a significant injury occurs, the body responds with too much vigor, and sends an excess of blood to the area. This is bad anywhere, but particularly bad in a few areas. The shoulder is certainly one of them. When there is too much inflammation pressing on a tendon/muscle, that muscle decreases its ability to contract. Because the supraspinatus needs to contract to help pull the humeral head down, this becomes very bad. Also, the more inflammation in the area, the less room there will be for the humeral head to move without impinging the supraspinatus. Inflammation is very much the enemy with this type of injury. I prefer that any patient be on an antiiflammatory as soon as they know they are injured, and that they ice 2-3 x daily with this type of injury. Anyone who suggests inflammation is good with this type of injury is seeling something you do not want to buy.
Click to expand...

http://www.caringmedical.com/sports_injury/rice.asp

What about this? This link says that ice and anti-inflammatories will basically destroy your joints, and looks to have plenty of documentation. What do you think?

unknownpro
Click to expand...
 
You must log in or register to reply here.
Back
Top