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SHOULDER
Taking Care of Your Shoulder
The shoulder joint is capable of a wider and more varied
range of motion than any other joint in the human body.
This extraordinary flexibility has allowed human beings
to do everything from pitch a baseball to paint the
Sistine Chapel.
Unfortunately, because the shoulder is so flexible,
it also tends to be unstable. And this instability contributes
to a variety of problems, some of which can be treated
with rest, and others which may require the expertise
of a licensed physical therapist.
In this article you will learn about:
the basic anatomy of the shoulder;
common shoulder ailments;
ways to reduce the risk of injury;
exercises to do at home;
physical therapy treatments.
Certain athletes (throwers, tennis players, swimmers)
are at especially high risk for shoulder problems, though
they can occur in anyone. And in most cases- even those
requiring surgery- a physical therapist plays an integral
role in the rehabilitation process. The physical therapist's
expertise can help you recover function as quickly as
possible and get you back in the swing.
Shoulder Anatomy
The shoulder has three major joints: the glenohumeral
(GH) joint, the acromioclavicular (AC) joint, and the
scapulothoracic (ST) joint. Each joint can become dysfunctional
and painful.
When people refer to the shoulder joint they're usually
talking about the glenohumeral joint- the ball-and-socket
which links the upper arm to the body through the collarbone.
This joint has been compared to a golf ball sitting
on a tee: the large, rounded end of the humerus (upper
arm bone) moves within the shallow, scooped-out glenoid
next to the end of the clavicle (collarbone). The anatomy
of the glenohumeral joint permits the greatest flexibility
and range of motion of any joint in the human body;
it can also allow the shoulder to become unstable.
The acromioclavicular joint, more commonly called the
AC joint, joins the scapula (shoulder blade) to the
clavicle. The AC joint can become separated; this commonly
occurs in contact sports, such as when a football player
falls on the tip of the shoulder.
The third shoulder joint is the scapulothoracic or
ST joint, which is the scapula as it lies over the thorax
(back of the rib cage). The ST joint is attached to
the thorax by muscles and tendons. Posture is closely
linked with the healthy functioning of the ST joint,
which in turn affects the shoulder structure.
The shoulder is more than just these three joints,
of course; it's an intricate system of bones, muscles,
tendons, ligaments, and bursa sacs that work in precise
harmony with each other.
Four muscles in this region form the rotator cuff,
a complex of muscles that encircles the shoulder joint.
This complex is a major source of muscular stability
in the shoulder. The rotator cuff can be prone to tears
and weakening due to a number of causes, including strain
and overuse.
Tendons are strong fibrous cords that attach muscles
to bones. Inflammation of the tendons is called tendinitis.
An additional structure essential to this system is
the bursa sac. Bursa sacs are fluid-filled membranes
within and around the shoulder; they cushion the joints
and help minimize friction. Inflammation of the bursae
is known as bursitis.
What Causes Shoulder Problems?
There are several factors involved in shoulder disorders:
the aging process, including disuse and atrophy;
strain and overuse;
trauma.
It's not unusual for many of the common shoulder problems
described below to result from a combination of these
factors.
The Aging Process
Whether you're 17 or 70, age has a profound impact
on how the body responds to shoulder strain or trauma.
As young people, the tissue around our shoulder joints
is soft and resilient. Before age 30, if we "overdo
it" through sports or physical labor, the most
we're likely to suffer is a slight, short-lived soreness
or stiffness in the tendons. This condition- tendinitis-
is perhaps the most common of all shoulder problems.
It rarely requires treatment in young people; as we
enter middle age, however, the cumulative effects of
years of tendinitis can result in much more serious
ailments.
As we move into our 30s and 40s our muscles and tendons
begin to undergo a structural weakening because of the
aging process. By age 40 or 45, simple tendinitis can
degenerate into actual tearing of the muscle tissue.
What's worse, each episode of tendinitis weakens the
muscles further. Ultimately, this cumulative damage
can lead to larger tears in the muscles and tendons.
This is why conservative treatment of tendinitis at
an early stage, along with education about the way the
shoulder works and proper exercise, is crucial to preventing
further (and more serious} injury.
Strain and Overuse
Imagine a 45-year-old woman- after spending the winter
sitting at a desk or parked in front of the TV set-
going out to play three tough sets of tennis on the
first warm day of spring. On the day after, the soreness
in her shoulder reminds her that she's not 25 anymore.
So what does she do? She goes out and swims 50 laps
of the butterfly stroke to reassure herself that she's
still "got it." And the day after that she
stays home from work- taking pain relievers, soaking
in the tub, and wondering what went wrong. What went
wrong, in simple terms, is strain and overuse, coupled
with the effects of age.
Rotator Cuff Injuries. Tears in the rotator cuff can
result from the progressive worsening of tendinitis,
repetitive strain through overuse, or trauma- especially
as a result of athletics.
The gradual tearing of the rotator cuff is a process
similar to a shirt wearing out- it gets more and more
threadbare until the edges fray or a hole appears. This
sort of rotator cuff injury can be difficult to repair
surgically, and conservative treatment under the direction
of a physical therapist is often the best course of
action. A "clean" tear to the rotator cuff
(due to trauma) can often be repaired surgically. Whether
or not surgery is indicated, a physical therapist will
almost certainly be involved in all stages of the recovery
process.
Researchers have found that rotator cuff tears occur
more often in people who rarely exercise or who participate
in sports only sporadically. People who keep in shape
through regular exercise are more likely to maintain
strong bones and rotator cuff strength, and to diminish
the chance of future shoulder injury . Bursitis goes
hand-in-hand with tendinitis. Inflamed bursa sacs may
become thickened and reduce the "free" space
in the joint, thus restricting movement. In extreme
cases some of the bursa sacs can be removed surgically;
otherwise, the therapeutic approach to treating bursitis
and tendinitis is similar.
Osteoarthritis is a condition in which the joint cartilage
deteriorates and the joint becomes gritty and rough.
It can be caused by a number of factors, including disease,
trauma, and infection. Degenerative arthritis is often
associated with wear-and-tear in the joints over a long
period of time. The AC joint is particularly susceptible
because it degenerates faster than any other joint in
the body as we age. Arthritis in the glenohumeral joint
usually appears somewhat later, and may be related to
trauma earlier in life or rotator cuff problems.
Besides being painful, arthritis can lead to "frozen
shoulder," which is the inability to fully move
the arm due to tightness in the joint; attempts at movement
in the later stages of the condition are usually painful.
In advanced cases of arthritis involving the glenohumeral
joint, arthroplasty- surgical replacement of the joint-
is an option that can bring pain relief and greater
mobility. The rehabilitation period, however, is crucial,
with both the patient and the physical therapist playing
active roles. Arthroscopy, a medical procedure in which
miniature "telescopes" are inserted into the
shoulder area, is another option in diagnosing and treating
"frozen shoulder."
Subluxation is a quick, spontaneous "pop-in/pop-out"
or partial dislocation of the shoulder joint. Subluxations
can occur while playing "overhead" (throwing,
tennis, swimming) sports, though the activity need not
be strenuous to cause an occurrence. Subluxations usually
happen to people who are approximately 14 to 30 years
of age. Although they may not be painful, subluxations
may, over time, contribute to problems of wear and tear
in the shoulder region.
A dislocation is far more serious, involving tissue
damage, stretching, and tearing. Unlike a subluxation,
the shoulder doesn't "pop back in." The first
step in treating a dislocated shoulder is almost always
a trip to the emergency department. People under 20
and over 50 are most prone to dislocations, with younger
individuals more prone to experience further dislocations
in the future.
Both subluxations and dislocations require physical
therapy to restore motion and build up strength. The
goal is to enhance shoulder stability and reduce the
chances of a recurrence.
"Double-jointedness," or hyperlaxity, is
a condition that many people are curious about; you
may have seen "double-jointed" people do "tricks"
or stunts. Hyperlaxity simply means that the joint in
question (in this case, the glenohumeral joint) has
a much greater range of motion than is usual. Hyperlaxity
is not uncommon in athletes- it's probably not possible
to be a professional baseball pitcher and not be double-jointed
to some degree. Hyperlaxity, however, can leave the
patient predisposed to dislocations, subluxations, and
rotator cuff tears. It's especially important that these
individuals develop and maintain rotator cuff strength
through a safe exercise program designed by a physical
therapist.
Impingement refers to a condition, sometimes painful,
in which the shoulder joint lacks enough room to function
properly. Structural impingement is a "built-in"
organic condition, e.g., a bone spur in the shoulder
joint. This situation is usually the result of years
of tendinitis, rotator cuff injuries, and wear-and-tear.
It is important to note that physical therapy cannot
correct structural impingement; it's crucial that the
patient consult with an orthopedic physician.
Functional impingements often result from occupational
situations (such as being hunched over a computer keyboard
all day). Brief stretching and exercise breaks, along
with proper posture, can help prevent and alleviate
functional impingement.
Trauma
Trauma comes in two varieties: microtrauma and macrotrauma.
Microtrauma is common in everyday life- it can occur
while lugging an overstuffed suitcase, or straining
to reach a can of spaghetti sauce on the top shelf.
In both cases we're inflicting microscopic tears to
the soft tissue around our shoulders. Although a single
episode of microtrauma in itself is rarely serious,
over time it can set the stage for shoulder ailments
such as tendinitis, bursitis, and rotator cuff injuries.
Macrotrauma is the result of violent force, with falls
and sports injuries being the most common causes. Depending
on what position your arm is in when you fall or get
hit, you can fracture your collarbone, dislocate your
shoulder, or tear your rotator cuff.
How Physical Therapy Can Help With Your Shoulder Condition
Whether your condition requires a physician's care or
not, a physical therapist will likely be involved in
all phases of your shoulder's rehabilitation. If surgery
is a possibility, the physical therapist will work with
you before and after surgery to guide you through a
program to help increase your strength and regain motion.
"Use it or Lose It." In the past several
years there has been a dramatic change in the health
profession's approach to rehabilitation. The current
thinking can be summed up as "use it or lose it."
In the past, for example, you might have been told to
keep your arm in a sling for weeks after a procedure
such as rotator cuff surgery. Today, physical therapists
make it their top priority to "get you going"
again as soon as possible after surgery. Why? Because
keeping the shoulder immobilized causes the muscles
to weaken and atrophy; furthermore, immobilization weakens
bones and joint cartilage, and promotes soft-tissure
scarring.
Your physical therapist has the skills and knowledge
to make your recovery as quick as possible, and the
know-how to strike a balance between rest and function
in the healing process.
Exercise- stretching and strengthening- is the key
to preventing shoulder problems. If you already have
a shoulder problem or pain, it would be wise to consult
with a physical therapist before embarking on an exercise
regimen. Beyond that, it's important to remember "exercise"
is not a matter of high-tech weightlifting machines
or "going for the burn." You can stretch and
strengthen during the three minutes per hour that you're
not at your computer keyboard...or you can do it at
home even with a couple of soup cans for weights. Remember,
exercise is like medicine- in the right doses it can
work wonders; in the wrong doses it can do more harm
than good.
Evaluation. Physical therapy places great emphasis
on this process. Your therapist will take a medical
history, perform a thorough evaluation to identify the
problem, and discuss the findings and treatment plan
with you. Pain felt in the area of the shoulder can
sometimes be caused by a variety of conditions that
are beyond the scope of this article, including a pinched
nerve in the neck and cardiac ailments. If your problem
isn't suitable for treatment by physical therapy, your
physical therapist will refer you to the proper professional
for treatment.
Treatment. Your physical therapist, often in consultation
with a physician, will design a treatment regimen tailored
to your individual condition, working to restore flexibility
and ease discomfort. Treatment may include heat, cold,
massage, ultrasound, electrical stimulation, traction,
or mobilization, as well as exercises for relaxation,
conditioning, restoring range of motion, strength, endurance,
and coordination.
Aftercare and Education. You don't need to become an
expert in physical therapy to avoid or overcome injury,
but you may need to learn some new habits or modify
your physical activity, whether it involves work, recreation,
or both. Once your physical therapy goals are met, your
physical therapist will help you continue therapy on
your own with a home program designed to fit your needs.
The goal of physical therapy is to return you to normal
activity as soon as possible, with the skills you need
to prevent reinjury or disability.
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