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Shoulder Injury
mvpboxing |  May 04, 2017, 12:05PM
Impingement Syndrome
  1. Definition and Occurrence
    1. There is a limited amount of space between the top of the arm bone and the bones that comprise the shoulder girdle. Impingement syndrome results when this space is narrowed and the tendons comprising the rotator cuff muscles become crowded and inflamed.
    2. Most common in overhead athletes/workers and is usually due to overuse. Can commonly be caused by de-conditioned rotator cuff muscles failing to perform their function of stabilizing and depressing the head of the upper arm bone during overhead activity. Other common causes include acriomio-clavicular joint spurs, down sloped acromion, and capsular contractures.
  2. Symptoms
    1. Pain on anterior aspect of shoulder between arm bone and clavicle
    2. Pain can sometimes be present on the outside aspect of the arm and radiate down the arm
    3. Pain during overhead movements
    4. Some people notice a “painful arc” while raising their arm. Before a certain point and after a certain point the movement will be pain free, but they will experience the pain during a very specific point in the movement
  3. Treatment
    1. Pain management and rest
      1. Avoid resisted overhead movements to allow tendons proper healing time
      2. If you must perform overhead movements, make sure your palm is facing up as you come overhead
      3. ICE
    2. Stretching
      1. Posterior capsule
      2. Lattissimus
      3. Pectoralis major and minor
    3. Strengthening
      1. Shoulder lateral rotators progressing to the muscles that raise your arm overhead
      2. Shoulder retractors, depressors and scapular stabilizers
    4. Body mechanics
      1. Important to remember to have shoulder blade down and back during strengthening exercises to allow the rotator cuff tendons as much room as possible to move freely.
  4. Prehab (Prevention)
Rotator Cuff tear
  1. Definition and Occurrence
    1. Rotator cuff tears occur when there is too much stress placed on the muscle tendons that move and control the shoulder girdle. Often times, rotator cuff tears are preceded by a bout of impingement and thus have an gradual onset from overuse. They can also be caused by a traumatic injury in which there was a sudden traction or pulling on the arm and the resistance exceeded the tensile strength of the muscle tendon. The tendon then literally tears and the muscles function to lift and rotate the arm is compromised. This injury typically occurs with overhead athletes and workers.
  2. Symptoms
    1. Pain or even inability to raise the arm overhead/strength deficits
    2. Pain at night since gravity is not helping keep the top of the arm from moving into the bottom of the shoulder girdle bones
    3. Visible Atrophy of muscles surrounding the shoulder
  3. Treatment
    1. Depending on the size of the tear, your doctor will most likely need to repair the muscle tendon surgically. Some small tears can be managed conservatively through physical therapy. After the operation, you will be referred for physical therapy for rehabilitation to regain shoulder function. Rehab will consist of:
      1. Regaining your range of motion after the surgery is of paramount importance. This is a slow process since there is healing muscle tissue involved from the repair. Patience, hard work, and diligence are required. The time it takes to regain full range of motion depends on the type of surgical approach used, the size of the original muscle tear, and the quality/integrity of the tissues.
      2. Strengthening to make up for the atrophy that has taken place in the muscles during the immobilization period and to help ensure that the rotator cuff and scapular stabilizing muscles are strong enough to prevent re-injury other rotator cuff musculature.
  4. Prehab (prevention)
    1. Preventing a rotator cuff tear is similar to that of preventing impingement, since they are usually seen in a progression.
    2. Strengthen internal and external shoulder rotators
    3. Stretch posterior shoulder capsule
      1. If the back part of your shoulder capsule is tight, it can lead to movement of the top of the arm bone towards the front of the shoulder joint, leading to further crowding of the valuable space the tendons need to function
    4. Dynamic strengthening of shoulder stabilizers
      1. Perform strengthening exercises with destabilizing forces to force your stabilizing muscles to fire and hold the shoulder girdle in optimum position
Labral Tear (Labrum Tear)
  1. Definition and Occurrence
    1. The shoulder is a joint that sacrifices stability for increased mobility. The labrum is a structure that deepens the socket in which the arm bone sits in an attempt at increased stability. A tear in the labrum can result when too much force is transferred through the joint, such as in a fall on an outstretched hand. It can tear as a consequence of pulling away from the joint very quickly, such as grabbing an object in an attempt at avoiding a fall.
    2. Since the tendon of the biceps attaches to the top of the labrum, the tendon and the labrum both have a possibility of pulling away from their anchors. Whether both tendon and labrum are disrupted will help determine both the type of surgery necessary and the length of time necessary for rehabilitation.
    3. This type of injury is common in overhead athletes and usually occurs in conjunction with other rotator cuff dysfunction. Boxers could also be prone to this injury because of the large forces transferred through the upper extremity when landing a big hit.
  2. Symptoms
    1. Common symptoms associated with a labral tear are popping, locking, catching, or grinding felt in the shoulder joint during activity. Overhead activities will be painful.
  3. Treatment
    1. Operative treatment is usually indicated for this type of injury. The severity of involvement of the biceps tendon will determine whether the surgeon needs to clean the lesioned tissue or if the torn structure needs to be anchored back down to its origin.
    2. After the operation, the surgeon will refer you to physical therapy to regain your functional range of motion and strength. Rehab. will consist of:
      1. Passive range of motion performed by the therapist, progressing to active assisted and eventually active range of motion
        1. Depending on the type of tear, some motions will be limited for an extended period of time to allow the repaired tissues ample time to heal.
      2. Once range of motion is regained, light strengthening will be initiated, progressing to dynamic strengthening and stability to encourage the return of normal upper extremity use.
  4. Prehab (prevention)
    1. Preventing a labrum tear is similar to that of preventing rotator cuff injury
      1. Strengthen internal and external shoulder rotators
      2. Strength
      3. Stretch posterior shoulder capsule
        1. If the back part of your shoulder capsule is tight, it can lead to movement of the top of the arm bone towards the front of the shoulder joint, leading to further crowding of the valuable space the tendons need to function
      4. Dynamic strengthening of shoulder stabilizers
        1. Perform strengthening exercises with destabilizing forces to force your stabilizing muscles to fire and hold shoulder girdle in optimum position
        2. Increased stability at around the shoulder girdle will lessen the likelihood of a biceps tendon or labrum tear when the shoulder is in a compromised position
Subacromial Bursitis
  1. Definition and Occurrence
    1. The bursa is a fluid filled pouch located between the upper arm bone and the bones of the shoulder. Specifically, it is between the supraspinatus muscle portion of the rotator cuff and the overlying bones of the shoulder. It serves as a smooth surface for the tendons of the rotator cuff muscles to glide upon when they contract to help move the arm. With overuse and improper shoulder mechanics, the bursa can become irritated when it is pinched between the two structures.
    2. This condition usually occurs in overhead athletes or workers. Often times it will occur where there are muscle imbalances and asymmetrical tightness between the muscles on the front and back part of the shoulder.
  2. Signs and Symptoms
    1. Pain with overhead sports or overhead working conditions
    2. Pain between a very specific range of motion when raising your arm overhead
    3. Weakness with rotating your arm outward
    4. Tenderness on the front part of your shoulder between your arm and collar bone
  3. Treatment
    1. Rest and activity modification are the first steps. The inflamed bursa needs time to calm down and return to normal function. Without the proper resting period, the space between the arm bone and shoulder bone could become more crowded and eventually irritate the muscle tendons, causing further dysfunction.
    2. After the pain has significantly diminished, strengthening of the rotator cuff should be initiated to allow for proper shoulder function during overhead movements.
      1. Begin with strengthening of external and internal arm rotators with elbow against side. Progress to the muscles that raise your arm over head. Strengthening these muscles too soon will result in the bursa becoming inflamed again and further narrowing of the space where the muscle tendons function.
      2. Stretch the shoulder joint capsule where needed. A physical therapist should be able to recognize if there is a tight part of the shoulder capsule that could be contributing to narrowing the sub-acromial space.
    3. If the pain doesn’t resolve with conservative management, your physician may recommend a cortisone injection to reduce the inflammation in the bursa.
  4. Prehab (prevention)
    1. Stretch and strengthen the muscles that stabilize the scapula and control its positioning against the wall of the thorax.
      1. Lower trapezius strengthening
      2. Middle trapezius strengthening
      3. Rhomboid strengthening
      4. Stretching pectoralis major and minor and latissimus dorsi
      5. Rotator cuff strengthening
      6. Dynamic scapular control
        1. Upper Extremity Plyometrics
        2. Pushups on destabilizing surface
        3. Body Blade with shoulder motion

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