Common Shoulder Problems in the Athlete:
DIAGNOSIS , TREATMENT, AND PREVENTION
By Arif Saleem. M.D.

Rotator Cuff Tendonitis
The rotator cuff is a collection of four different muscle/tendon units that surround the shoulder joint. They are essential for normal function of the shoulder. The rotator cuff provides stability to the inherently unstable shoulder as well as rotational strength of the arm. Many athletes put significant strain on the rotator cuff including overhead throwing athletes, swimmers, tennis players and volleyball players. Tremendous rotational torque is applied to the shoulder with the throwing motion; the rotator cuff is the main stabilizer of this rotational torque and is often injured by repetitive strain to the tendon. Initially, the tendon becomes inflamed and thickened as a response to the injury, resulting in rotator cuff tendonitis. With further repetitive microtrauma to the rotator cuff, the tendon can become physically damaged leading to a rotator cuff tear.

An athlete with an injured rotator cuff will initially present with pain during activity and as the symptoms progress, pain can be felt even at rest. In fact most patients complain of significant pain at night and difficulty sleeping due to the shoulder. When there is inflammation of the rotator cuff, raising the arm horizontally above shoulder level usually causes pain as the thickened tendon gets pinched between two bones. This position is often referred to as the position of “impingement.” As the impingement becomes worse, the tendon becomes more inflamed which sets up a cycle of progressive tendonitis.

In the initial phases of rotator cuff tendonitis, your physician can use multiple modalities to control the inflammatory response and regain normal rotator cuff function. Anti-inflammatory medication, rest and ice are all effective methods of decreasing the initial inflammation. If necessary, your physician may prescribe physical therapy for stretching and strengthening of the inflamed rotator cuff. In addition to the above treatments, cortisone injections can be used as an adjunct to treating tendon inflammation. If there is concern of a torn rotator cuff, an MRI scan of the shoulder is ordered. When a rotator cuff tear is present or if nonoperative methods are unsuccessful in treating rotator cuff tendonitis, surgery maybe recommended. Often arthroscopic techniques can be used to remove inflammatory tissues and repair torn tendons.

The most effective way to prevent rotator cuff injury is a regular stretching program and a targeted strengthening routine for each of the rotator cuff muscles. In the younger athlete, monitoring the number of throws or pitches per game and/or practice is an important component to injury prevention. Coaching staff are needed to review proper throwing mechanics, which can also prevent injury.

Shoulder Instability
The shoulder joint is the most mobile joint in the body and is therefore also the most commonly dislocated joint in the body. The structures that keep the joint stable include the rotator cuff, the joint capsule (glenohumeral ligaments), and the rim of cartilage (labrum) around the shoulder socket (glenoid). Athletes not only put significant strain on the rotator cuff, but also the glenohumeral ligaments often become stretched or torn as in the case of a complete dislocation of the shoulder. The symptoms of instability can manifest as weakness, a feeling of apprehension (as if the shoulder is about to “pop out”), pain and even a popping or catching of a torn labrum. In the case of a torn labrum, the pain and discomfort is usually worse with the follow-though portion of the throwing motion. When a ligament is injured with a dislocation, the symptoms are most commonly felt with the arm in the “cocking” position.

When an athlete is first diagnosed with instability, a physician will try and determine the direction and the severity of the instability. A shoulder can be unstable towards the front of the body (anteriorly), towards the back (posteriorly), or in all directions (multidirectional). Also, the shoulder can be slightly unstable causing the joint to slide excessively (subluxate) or it can be completely unstable causing it to come out of the socket (dislocate). Often, an MRI scan will be ordered to evaluate the location of the ligament damage and to look for associated injuries to the rotator cuff and biceps tendon.

Ultimately, the treatment for instability is determined by evaluating all of the above factors. Specifically, if the ligament and/or labral damage is small and the degree of instability is not great, then physical therapy, bracing and rest may be selected as the best treatment. However, if there is significant instability with a substantial tear of the ligaments and/or labrum, surgery will likely be recommended to fix the torn structures. Often arthroscopic techniques can be used and offer the ability to perform minimally invasive surgery with a quicker recovery period.

Unfortunately, contact sports are inherently risky and shoulder dislocation can occur anteriorly if sufficient force is applied to the arm with the shoulder in the “cocked” position or posteriorly with the arm extended in front of the body. Nonetheless, a regular strength training program targeted at the rotator cuff as well as the chest and back muscles that support the shoulder will decrease the risk of dislocation. In some sports such as football, restrictive braces can be applied to prevent the arm from going into a position of risk. Braces are not useful, however, for many skill positions such as wide receivers or quarterbacks. Early diagnosis of instability, when treated appropriately, can prevent further damage to other structures around the shoulder.

AC Joint Problems
The acromioclavicular (AC) joint is formed by the top of the shoulder blade (acromion) and the end of the collar bone (clavicle). The AC joint is the only true joint between the clavicle and the entire shoulder and upper extremity. Although, very little motion occurs at this joint, the AC joint helps to anchor the entire arm to the body. Therefore, tremendous loads are applied across this joint predisposing it to injury as well as arthritis. Traumatic injuries to the AC joint are commonly referred to as a “shoulder separation.” This typically occurs when an athlete falls directly onto the top of the shoulder and disrupts the ligaments which stabilize the AC joint. Athletes also can injure the AC joint with heavy overhead weightlifting. Usually this injury is a cumulative effect of heavy lifting in positions that compromise the shoulder.

The symptoms from an AC joint injury include pain, starting on top of the shoulder, which can often radiate to the arm or even the base of the neck. A painful pop or clicking may be felt in the same area especially when crossing the arm across the body. If an injury or fall has occurred, bruising, swelling, and even a slight deformity of the AC joint will be noticed. The degree of deformity after a fall is determined by the amount of ligament disruption. X-rays are a useful diagnostic tool for AC joint problems, and an MRI is only ordered if other abnormalities are suspected.

Several treatment options are available for AC joint injuries. If the ligament is only strained without significant deformity, a brief period of immobilization is used followed by a gradual return to function over six to eight weeks. When significant ligament disruption has occurred, surgical repair of the ligaments may be performed. In the case of chronic AC joint injury from weight lifting, strength training is limited to exercises that do not load the AC joint significantly. If the pain is persistent, anti-inflammatory medications as well as avoiding weightlifting for an extended period are recommended. In a severe case causing limited range of motion and persistent pain, arthroscopic surgery, to remove the end of the clavicle bone, may relieve the pain.

The risk of AC joint injury can be decreased with the use of appropriate protective equipment such as shoulder pads during contact sports like football, lacrosse and hockey. Although AC joint injury may occur during these sports, the severity of injury is usually lessened with protective equipment. When the athlete is training in the gym, excessive weights should be avoided and specific exercises like military press should be altered to decrease stress on the AC joint. When possible, lighter weights should be substituted for heavier weights and the number of repetitions correspondingly increased.

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