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1st Aug

2010

Is Shoulder Pain on the Rise?

Orthopedic surgeons I talk to seem to agree that we treat more people with shoulder problems, than we did 10-15 years ago. We are not quite sure why, although the aging baby boomers in general are more active than people their age in the past, which may be one explanation.

CHANGES IN THE SHOULDER AS WE AGE

Shouldn’t it help our health, including of the musculoskeletal system, to stay active throughout life? The answer is yes, but we need to increasingly pay attention to certain anatomical and physiological changes as we enter our 40s and 50s and beyond, in order not to get in trouble.

The shoulder is the most mobile joint in our body. Therefore, it also needs more stability from muscles and ligaments, in order to function well and without pain. The main muscle group which provides such shoulder stability is the rotator cuff, which consists of four muscles, which pull the shoulder ball down into the little flat socket on the shoulder blade. There is also a cartilage ring around the perimeter of this socket, called the labrum, which adds stability as well.

As we remain on earth for several decades, we tend to develop some wear and tear. The joint on top of the shoulder, called the AC joint, connects the end of the collar bone to the shoulder blade. This is a typical “arthritis joint”, where we often grow bone spurs over time, some of which may project downward to the space where the main rotator cuff tendons come out.

The rotator cuff are the “core muscles” of the shoulder, together with the muscles that keep the entire shoulder blade stable. As is the case throughout the body, we tend to develop muscle imbalances over time, where such core muscles get weaker, and other bigger muscles take over. This usually leads to trouble, if we overdo it with activities.
In the shoulder, the bigger muscles that start to dominate include the deltoid, pectorals and to some extent the biceps. The effect is, that when we reach up or out with the arm, keep the arms elevated for some time, or exert extra force such as with throwing, overhead lifting or pulling, swimming or with racket sports, the shoulder ball migrates upwards towards the roof of the shoulder blade, as the rotator cuff can no longer keep the ball down.

The result may be an impingement of the cuff tendons and adjacent bursal sac, or over the years a grinding effect on the tendons, especially if there is a bone spur present. This may result in degenerative tears in the tendon. A sudden strong contraction, or a fall on the arm, could then even cause a large or complete rotator cuff tear. The extra load placed on the labrum could also result in a labrum tear. Complete cuff tears and labrum tears usually require surgical repair, in order for the active person to be able to use the shoulder normally again.

GOOD PREVENTIVE MEASURES

Since many middle aged and older individuals today do some strengthening exercises, it would be recommended to add a few specific rotator cuff exercises, and avoid exercises which may put you at risk for developing shoulder impingement or rotator cuff tears.

The simplest exercise is a rotation exercise in and out, with the arm by your side against a towel roll, and the elbow bent to 90 degrees. The best way to get resistance is to use a pulley or cable machine, with light weights. Rotating the arm out typically requires less than half the resistance used when rotating the arm in. Proper technique is important. The exercise should not hurt.

If there is no pain, another helpful exercise is to raise the straight arm out to the side, holding onto a light hand weight, with the thumb pointing slightly up, and trying not to shrug the shoulder during the motion.

Exercises which often cause tears or impingement irritation include the overhead or military press, or pull down exercises starting with the arms fully elevated. Reaching out to the side against resistance with the arm rotated in (e.g. thumb pointing down, or leading with the elbow) may do the same. If these exercises are part of your routine, change them or take them out.

When we keep our arms lifted up during daily activities such as painting, yard work, handyman work etc, the best preventive measure is to let the arms down in regular intervals, to rest the rotator cuff. The irritation and pain may not start until the next day, so pain alone during the activity is not the best guideline.

REHABILITATION

Minor shoulder problems can usually be taken care of by rest, over the counter anti-inflammatory medications, and ice. However, if the pain has remained for several weeks, or it keeps coming back, it may be best to see your physician or physical therapist.

In physical therapy, we put particular emphasis on rehabilitating the rotator cuff and stabilizing shoulder blade muscles, in a step-by-step approach, until full and pain free function of the shoulder has been restored. Correct muscle recruitment and technique, and dosage of exercise intensity is essential for the rehabilitation to be successful. Continued equally specific home exercise is also crucial after the conclusion of physical therapy, in order to get long lasting improvement.

With best wishes for a healthy summer,

Gunnar

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