Shoulder Pain
Shoulder Pain – conditions treated are listed and then discussed below.
- 1. Rotator cuff tendinopathy
- 2. Calcific tendonitis of the rotator cuff
- 3. Rotator cuff strain
- 4. Dislocation of the shoulder joint (glenohumeral joint)
- 5. Shoulder instability
- 6. Fracture of the clavicle
- 7. Acromioclavicular (AC) joint injury
- 8. Adhesive capsulitis (frozen shoulder)
- 9. Biceps tendinitis
- 10. Rupture of the long head of biceps
- 11. Pectoralis major strain
- 12. Levator scapulae syndrome
- 13. Nerve entrapments around the shoulder
Fibrosis and pain at the inside of the shoulder blade – commonly makes a crunchy sound when moving and feels hard to pinpoint. Can be aching or burning and may relate to pain into the neck and further up the shoulder.
Usually related to overuse and also posture problems, can also stick the joints of the ribs where they ariculate with the spine and also the spinal joints themselves causing some pain referal from the joints too. Treatment is usually by Microcurrent, Trigger point treatment and manipulation of the associated joints. ART and or tool assisted treatment of the tissues to break down the adhesions.
Rotator cuff muscle pathology – Pain commonly in the front of the shoulder and also may go into the arm.
The rotator cuff muscles can become easily stresses when asked to brace suddenly in a fall or car accident when holding the steering wheel at time of impact. Pain in muscles can occur from Trigger Points and first described by the late Dr Janet Travell. Fibrotic changes in the muscle from a tear or microtears can adhere and cause the muscle to shorten, to feel tight and ‘knotted’ and they can trap peripheral nerves too.
Rotator cuff strain
What is it?
The rotator cuff refers to a group of four small muscles which run from the shoulder blade to the top of the arm bone. They act to both support and move the shoulder joint. A rotator cuff strain refers to a tear in one or more of these muscles.
How does it happen?
A rotator cuff muscle may be strained when it is forcibly contracted or overstretched. This can occur in any activity which requires movement of the shoulder.
How does it feel?
A tear of a rotator cuff muscle is usually felt as sudden pain or a ‘twinge’ felt in the shoulder area. In minor tears you may be able to continue participating with minimal hindrance. However, as the muscle cools down following participation the pain may gradually worsen as bleeding and swelling around the injured muscle takes place. In more severe tears, pain may be exaggerated such that you are unable to continue participating immediately following injury. In these cases the shoulder may also feel weak.
What should you do?
If you have or suspect you have a rotator cuff strain, it is advised you cease participating and begin initial treatment. The most important time in the treatment of a rotator cuff strain is the first 24–48 hours. This is when bleeding and swelling around the injured muscle is most active. Although swelling is a necessary step in the healing process, too much can delay healing and cause further tissue damage. To control the amount of swelling and limit the degree of damage, the injured rotator cuff muscle should be rested and iced. Rest involves ceasing to participate and limiting the use of the injured arm. Icing involves applying ice to the injured site for 15–20 minutes every 1–2 hours. Ideally, it should be applied using crushed ice wrapped in a moist cloth or towel. You should continue this until you consult a sports medicine professional. This should be undertaken as soon as possible following the injury (within the first couple of days).
What shouldn’t you do?
In the first few days following rotator cuff strain you shouldn’t undertake activities which increase blood flow to the injured muscle. These include hot showers, shoulder stretching, heat rubs, massage, the consumption of alcohol and excessive use of the arm. These can prolong muscle bleeding and exaggerate swelling resulting in further pain and an extended recovery.
Could there be any long-term effects?
Most rotator cuff strains heal without complication within a matter of weeks. However, a proportion of injuries can result in longer-term effects, depending on the severity of the injury and the extent of damage. For example, when a rotator cuff muscle is completely, torn surgery may be required to repair the muscle. To recover from surgery and enable the muscle to fully heal, a prolonged recovery may be required. Similarly, in minor tears recovery may be prolonged if the tear is not appropriately managed. This may result in a tight, weak rotator cuff muscle which is prone to reinjury with return to participation. This weakened muscle may also predispose you to other shoulder injuries such as rotator cuff tendinopathy.
Management
The assistance of a sports medicine professional is important in the treatment of a rotator cuff strain. Initially, they can assist in determining the exact tissue/s damaged and the extent of this damage. This may require the use of imaging techniques such as ultrasound to aid in the diagnosis. From this, a determination of how long the injury is expected to take to heal can be provided and an appropriate management plan developed. The latter may involve activity modification, the use of soft tissue treatment such as massage and stretching, and the progression through a series of specific strengthening exercises. These exercises will facilitate your return to participation, help prevent reinjury and reduce the likelihood of developing longer-term effects.
Rotator cuff tendinopathy
What is it?
The rotator cuff refers to a group of four small muscles which run from the shoulder blade to the top of the arm bone. They support and move the shoulder joint. The rotator cuff muscles attach to the arm bone by tendons. Rotator cuff tendinopathy refers to inflammation and swelling within one or more of these tendons.
How does it happen?
Rotator cuff tendinopathy results from overuse or injury to a rotator cuff tendon. The most commonly involved tendon is that of the supraspinatus muscle. This muscle helps to raise the arm into the air. Its tendon passes through a small space between the top of the arm bone and the point of the shoulder. In this space the tendon is susceptible to ‘wear and tear’. Repetitive use of the supraspinatus muscle and, therefore, the supraspinatus tendon can rub the tendon against the edges of the bony space resulting in microscopic tears within the substance of the tendon.
How does it feel?
Rotator cuff tendinopathy results in pain felt in the top of the upper arm. This is usually felt when you try to lift your arm into the air and typically develops gradually. Initially, the tendon may only be painful following exercise. For example, it may be first felt on rising the day following participation. Associated with the pain may be stiffness or tightness in the shoulder. Typically, these initial signs of rotator cuff tendinopathy are ignored, as they disappear quickly with use of the arm or applying heat (i.e. a hot shower) over the shoulder. However, as you continue to participate, the tendinopathy progresses and the pain within the tendon becomes more intense and more frequent. For example, it may begin to be present during participation. In the earlier stages, this pain during participation may initially disappear as you warm up, only to return when you cool-down. However, as you continue to participate, the tendinopathy worsens and your pain may begin to be present for longer periods during participation until it is present each you lift your arm. This may interfere with your performance.
What should you do?
Rotator cuff tendinopathy generally does not get better on its own if the cause is not addressed and you continue to participate. If you have or suspect you have rotator cuff tendinopathy, you should consult your nearest sports medicine professional. In the meantime, you can begin initial treatment. This should consist of icing following participation. Icing may consist of crushed ice wrapped in a moist towel applied to the sore area for 15–20 minutes.
What shouldn’t you do?
If you have or suspect you have rotator cuff tendinopathy, you shouldn’t ignore the problem. Your pain may get better as you exercise; however, the exercise you are doing may be interfering with the healing process and causing further damage. This can lead to your injury getting worse such that your pain does not ‘warm up’ and you feel it throughout participation. If this occurs, your recovery may be prolonged and it may take a number of weeks or months for you to return to full participation.
Could there be any long-term effects?
Rotator cuff tendinopathy does not produce any long-term effects as long as it is properly diagnosed and appropriately treated. If not, it can lead to prolonged pain in the upper arm and a prolonged lay-off from participation.
Management
The assistance of a sports medicine professional is important in the treatment of rotator cuff tendinopathy.
Initially, they can assist in diagnosing the problem and its severity. From this, the sports medicine professional will be able to determine an appropriate treatment plan. This may involve activity modification, soft tissue treatment such as Active Release Technique, or trigger point therapy, dry needling and stretching, and the progression through a series of specific strengthening and rehabilatation exercises. The sports medicine professional will also be able to assess and determine why you developed rotator cuff tendinopathy and address this during your recovery to prevent a re-occurrence when you return to full activity.
Whiplash Injury
What is it?
Acceleration/deceleration injury to the neck (whiplash) refers to the injury to any of a number of structures in the neck as a result of whiplash. These include ligaments, muscles and in severe cases the bones i.e Cervical Vertebrae
How does it happen?
Acceleration/deceleration injury to the neck is a common injury in motor vehicle accidents and contact sports and extreme sports such as downhill mountainbiking. In most instances the head is either violently thrust forward or backward on impact, and injury to the structures in the neck results.
How does it feel?
Typically there is little or no pain at the time of injury. Depending on the severity of the injury, there will be a gradual increase in the intensity of the pain over the following 2–3 days. Pain is usually felt in the neck, and occasionally in the head and shoulders. This may either be a dull ache or a sharp pain which is made worse by movement. In some situations it may prevent full motion of your neck. The pain may be in the middle of the neck, or to one or both sides of the neck. It may also radiate into the head, shoulders or arms.
What should you do?
If you have had a whiplash episode you should consult your nearest sports medicine professional for treatment. I advise always best to go to A & E and get X-rayed to rule out a vertebral fracture. If this is OK then get treatment. I treat whiplash successfully with Frequency Specific Microcurrent and Positional release especially in acute cases.
What shouldn’t you do?
If you have had an acceleration/deceleration injury, you shouldn’t ignore the problem and continue to exercise. This may lead to your problem getting worse, resulting in a prolonged recovery. In addition, you should avoid activities which aggravate your pain.
Could there be any long-term effects?
Possibly the worst potential outcome I see from whiplash that is not successfully treated is a type of fibromyalgia termed ‘cervical induced fibromyalgia’. See the link to fibromyalgia if you suspect this. FSM (Frequency Specific Microcurrent) is usually the most successful treatment of this type of fibromyalgia. Symptom include excruciating pain in the neck region, back, legs, arms and burning sensations in hands and feet.
Mild–moderate acceleration/deceleration injury usually does not produce any long-term effects, as long it is properly diagnosed and appropriately treated. Recovery in a mild–moderate case usually takes place in matter of weeks to months. A severe case, however, can occasionally lead to degeneration of the discs in the neck and joint damage, resulting in long-term mobility and pain problems.
Management
The assistance of a sports medicine professional is important in the treatment of an
acceleration/deceleration injury. Initially, they can assist in diagnosing the problem and in determining its severity. This may require the use of imaging techniques such as X-ray, CT scanning or MRI. From this, the sports medicine professional will be able to determine an appropriate treatment plan. This may initially involve techniques to reduce your pain. These may include activity modification, wearing of a soft collar, the taking of anti-inflammatory medications, and physiotherapy treatment. When your pain has settled sufficiently, the sports medicine professional will be able to provide you with a series of stretching and strengthening exercises designed to return you back to work and exercise, and to reduce the chances of your neck pain re-occurring.
What is it?
A dislocation of the shoulder joint refers to when the top of the arm bone comes out of and stays out of its
socket.
How does it happen?
When forces acting on the shoulder joint are too great for the supporting muscles and ligaments to resist, the
top of the arm bone may be caused to ‘pop out’ or dislocate. This can occur with a direct blow to the
shoulder joint which pushes the ball-shaped top of the arm bone out of its socket. Alternatively, it may result
from the transmission of forces up the arm to the shoulder joint. For example, when you land on an
outstretched hand, forces can be transmitted up the arm to the shoulder joint causing it to dislocate.
How does it feel?
The first sensation felt when the shoulder is dislocated is immediate and intense pain. This is often felt all
over the shoulder and may also radiate down the arm. It is usually so intense that you cradle your arm
against your body with your other arm. At the time of injury you may have also sensed the shoulder ‘popping
out’. This ‘popping-out’ or dislocation of the joint is often visible when you compare the appearance of the
injured shoulder to the opposite side.
What should you do?
A shoulder dislocation is a serious injury which requires immediate medical attention. If you have or suspect
you have dislocated your shoulder you should cease participating and go directly to your nearest sports
medicine professional or doctor. To support your arm whilst travelling you should wear an arm sling or, if
one is not available, fold up the bottom half of your jumper or shirt to support and cradle your arm. To help
with your pain and reduce and control any swelling you should also apply ice to the shoulder. Ideally, this
should be in the form of crushed ice wrapped in a moist towel or cloth applied for up to 20 minutes.
What shouldn’t you do?
If you have or suspect you have dislocated your shoulder, the main thing you shouldn’t do is try to ‘reduce’ or
relocate the top of the arm bone back into its socket by yourself. This requires the assistance of a sports
medicine professional or a doctor. If not done properly serious damage may be done to other structures
(nerves, bones, ligaments, cartilage) resulting in irreparable damage and/or a longer recovery time. In
addition, you shouldn’t undertake any activities which increase blood flow to the injured site. These include
hot showers, heat rubs, the consumption of alcohol and massage. These will cause further swelling in the
damaged tissues resulting in a prolonged recovery.
Could there be any long-term effects?
Due to the seriousness of a shoulder dislocation, there are unfortunately potential long-term effects. The
most common of these is recurrent or ongoing shoulder dislocations. When the shoulder joint is dislocated,
the tissues which support it are overstretched and in some cases torn. This makes the joint less stable and
decreases its ability to resist or withstand external forces. As a consequence, it dislocates much more
easily. Other long-term effects result from damage to surrounding structures when the shoulder joint is
dislocated. Occasionally, when the shoulder joint is dislocated, nearby nerves may be damaged. This can
result in numbness or altered sensation over the outside of the shoulder and occasionally weakness in the
shoulder muscles. This can prolong your recovery. Similarly, recovery may be prolonged if a bone is
fractured or broken when the shoulder is ‘popped out’.
Management
The assistance of a sports medicine professional is important in the treatment of a dislocated shoulder.
Initially, they can confirm that the shoulder is actually dislocated. If it is, they can assist in relocating or
‘reducing’ the bones back into their normal position. Following this, they can assess which tissues have
been damaged and the extent of this damage. This may require the use of an X-ray to determine whether
any of the bones are damaged. From this, the sports medicine professional will be able to provide you with a
determination of how long the injury is expected to take to heal. During your recovery, they will be able to
assist in reducing your pain and promoting your recovery. This will usually involve wearing a sling for the
first few weeks followed by progressing you through a series of exercises designed to return you back to
participation and reduce the risk of ongoing shoulder dislocations.
BRUKNER AND KHAN, CLINICAL SPORTS MEDICINE 3E, MCGRAW-HILL PROFESSIONAL
Shoulder instability
What is it?
Shoulder instability refers to when the capsule and ligaments supporting the shoulder joint become loose,
enabling the bones forming the joint to move excessively on one another.
How does it happen?
Shoulder instability occurs when the capsule and ligaments supporting the shoulder joint become loose and
allow excessive movement of the bones that make-up the joint. This most commonly occurs following a
shoulder dislocation where the top of the arm bone is ‘popped out’ of its socket. This overstretches and
injures the capsule and ligaments surrounding the shoulder joint, reducing their ability to support the joint
and making the joint ‘unstable’. Similarly, the capsule and ligaments supporting the shoulder joint may be
overstretched and damaged if they are repetitively stressed. This can occur, for example, during throwing
which stretches out these structures. If performed repetitively, this can make the capsule and ligaments
loose and the shoulder joint ‘unstable’. Shoulder instability may also result from ligament laxity you were
born with. People with this type of laxity are often referred to as ‘double jointed’ and have loose ligaments
and instability at most joints in the body.
How does it feel?
Shoulder instability may cause a number of sensations. In certain positions of the arm, the bones within the
shoulder joint may slip or ‘sublux’. This is often felt as a clunking sensation as the bones within the shoulder
joint move excessively on one another. This clunking may be associated with pain which is felt deep within
the shoulder. This may create a situation where you don’t like moving the arm into the position where it
clunks. In some situations you may also experience a ‘dead arm’ where the arm feels momentarily numb
and weak after the bones slip or ‘sublux’. When the capsule and ligaments supporting the shoulder joint are
extremely loose, the shoulder joint may continually dislocate.
What should you do?
If you have or suspect you have shoulder instability, it is advised you seek the assistance of a sports
medicine professional. Shoulder instability does not get better on its own.
What shouldn’t you do?
If you have or suspect you have shoulder instability, you should avoid those positions or activities that are
likely to cause a further episode. This may cause further damage and prolong your recovery.
Could there be any long-term effects?
Shoulder instability generally does not produce any long-term effects as long as it is accurately diagnosed
and appropriately treated. Treatment often involves several months of intense shoulder rehabilitation. This
is often successful; however, in some situations your instability may continue to be a problem. This may
result in dislocation/s of the shoulder joint and subsequent damage to surrounding structures, including
nerves, bone, and the cartilage lining the joint surfaces. Damage to the cartilage may result in shoulder
arthritis later in life. To treat the ongoing laxity in the capsule and ligaments supporting the shoulder joint,
surgery may be required to tighten these structures and increase the ‘stability’ of the joint.
Management
The assistance of a sports medicine professional is important in the treatment of shoulder instability. Initially,
they can confirm your diagnosis and the extent of the damage. This may require the use of imaging
techniques such as X-ray, CT scans or MRI. Following this, they can provide you with a determination of
how long your rehabilitation is expected to take and determine an appropriate treatment program. This may
involve the use of massage, stretches and a series of specific exercises designed to strengthen the muscles
that stabilise and support the shoulder joint. Surgery to reconstruct the damaged joint lining (‘labral tear’)
and tighten the loose ligaments is sometimes necessary. The sport medicine professional is able to
determine whether and when this may be appropriate in your overall circumstances.
BRUKNER AND KHAN, CLINICAL SPORTS MEDICINE 3E, MCGRAW-HILL PROFESSIONAL
Fracture of the clavicle
What is it?
A fracture of the clavicle refers to a break in the collarbone.
How does it happen?
The clavicle is usually fractured following an impact to the point of the shoulder. The impact may be with a
stationary object, such as the ground or wall, or with a moving object, such as an opponent. Similarly, the
clavicle may be fractured when you fall on either your elbow or an outstretched hand. When this occurs, the
force of the impact is transmitted along the bones in the arm to the clavicle. If the force is sufficient the
clavicle may break.
How does it feel?
The first sensation felt when the clavicle is fractured is extreme pain experienced somewhere between the
bottom of the neck and point of shoulder. There may also be an audible snap or crack as the bone breaks.
When you look at your collarbone, there may be an obvious deformity or bump. This is due to either
displacement of the broken ends of the bone or early bleeding and swelling around the site of the fracture.
What should you do?
A fracture of the clavicle is a serious injury. If you have or suspect you have a fracture of the clavicle, you
should stop participating and seek the assistance of a sports medicine professional. To support your arm
whilst travelling you should wear an arm sling or, if one is not available, fold up the bottom half of your
jumper or shirt to support and cradle your arm. To help with your pain and reduce and control any swelling
you should apply ice to the shoulder. Ideally, this should be in the form of crushed ice wrapped in a moist
towel or cloth applied for up to 20 minutes.
What shouldn’t you do?
If you have or suspect that you have fractured your clavicle, you shouldn’t perform any activities which may
cause the broken ends of the bone to move on one another. To do achieve this you shouldn’t use the
injured arm until it has been assessed by a sports medicine professional. In addition, you should avoid any
activities which may increase the blood flow to the injured area. These include hot showers, heat rubs,
massage and the consumption of alcohol. These may increase the bleeding around the fractured ends of
bone and potentially prolong your recovery.
Could there be any long-term effects?
Most fractures of the clavicle heal without complication in a matter of weeks. This may leave a visible bump
in the bone. However, this is a cosmetic problem in that it is a deformity which is pain free and doesn’t
interfere with the use of your arm. In a small number of cases the broken ends of the bone fail to heal or
‘unite’. When this occurs you may need latter surgery or alternative treatments to stimulate healing.
Management
The assistance of a sports medicine professional is important in the treatment of a fractured clavicle.
Initially, they can assist in diagnosing the injury and the extent of the damage. This may require the use of
an X-ray to view the bone. From this, the sports medicine professional will be able to provide you with a
determination of how long the injury is expected to take to heal and determine an appropriate treatment
program. If your clavicle is fractured, the latter will usually involve wearing a sling for the first few weeks
followed by a series of exercises designed to return you back to participation and reduce the risk of ongoing
problems.
BRUKNER AND KHAN, CLINICAL SPORTS MEDICINE 3E, MCGRAW-HILL PROFESSIONAL
Acromioclavicular (AC) joint injury
What is it?
An acromioclavicular or AC joint injury refers to an injury to the joint between the end of your collarbone
(clavicle) and the upper part of your shoulder blade (acromion).
How does it happen?
The AC joint is usually injured following an impact to the point of the shoulder. The impact may be with a
stationary object, such as the ground or wall, or with a moving object, such as an opponent. This impact can
push the upper part of the shoulder blade beneath the end of the collarbone. This can injure the capsule
surrounding the AC joint and the ligaments which support the joint.
How does it feel?
The first sensation felt when the AC joint is injured is pain experienced on the top of the shoulder. This pain
may be strong enough to stop you from using the injured arm and may cause you to cradle the arm close to
your body. Depending on the severity of the injury, when you look at the site where the pain is coming from
there may be an obvious deformity or bump. This is due to either displacement of the bones forming the
joint or early bleeding and swelling around the injured structures.
What should you do?
If you have or suspect you have injured your AC joint, it is advised you cease participating and begin initial
treatment. The most important time in the treatment of a AC joint injury is the first 24–48 hours. This is
when bleeding and swelling around the injured tissues is most active. Although swelling is a necessary step
in the healing process, too much can delay healing and cause further tissue damage. To control the amount
of swelling and limit the degree of damage to the injured tissues, the shoulder should be rested and iced.
Rest involves ceasing to participate and limiting the use of the injured arm. If the pain is strong you may use
a sling to support the arm and reduce the tension on the injured structures. Icing involves applying ice to the
injured site for 15–20 minutes every 1–2 hours. Ideally, it should be applied using crushed ice wrapped in a
moist cloth or towel. You should continue this until you consult a sports medicine professional. This should
be undertaken as soon as possible following the injury (within the first couple of days).
What shouldn’t you do?
In the first few days following AC joint injury, you shouldn’t undertake activities which increase blood flow to
the injured tissues. These include hot showers, heat rubs, massage, the consumption of alcohol and
excessive use of the arm. These can prolong bleeding and exaggerate swelling resulting in further pain and
an extended recovery.
Could there be any long-term effects?
Most AC joint injuries heal without complication, within a matter of weeks. However, a proportion of injuries
can result in longer-term effects. In more serious injuries, recovery may be prolonged due to the extent and
severity of damage to the injured tissues. Similarly, in more minor tears, recovery may be prolonged if the
tear is not appropriately managed. This may result in ongoing shoulder pain and an increased risk of reinjury
when you return to participation.
Management
The assistance of a sports medicine professional is important in the treatment of an AC joint injury. Initially,
they can assist in diagnosing the injury and the extent of the damage. This may require the use of an X-ray
to exclude damage to the bones. From this, the sports medicine professional will be able to provide you with
a determination of how long the injury is expected to take to heal and determine an appropriate treatment
program. The latter may involve the use of a sling to help with your pain, the use of ultrasound therapy to
assist with the healing of the injured tissues and a series of exercises designed to return you back to
participation and reduce the risk of reinjury. In terms of the latter, a sports medicine professional will also be
able to advise you on other preventive measures, such as the use of strapping tape.
BRUKNER AND KHAN, CLINICAL SPORTS MEDICINE 3E, MCGRAW-HILL PROFESSIONAL
Adhesive capsulitis (frozen shoulder)
What is it?
Often referred to as ‘frozen shoulder’, adhesive capsulitis refers to inflammation and scarring of the capsule
which surrounds the shoulder joint.
How does it happen?
The exact reason why adhesive capsulitis develops is not known. However, it tends to occur in the middle-
aged or older athletes and is believed to result from some form of irritation to the shoulder joint and its
surrounding capsule. Irritation to the shoulder joint capsule results in an inflammatory response. This
inflammation of the shoulder joint capsule is referred to as ‘capsulitis’. Associated with the capsulitis is the
formation of adhesions or small scars between folds within the capsule. Consequently, the condition is
referred to as adhesive capsulitis.
How does it feel?
The two main sensations felt with adhesive capsulitis are pain and a loss of movement in the shoulder. The
pain may be aching, dull or stabbing, and is most frequently felt deep in the shoulder and over the outside of
the upper arm. It is generally aggravated by almost all movements of the shoulder and arm, and its intensity
or strength may vary from day-to-day depending on how much you use the arm. The pain is often strong
enough to interfere with your normal activities and you may feel it at night when sleeping. The loss of
movement in the shoulder results from the adhesions or scars forming within the joint capsule. These
generally develop gradually resulting in a progressive rather than sudden loss in the range of motion in the
shoulder. Stretching of these adhesions may aggravate your pain.
What should you do?
If you have or suspect you have adhesive capsulitis you should seek the assistance of a sports medicine
professional or doctor as soon as possible.
What shouldn’t you do?
If you have or suspect you have adhesive capsulitis you shouldn’t ignore the problem. The longer you leave
the condition without treatment, the worse it may become. This may make your pain and restriction in
movement worse and prolong your recovery.
Could there be any long-term effects?
Adhesive capsulitis usually gets better on its own. However, this normally takes a number of months and
there is little that can be done to accelerate this time frame. Treatment markedly reduces this recovery time.
Fortunately, once recovery does occur the long-term outlook is good, unless there is some other underlying
condition affecting the shoulder, such as a tear of the rotator cuff.
Management
If the diagnosis of adhesive capsulitis is made, the sports medicine professional will be to provide you with
an appropriate treatment program. This will most commonly be aimed at reducing your pain and improving
your shoulder range of motion. It may involve the use of anti-inflammatory medications, electrotherapy
treatment, and stretching, strengthening and range of motion exercises. Occasionally, if these measures do
not provide relief, referral from the sports physician for an injection into the shoulder may be appropriate.
This is performed by a radiologist. It involves injecting fluid into the shoulder to stretch up the lining of the
joint (hydrodilatation) and stretches up the restricted lining of the joint. It is followed up by physiotherapy to
ensure that the extra range of motion gained by the procedure is maintained. The procedure also provides
significant pain relief.
BRUKNER AND KHAN, CLINICAL SPORTS MEDICINE 3E, MCGRAW-HILL PROFESSIONAL
Biceps tendinopathy
What is it?
Biceps tendinopathy refers to inflammation within the tendon which connects the biceps muscle on the front
of the upper arm with the shoulder blade.
How does it happen?
Biceps tendinopathy results from overuse of the biceps tendon. The function of the biceps tendon is to
transmit forces produced by the biceps muscle to the shoulder blade so as to produce or control movement
at the shoulder joint. To reach its insertion onto the shoulder blade, the biceps tendon passes through a
narrow groove in the arm bone. In this groove the tendon is susceptible to ‘wear and tear’. Repetitive use of
the biceps muscle and, therefore, the biceps tendon can rub the tendon against the edges of the bony
groove resulting in microscopic tears within the substance of the tendon. To repair these microscopic tears,
the body commences an inflammatory response. This inflammation within the tendon is tendinopathy.
How does it feel?
Biceps tendinopathy results in pain felt in the top of the upper arm. This pain typically develops gradually.
Initially, the tendon may only be painful following exercise. For example, it may be first felt on rising the day
following participation. Associated with the pain may be stiffness or tightness in the shoulder. Typically,
these initial signs of biceps tendinopathy are ignored as they disappear quickly with use of the arm or
applying heat (i.e. a hot shower) over the shoulder and upper arm. However, as you continue to participate,
the tendinopathy progresses and the pain within the tendon becomes more intense and more frequent. For
example, it may begin to be present during participation. In the earlier stages, this pain during participation
may initially disappear as you warm-up, only to return when you cool down. However, as you continue to
participate, the tendinopathy worsens and your pain may begin to be present for longer periods during
participation until it is present all of the time. This may interfere with your performance.
What should you do?
Biceps tendinopathy generally does not get better on its own if the cause is not addressed and you continue
to exercise. If you have or suspect you have biceps tendinopathy, you should consult your nearest sports
medicine professional. In the meantime you can begin initial treatment. This should consist of icing
following participation. Icing may consist of crushed ice wrapped in a moist towel applied over the sore site
for 15-20 minutes or ice in a paper cup massaged over the sore region until the skin is numb.
What shouldn’t you do?
If you have or suspect you have biceps tendinopathy you shouldn’t ignore the problem. Your pain may get
better as you exercise, however, the exercise you are doing may be interfering with the healing process and
causing further damage. This can lead to your injury getting worse such that your pain does not ‘warm up’
and you feel it throughout participation. If this occurs, your recovery may be prolonged and it may take a
number of weeks or months for you to return to full participation.
Could there be any long-term effects?
Biceps tendinopathy does not produce any long-term effects as long as it is properly diagnosed and
appropriately treated. If not, it can lead to prolonged pain in the upper arm and a prolonged lay-off from
participation.
Management
The assistance of a sports medicine professional is important in the treatment of biceps tendinopathy.
Initially, they can assist in diagnosing the problem and its severity. This may require the use of imaging
techniques such as ultrasound or MRI. From this, the sports medicine professional will be able to determine
an appropriate treatment plan. This may involve activity modification, soft tissue treatment such as massage
and stretching, and the progression through a series of specific strengthening exercises. The sports
medicine professional will also be able to assess and determine why you developed biceps tendinopathy and
address this during your recovery to prevent a re-occurrence when you return to full activity.
BRUKNER AND KHAN, CLINICAL SPORTS MEDICINE 3E, MCGRAW-HILL PROFESSIONAL
Rupture of the long head of biceps
What is it?
Rupture of the long head of biceps refers to a complete break within the tendon which connects the biceps
muscle on the front of the upper arm with the shoulder blade.
How does it happen?
A rupture of the long head of biceps can occur when the biceps muscle is forcibly contracted. The function
of the biceps tendon is to transmit forces produced by the biceps muscle to the shoulder blade so as to
produce or control movement at the shoulder joint. Forcible contraction of the muscle can overstress the
biceps tendon resulting in it breaking or rupturing. This most commonly occurs in the middle-aged or older
athlete who has a history of biceps tendinopathy. To reach its insertion onto the shoulder blade, the biceps
tendon passes through a narrow groove in the arm bone. In this groove the tendon is susceptible to ‘wear
and tear’. Repetitive use of the biceps muscle and, therefore, the biceps tendon can rub the tendon against
the edges of the bony groove resulting in microscopic tears within the substance of the tendon. To repair
these microscopic tears, the body commences an inflammatory response. This inflammation within the
tendon is tendinopathy. Where this occurs, it results in an area of weakness within the biceps tendon which
can rupture if forces are great enough.
How does it feel?
A complete rupture of the long head of biceps results in instant pain felt in the top of the upper arm. This is
often associated with a sensation of something suddenly snapping or tearing. The pain may settle quickly,
however, when you look at the front of the upper arm and biceps muscle it appears different than normal.
There may be bunching up of the muscle in the lower part of the upper arm resulting in a prominent lump.
This lump may become more apparent if you contract or tighten your biceps muscle.
What should you do?
A rupture of the long head of biceps does not get better on its own. Therefore, if you have or suspect this
injury, it is advised you seek the assistance of a sports medicine professional as soon as possible (i.e. on the
same day as the injury). In the meantime you can begin initial treatment to limit the amount of bleeding and
swelling within and around the torn ends of the tendon. This should consist of rest and the application of ice
to the shoulder. Rest involves ceasing to participate and limiting the amount you use the injured arm. Ice
should be applied to the injured site for 15–20 minutes every 1–2 hours. Ideally, this should be applied using
crushed ice wrapped in a moist cloth or towel.
What shouldn’t you do?
Following a rupture of the long head of biceps you shouldn’t undertake activities which increase blood flow to
the injured site and, therefore, bleeding and swelling to the area. These include hot showers, heat rubs,
massage, the consumption of alcohol and excessive activity.
Could there be any long-term effects?
A rupture of the long head of biceps does not heal by itself. As a result it may be repaired surgically. The
decision to perform surgery will depend on how much the injury is interfering with the functioning of your arm,
and your individual sport and situation. If your arm functioning is not impaired, the tendon may not be
repaired. In these cases you should be able to return to participation following a short period of
rehabilitation.
Management
The assistance of a sports medicine professional is important in the treatment of a rupture of the long head
of biceps. Initially, they can assist in diagnosing the problem and establishing its severity. This may require
the use of imaging techniques such as ultrasound or MRI. From this, the sports medicine professional will
be able to determine an appropriate treatment plan. This may require surgery, the use of soft tissue
treatment such as massage and stretching, and the progression through a series of strengthening exercises.
BRUKNER AND KHAN, CLINICAL SPORTS MEDICINE 3E, MCGRAW-HILL PROFESSIONAL
Pectoralis major strain
What is it?
A pectoralis major strain refers to a tear in the large muscle which covers the chest.
How does it happen?
A pectoralis major strain typically occurs when the muscle is forcibly contracted whilst in a stretched position.
This can occur during weight training when performing bench press exercises. When the bar is lowered, the
pectoralis major muscle is stretched across the chest. In this position, overstretching of the muscle
combined with the need to generate high muscle forces to lift and lower the bar may place too much stress
on the muscle. The muscle subsequently tears.
How does it feel?
The first sensation you feel when the pectoralis major muscle is torn is sudden pain felt in the chest or, more
commonly, at the front of the armpit. At the same time you may have a sensation of something tearing. In
minor tears you may be able to continue participating with minimal hindrance. However, as the muscle cools
down following participation, pain may gradually worsen as bleeding and swelling around the injured muscle
takes place. This may be associated with progressive tightening and stiffening of the pectoralis muscle. In
more severe tears these sensations may be exaggerated such that you are unable to continue participating
immediately following injury due to excessive pain, and muscle tightness, weakness and spasm. In
complete tears of the pectoralis major muscle, you may have instant pain which quickly subsides. However,
as the muscle is completely torn, you are unable to produce force and the arm is substantially weakened.
What should you do?
To limit the severity of the injury, it is advised you cease participating and begin initial treatment. The most
important time in the treatment of a pectoralis major strain is the first 24–48 hours. This is when bleeding
and swelling around the injured muscle is most active. Although swelling is a necessary step in the healing
process, too much can delay healing and cause further tissue damage. To control the amount of swelling
and limit the degree of damage to the pectoralis muscle, the muscle should be rested and iced. Rest
involves ceasing to participate and limiting the use of the injured arm. Icing involves applying ice to the
injured site for 15–20 minutes every 1–2 hours. Ideally, it should be applied using crushed ice wrapped in a
moist cloth or towel. You should continue this until you consult a sports medicine professional. This should
be undertaken as soon as possible following the injury (within the first couple of days).
What shouldn’t you do?
In the first few days following a pectoralis major strain you shouldn’t undertake activities which increase
blood flow to the injured muscle. These include hot showers, pectoralis stretching, heat rubs, massage, the
consumption of alcohol and excessive use of the arm. These can prolong muscle bleeding and exaggerate
swelling resulting in further pain and an extended recovery.
Could there be any long-term effects?
Most pectoralis major strains heal without complication, within a matter of weeks. However, a proportion of
injuries can result in longer-term effects, depending on the severity of the injury and the extent of damage.
Complete tears of the muscle rarely heal by themselves and may require surgery to reunite the torn ends of
the muscle. If a complete tear is not diagnosed and addressed early, it may prolong your recovery.
Similarly, in more minor tears, recovery may be prolonged if the tear is not appropriately managed. This may
result in a tight, weak pectoralis major muscle which is prone to reinjury when you return to participation.
Management
The assistance of a sports medicine professional is important in the treatment of a pectoralis major strain.
Initially, they can assist in determining the exact tissue/s damaged and the extent of this damage. This is
particularly important in complete tears of the pectoralis major muscle and may require the use of imaging
techniques such as ultrasound. From this, a determination of how long the injury is expected to take to heal
can be provided and an appropriate management plan developed. The latter may mean the use of a number
of treatment techniques to assist in reducing pain and swelling and to enhance the healing of the injured
structures. This can be facilitated by providing you with an appropriate progression of exercises aimed at
increasing your muscle length, strength and function. These exercises will facilitate your return to
participation and help prevent reinjury.
BRUKNER AND KHAN, CLINICAL SPORTS MEDICINE 3E, MCGRAW-HILL PROFESSIONAL
Levator scapulae syndrome
What is it?
Levator scapulae syndrome refers to pain arising from the levator scapulae muscle where it attaches to the
top of the shoulder blade in the upper back.
How does it happen?
Levator scapulae syndrome results from prolonged overstretching of the levator scapulae muscle. This can
occur if you have poor posture of your shoulders. For example, when sitting hunched over with your
shoulders rounded. This stretches the levator scapulae muscle and, when performed over a long-period of
time, can result in inflammation and pain within the muscle.
How does it feel?
Levator scapulae syndrome produces pain which is felt in the upper back. This is most often felt where the
muscle attaches to the top of the shoulder blade. However, it may also be felt in the neck, over the top of the
shoulder or between the shoulder blades. This pain may disappear quickly when heat (i.e. a hot shower) is
applied over the shoulder blade.
What should you do?
If you have or suspect you have levator scapulae syndrome, you should seek the assistance of a sports
medicine professional.
What shouldn’t you do?
If you have or suspect you have levator scapulae syndrome, you shouldn’t ignore the problem. Your pain
may improve if you apply heat over the shoulder or massage the sore area; however, unless the cause of the
problem is identified and addressed the pain will continue to return and may get progressively worse.
Could there be any long-term effects?
Levator scapulae syndrome does not produce any long-term effects, as long as it accurately diagnosed and
appropriately treated.
Management
The assistance of a sports medicine professional is important in the treatment of levator scapulae syndrome.
Initially, they can assist in confirming your diagnosis and the reason why you developed it. Following this,
the sports medicine professional will be able to design an appropriate treatment plan to reduce your pain and
reduce the chance of it returning. This may involve massage, stretching and strengthening exercises, and
exercises designed to improve your posture.
Nerve entrapments around the shoulder
What is it?
A nerve entrapment around the shoulder refers to when a nerve within the shoulder becomes stuck to or
compressed by tissues surrounding it.
How does it happen?
Nerves in the shoulder may become entrapped when adhesions develop between the nerve and the
surrounding tissues. These adhesions may restrict how much the nerve can slide forwards and backwards
as the arm is moved. This may cause overstretching of the nerve at the site of the adhesions resulting in the
interference of signals being transmitted by the nerve. Alternatively, the nerves in the shoulder may become
entrapped by excessively tight surrounding tissues. These may compress the nerve and interfere with the
transmission of its signals. In the shoulder the most commonly entrapped nerve is the suprascapular nerve.
This may be entrapped as it passes around the bony edges of the shoulder blade.
How does it feel?
When a nerve in the shoulder is entrapped the most common sensation felt is pain. For the suprascapular
nerve this is usually felt over the shoulder blade. However, it may also be felt in the arm, neck or even the
chest. Often associated with this is a feeling of weakness in the shoulder.
What should you do?
Nerve entrapments in the shoulder generally do not get better on their own if the cause of the entrapment is
not treated. If you have or suspect you have a nerve entrapment, you should consult your nearest sports
medicine professional. In the meantime, you should avoid activities which aggravate or provoke your pain.
This may lead to the further entrapment and worsening of your pain.
What shouldn’t you do?
If you have or suspect you have an entrapped nerve in your shoulder, you shouldn’t ignore the problem.
This can lead to your injury getting worse which may prolong your recovery.
Could there be any long-term effects?
Nerve entrapments in the shoulder do not usually produce any long-term effects as long as they are properly
diagnosed and appropriately treated. If not, they can lead to ongoing pain in the shoulder, wasting of the
muscles the entrapped nerve supplies and a prolonged lay-off from participation. Appropriate treatment
often involves surgery to remove the structures that have entrapped the nerve.
Management
The assistance of a sports medicine professional is important in the treatment of an entrapped nerve in the
shoulder. Initially, they can assist in diagnosing the cause of the problem and establishing its severity. This
may require the use of electromyography tests which assess whether the muscles supplied by the nerve are
functioning normally. From their assessment, the sports medicine professional will be able to determine an
appropriate treatment plan. In the shoulder, this often requires surgery to remove the structures that have
entrapped the nerve. Following surgery the sports medicine professional will also be able to assist in
returning you to participation. This may involve soft tissue treatment such as massage and stretching, and
specific exercises to strengthen your shoulder.