Shoulder pain can be a common complaint to athletes who use their shoulders a lot in a repetitive action, such as swimmers and tennis players. Athletes, however, are not the only ones afflicted with shoulder pain as many occupations can also result in repetitive actions of the shoulder, and lead to shoulder injury. Sudden unaccustomed use can also trigger shoulder problems.

The shoulder is a highly mobile joint, consisting of 3 bones, a joint capsule, ligaments, tendons and a bursa. The humerus is acted upon by the various muscles to perform the actions of flexion, extension, abduction, adduction, internal rotation, external rotation and circumduction. In perfect health, it has the greatest range of movement of any of the joints of the body. But each of the constituents of the shoulder is subject to injury, alone or in combination. As well, pain may be referred to the shoulder from the heart, the neck, the gallbladder, spleen, etc

Above: Shoulder movements.

ETIOLOGY

The most common shoulder problem is that of the 'impingement syndrome'. When the arm is held out away from the body, the rotator cuff tendons and the bursa get squeezed. This trauma, sustained or applied repetitively, can cause inflammation of the bursa (known as bursitis) or of the tendons (tendonitis). The tendon usually affected is the supraspinatus because it has a restricted space. As it or the bursa become inflamed, the space becomes even more restricted, increasing the squeeze and thus increasing the inflammation, and so goes the cycle. The inflammation can lead to calcification or to rupture of a tendon, commonly known as a 'tear' It is interesting to note that it is possible to trigger this painful condition by sleeping on the arm with it held away from the body. In this position, 'squeezers maintained and the oxygen supply is interrupted, resulting in cell damage.

a) bursa and tendon are impinged.
b) inflamed bursa and tendon.
c) damage to rotator cuff.

1. Overuse, i.e. 'wear and tear'.
2. Sudden, unaccustomed use, e.g. weekend athlete.
3. Injury, such as a direct blow or a fall, causing the onset of inflammation.
4. Poor posture.
5. Muscle weakness, i.e. lack of fitness.

The aims of treatment are to reduce the inflammation, aid in complete healing and prevent recurrence of the injury
1. Immediate Treatment - should consist of ice packs, made from crushed ice in a damp towel, applied for 20 minutes, 2-3 times daily.

Left: Making an ice pack. Right: Ice pack.

2. Anti-inflammatory medication prescribed and must be taken as directed.
3. Physiotherapy - is essential to ensure the return of full shoulder mobility and prevent recurrence of the injury.
Physiotherapy may include one or a combination of the following:
a) cryotherapy (ice and exercise)
b) ultrasound
c) electrical stimulation
d) electromagnetic therapy
e) mobilization techniques
f) stretch and strengthen routines

Flexiblity exercises can be done twice daily Each stretch is held, to the point of tightness (NOT PAIN) for at least 10 seconds, up to 60 seconds, and repeated 3 times.
a) hand on hip
b) external rotation
c) gravity stretch

When flexibility is 90% or normal, as compared to the other shoulder, strengthening exercises may begin. Initially, exercises are done with no resistance and with the assistance of gravity.

Circles pendulum - forward backwards - across chest, out to side

These are done slowly and pain-free. The next progression is stand-up exercises
(wall-walking, pully, range of motion (ROM), cane exercises, can).

When full range of motion has been recovered, concentration should be placed on strengthening the external rotators.

Exercises to avoid are: bench press, military press, push-ups.The physiotherapist will prescribe and supervise an exercise program designed to gradually increase the range of motion, some of which may be done at home after instruction. When rehabilitation is complete, return to activity can be effected with a gradual return to full activity. Ice packs should be applied following activity, for 20 minutes for 2-3 weeks.

1. Maintain a general level of fitness - strength and flexibility.
2. Practice good posture - avoid slumping.
3. Avoid working overhead for long periods.
4. Warm-up (including stretching) and warm-down (including stretching) before and after exercise.
5. Recognise and respond to signs of injury, e.g., compensation, disuse.
6. Avoid repetitive action, e.g. swimmers, breathe on both sides for crawl.

DISCLAIMER
The information in this brochure is of a general nature. Individual circumstances may require modification of general advice from an appropriate health professional eg Doctor or Dietitian.