Shoulder Pathology and the Industrial Athlete
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This document discusses common shoulder pathologies seen in industrial athletes. It begins with shoulder anatomy including bones and muscles. It then discusses common injuries like impingement and rotator cuff tears. Impingement is caused by encroachment in the subacromial space and can be primary from bone spurs or congenital issues, or secondary from muscle imbalances or poor posture. Rotator cuff tears can be partial or full thickness and result from repetitive stress or acute trauma. Treatment involves rehabilitation exercises and potentially surgery. Trigger points are also discussed as a potential cause of shoulder pain presenting in specific patterns that can be treated with massage or spray techniques. Overall the document provides an overview of shoulder issues in industrial settings and potential
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Shoulder Pathology and the Industrial Athlete
- 1. Shoulder Pathology in the Industrial Athlete By Lyliette Aquino
- 2. Anatomy
- 3. Bones
- 4. Muscles Levator Scapula Supraspinatus Teres Minor Trapezius Deltoid Rhomboid Major Teres Major Infraspinatus Rhomboid Miinor Latissimus Dorsi
- 5. Muscles Subscapularis Pectoralis Minor Coracobrachialis Serratus Anterior Upper Trapezius Deltoid Pectoralis Major Biceps Brachii
- 6. Rotator Cuff
- 7. Nerves
- 8. Nerves
- 10. Impingement Encroachment of the subacromial space that decreases the area through which the supraspinatus and subacromial bursa pass underneath the subacromial arch
- 11. Causes Primary Impingement • Congenital anomaly of the acromion • Osteophyte (bone spur) of the distal acromion Secondary Impingement • Capsular laxity or tightness • Postural deviations • Rotator Cuff weakness • Muscular imbalances • Cervical radiculopathy
- 12. Primary Congenital anomaly of the acromion
- 13. Primary Osteophyte (bone spur) of the distal acromion
- 14. Secondary Capsular laxity or tightness
- 15. Secondary Postural deviation
- 16. Secondary Rotator cuff weakness
- 17. Secondary Muscular imbalances
- 18. Symptoms Stage I: • Pain only with activity and little or no weakness with ROM not restricted Stage II: • Pain both during and after activity, including ADL, and sometimes also at night Stage III: • Continuous pain and restricted ROM
- 19. Symptoms Pain and weakness pronounced midrange from 60-120 degrees of abduction and flexion Dull or deep pain underneath the acromion Pain may also be experienced along the bicep and the lateral side of the arm
- 20. At ↑ risk Day-to-day activities that involve using the arm above shoulder level Continuously working with the arms raised overhead Repeated throwing activities Other repetitive actions of the shoulder Age >30
- 21. Treatment Secondary • Strengthening of the rotator cuff muscles: • Internal Rotation and External Rotation @ N & 90⁰ • Side Lying External Rotation • Scaption • D1 and D2 Patterns • Rhythmic Stabilizations
- 22. Treatment
- 23. Treatment Secondary • Strengthening of the scapulothoracic muscles • Thoracic 3’s (standing or lying on stomach) • Serratus Punches • Prone Row with Retraction
- 24. Treatment
- 25. Treatment Secondary • Other shoulder glenohumeral joint muscles • Lat Pull Down • Bicep Curl • Chest Press • Shoulder Shrugs • Seated Rows • Lateral Raises • Forward Flexion
- 26. Treatment
- 27. Treatment Primary • Arthroscopic Subacromial Decompression/Acriomioplasty
- 29. Types Partial tear Full Thickness Tear
- 30. Causes Chronic • Impingement • Repetitive Stress Acute / Traumatic • Shoulder dislocation • Lifting an object that is too heavy with one arm • Lifting a heavy object improperly
- 31. Symptoms Dull deep ache in the shoulder that can become sharp with sudden movements or lifting of objects Disturbed sleep, especially when laying on affected side Difficulty with ADL such as combing the hair, reaching behind the back, and reaching a high shelf Weakness of the arm
- 32. At ↑ Risk Age >30 Individuals who play sports that require repetitive arm motions, particularly overhead Individuals whose job consist of repetitive arm motions overhead Those with impingement
- 33. Treatment Conservative Treatment • Rehabilitation Surgical Treatment • Open Repair • Arthroscopic Repair * All surgical procedures should be followed with rehabilitation*
- 34. Treatment Surgical – Open Repair • First technique used for rotator cuff tears • A traditional open surgical incision is often required if the tear is large or complex • This surgical incision is going to be larger than with other surgical procedures • The surgeon makes the incision over the shoulder and detaches the deltoid to see and gain access to the torn rotator cuff tendon
- 35. Treatment Open Repair
- 36. Treatment Surgical- Arthroscopic Repair Surgeon inserts a small camera, called an arthroscope, into the shoulder joint which displays pictures on a television screen, and the surgeon uses these images to guide miniature surgical instruments. The arthroscope and surgical instruments are thin needing only small incisions for surgery rather than the larger incision needed for open surgery. Least invasive method to repair a torn rotator cuff.
- 37. Treatment Arthroscopic Repair
- 38. Treatment • Rehabilitation • The rehab followed after surgery depends on the surgery type and the protocol that is being followed. • The shoulder will be immobilized after surgery and therapy will need to be done to regain ROM, strength, and neuromuscular control of the shoulder. • Exercises previously mentioned for impingement will be implemented later on during rehab for rotator cuff tears
- 39. Trigger Points Focus of hyperirritability in a tissue, that when compressed, is locally tender and, if sufficiently hypersensitive, gives rise to referred pain and tenderness.
- 40. Types Latent trigger point- painful only when touched Active trigger point- always tender and can produce referred pain whether muscle is active or inactive
- 41. Causes Injury • Fractures • Sprains • Dislocations • Muscle impact injuries • Stress of excessive or unusual exercise Overload • Prolonged stationary posture • Prolonged muscle immobilization in a shortened position • Nerve compression
- 42. Symptoms Dull ache Very Intense Muscle weakness Reduced ROM Pressure in a certain area elicits a referred pain pattern that is unique for each muscle *The referral patterns do not follow neurological referral patterns * *The sensation of trigger point pain is also different from neurologically referred pain*
- 43. Symptoms Pain becomes amplified with: • Muscle activity • Passive stretch of the muscle • Direct pressure • Prolonged stationary periods followed by moving
- 44. At ↑ Risk Working at a desk that has not been ergonomically assessed Constant overhead activity Working out in short, overly intense, manner Not giving muscles time to relax after a workout Poor posture
- 45. Examination Check for improper posture : forward head tilt, rounded shoulders Check for muscular imbalance Check bilateral ROM Palpate the area to locate any possible tenderness over what feels like a hard ball within the muscle
- 46. Examples
- 47. Examples
- 48. Treatment Spray/Ice-and-Stretch Before treatment the muscle is moved throughout its ROM With the muscle anchored at one end, the ice or vapocoolant spray is applied in a sweeping motion in parallel strokes in only one direction over the length of the muscle and then over the referred pain pattern As this is applied a rhythmic, passive, slow, and continual stretch is applied progressively to the muscle
- 49. Treatment Ischemic Compression Pressure is applied slowly and progressively over the trigger point as the tension in the trigger point and its taut band subsides. This is followed by a stretch of the muscle
- 50. Treatment Deep-Stroking Massage A firm pressure is used along the muscle Pressure increases progressively A milking movement from farthest to closest end of muscle
- 51. Take Home Points If you suspect you may have impingement or a rotator cuff tear try conservative method of rehab first • Make sure you focus on strengthening the rotator cuff and scapulothoracic msucles If symptoms do not subside you can always conveniently come and pay us a visit at RehabWorks and we can schedule a consult with you to try and pinpoint the cause of your pain and make a diagnosis
- 52. Take Home Points Remember that some shoulder pain can simply be a trigger point in a tense muscle, which that follows a referral pain pattern that targets the shoulder • The pattern it follows and the associated pain is different than nerve pathology associated pain Massages and trigger point balls are very effective ways of controlling and minimizing the pain
- 53. Thank You!!! Any Questions?
Editor's Notes
- - Good morning everyone! As you all know by now I have had the privilege of being an intern here at KSC RehabWorks. I wanted to first thank you all for coming this morning and sharing a little bit of your time with us. I am glad to see some familiar faces and also glad to see new faces. For some this will be familiar information that I will hopefully go more in detail about For some it will be completely new information My goal today is to have you walk out of here with a better understanding of some of these shoulder pathologies We will be talking about three shoulder pathologies today: shoulder impingement, rotator cuff tears, and trigger points that commonly affect the shoulder But before we start lets get some basic education on the anatomy we will be dealing with
- - First I would like to educate everyone on the basic anatomy of the shoulder This will give you all a base from which to understand the injuries I will be speaking of today Knowing this anatomy will help pinpoint possible causes of injury to the shoulder as well as give us an idea as to what route to take for treatment of these injuries If you have a specific locations of pain and can identify the structures in that area you can normally narrow down your diagnosis much easier
- In this picture you see in front of you there are basic bones and bony landmarks essential for understanding shoulder injuries Our bones act as the framework of the body They also act as attachments sites for muscles and other tissue The bones you see here and the names given to different parts of these bones are all we need to know for the injuries I will be discussing today Point and state the names of all important areas
- Next we will talk about the important muscles that work in some form or another to keep movement at the shoulder in optimal condition Muscles are responsible for the movements of the body and the image you see here gives all the muscles generally associated with the posterior shoulder complex On the left side we see the more superficial muscles On the right side you we see the deeper musculature It is important to note that there are scapulothoracic muscles that help with proper dynamic movement of the shoulder. They allow the scapula to move in unison with the humerus to keep the humeral head in the glenoid. Strength in these muscles is key to avoiding several shoulder pathologies.
- The image you see here gives all the muscles generally associated with the anterior shoulder complex On the left side again you will find the more superficial muscles On the right side again you will find the deeper musculature The serratus anterior shown in this picture is a part of the scapulothoracic muscles
- The rotator cuff is made up of four muscles: supraspinatus, infraspinatus, subscapularis, and teres minor The rotator cuff muscles is the second group of muscles that are extremely important when talking about proper movement of the shoulder joint and proper strength of these muscles can prevent shoulder pathology. Normal function of the rotator cuff is to depress the humeral head during shoulder elevation motions and keep in tightly inside that glenoid cavity.
- Muscles cannot fire without the proper nerves innervating them and so I wanted to give you just a basic picture illustrating exactly what is going on in regards to nerves at the shoulders It’s a pretty big group of nerves collectively known as the brachial plexus that run from the spine and separate further as they run into the entire arm and hand Name the nerves on the bottom right.
- Nerve pain sensation is tingling, burning, and numbness This type of pain follows a specific path depending on which nerve if being irritated These pictures show how the brachial plexus branches out into several nerves and innervates the arm. (Right picture has innervation sections clearly defined and can help you all visual the concept of having never pain that is specific to only some portions of the arm because the associated irritated nerve only innervates that specific portion of the arm) This will be important to remember later on when we discuss trigger points.
- Okay so we have a general understanding now of the pieces of the puzzle that make up the shoulder So now we want to see how these pieces are affected by injury and how some of these pieces can cause an injury
- The first pathology I would like to talk about is shoulder impingement Who here has heard of shoulder impingement before, or knows someone who has shoulder impingement, or has shoulder discomfort and pain and have gone above and beyond doing their google searching (avoiding a doctor) and think they might have shoulder impingement themselves? Okay well pay close attention as I go through all these points if you want to be further informed - Impingement is a narrowing of the space within the shoulder which leads to a pinching of deep musculature in the shoulder, particularly the supraspinatus which runs directly under the subachromial arch (seen here – point out on picture) The space is already narrow to begin with and further narrowing can cause impingement to occur.
- - Now how does this happen?! Well there are two kinds of impingement primary and secondary which are differentiated by their causes Primary Impingement- result of structures present within the subacromial space that narrow the normal size of the space (read off slide) Congenital anomaly of the acromion, Osteophyte (bone spur) of the distal acromion Secondary Impingement- reduces the subacromial space because of alterations in the shoulder’s function. (read off slide) Capsular laxity or tightness, Postural deviations, Rotator Cuff weakness, Muscular imbalances, Cervical radiculopathy
- We’re going to go into further depth of primary causes first starting with congenital anomaly of the acromion The acromion does not somehow progress from one type to another, the shape of the acromion is determined at birth through genetics and maintains its shape throughout life You can clearly see in these pictured that having a slight curved or hooked acromion significantly decreases the subacromial space, leading to the distal acromion impinging on the structures below it
- - The excess bone grown over the acromion can decrease the subacromial space and impinge the structures underneath
- Now we will go into further depth on secondary causes starting with capsular laxity or on the other hand capsular tightness because both can affect the movement of the humeral head in the glenoid cavity If the capsule is loose, the humeral head moves forward during follow-through of throwing motions and leads to impingement If the capsule is loose it can also lead to instability of the shoulder, which then leads to impingement If the posterior capsule is tight, it tends to push the humerus upwards and forwards into the anterior joint, during shoulder motions, which can narrow the space and cause impingement
- Rounded shoulders Poor posture causes the shoulders to round forward so that the greater tubercle is more directly under the acromial arch and can create impingement earlier in a range of motion We see this postural deviation very often in the industrial and occupational setting due to constantly sitting and working at a computer desk that has not been ergonomically checked.
- Normal function of the rotator cuff is to depress the humeral head during shoulder elevation motions to provide adequate subacromial space; but if the rotator cuff is weak, the humeral head will ride higher than it should in the joint causing impingement. Show them using the picture what the rotator cuff does and how humeral head rising can cause impingement
- When scapulothoracic muscles are imbalanced this can cause problems with scapulohumeral rhythm and the overall biomechanics of the shoulder This picture shows a force couple - the rotator cuff and the deltoid. The anterior and posterior rotator cuff muscles depress the humeral head while the deltoid helps elevate the humerus. If the rotator cuff is weak and the deltoid is strong the deltoid will overpower the rotator cuff and elevate the humeral head not keeping it in the glenoid and decreasing the subacromial space, which leads to impingement.
- Know that we know how shoulder impingement happens lets look into what symptoms may arise when it is present The severity of impingement can be graded into 3 different staged increasing in severity with the increase in stage. Therefore as you were all probably already assuming the increase in stage creates greater complaints of pain Stage I: Pain only with activity and little or no weakness with ROM not restricted Stage II: Pain both during and after activity, including ADL, and sometimes also at night Stage III: Continuous pain and restricted ROM
- - Here are some further general complaints of pain associated with this injury as well Generalized shoulder aches in the condition's early stages Also causes pain when raising the arm out to the side or in front of the body Most patients complain that the pain makes it difficult for them to sleep, especially when they roll onto the affected shoulder Okay so far we know the how its caused, what symptoms are present with the injury, and now we will learn what can put you at an increased risk of developing impingment. http://www.eorthopod.com/impingement-syndrome/topic/81
- Day-to-day activities that involve using the arm above shoulder level Continuously working with the arms raised overhead Repeated throwing activities Other repetitive actions of the shoulder Age >30
- I wanted to give you guys some exercises that we would give to someone who came in for a shoulder consult and we found impingement. I wanted to talk about the treatments for secondary impingement first because more than likely a primary impingement cause will also be accompanied with a secondary impingement weakness These are exercises you can do at home or at the gym if you have the right tools We’re going to separate the exercises into muscle groups that we spoke of earlier when talking about anatomy Rotator Cuff muscles being our first to target Remember we want the rotator cuff to effectively keep the humeral head depressed in the glenoid and maintain the humeral head tightly in the joint throughout our entire range of motion Strengthening of the rotator cuff muscles: Internal Rotation and External Rotation @ N & 90⁰ Side Lying External Rotation Scaption D1 and D2 Patterns Rhythmic Stabilizations
- Describe each For internal and external rotation you can also use a pulley system once theraband gets too easy. You could always make things a little more fun and add throwing drills for IR/ER using small medicine balls which will also help proprioception development Rythmic stabilization is done with a physioball/swiss ball and also helps with proprioception You can try and perform a slanted push up on a swiss ball for more difficulty or a normal push up on a BOSU ball. Your ability to balance during these exercises trains your muscles to activate when needed and increase proprioception and strength of those muscles Do not forget to explain and show D1 (seatbelt) and D2 (sword) patterns
- Next we will target the scapulothoracic muscles Thoracic 3’s (standing or lying on stomach) Serratus Punches Prone Row with Retraction
- And lastly we will target some of the other muscles that cross the joint that also help with movement of the shoulder Lat Pull Down Bicep Curl Chest Press Shoulder Shrugs Seated Rows Lateral Raises Forward Flexion
- Remember that the causes of primary impingement were bone spurs and congenital anomaly of the acromion or bone spurs Therapy cannot correct these abnormalities, but may sometimes work to decrease symptoms because usually there is an accompanying secondary cause of weakness also creating impingement. When therapy does not work then this surgical technique is recommended. What they do is they go into the shoulder and arthroscopically remove the bone spur/hooked distal acromion that is present to increase the subacromial space and remove the cause of impingement
- You want to make sure that impingement is not left untreated because If impingement is not treated properly rotator cuff tears can develop Just picture constant rubbing of the muscles in the subacromial space, eventually the muscle cannot take anymore and begins to tear. Seen more in older individuals
- There are different types of rotator cuff tears Parital tears which can be graded depending on how much of the tendon has been torn and complete/full thickness tear where the tendon has completely torn and is no longer in contact
- So what are some causes of rotator cuff tears, well we already talked about impingement being one cause which is considered chronic because it accumulated over time into a tear and repetitve stress also falls under chronic causes Some more acute/traumatic causes would be Shoulder dislocation, Falling and catching yourself with one arm, Lifting an object that is too heavy with one arm, Lifting a heavy object improperly
- Surgery is highly recommended for those that want to stay active or perform work at their best Conservative treatment is only recommended for minor partial tears if the person does not live an active lifestyle
- Sometimes what may seem like impingement or a rotator cuff injury really turns out to be a trigger point. Not a lot of individuals are familiar with trigger points and therefore I would like to inform you all a little more on this topic A trigger point is a focus of hyperirritability in a tissue, that when compressed, is locally tender and, if sufficiently hypersensitive, gives rise to referred pain and tenderness.
- There are two types of trigger points Latent trigger point- painful only when touched Active trigger point- always tender and can produce referred pain whether muscle is active or inactive
- Lets now go over some main causes of trigger points Trigger points can be caused by various injuries or overload Injury Fractures Sprains Dislocations Muscle impact injuries Stress of excessive or unusual exercise Overload Prolonged stationary posture Prolonged muscle immobilization in a shortened position Nerve compression Overload it the most common cause of gradual trigger point onset Travell and Simons’ theory When a muscle is damaged in some way calcium is released to this location to cause a sustained contraction. Muscles need ATP to stop contractions But in this case this sustained contraction causes ischemia and because of this cannot produce enough ATP to relax the contraction and so the sustained contraction remains. When this trigger point occurs histamine, seratonin, kinins, and prostaglandins are released which may be the cause of increased sensitivity and irritability
- Some of the symptoms you may feel are: Dull ache Very Intense Muscle weakness Reduced ROM Pressure in a certain area elicits a referred pain pattern that is unique for each muscle It is very important to note the difference between symptoms of a trigger point and those of a neurological condition. If you guys recall from the beginning of this presentation nerve pain follows a specific neurological pathway because specific nerves innervate specific parts of the shoulder and arm *The referral patterns for trigger points do not follow neurological referral patterns* you will see later on in some slides some of the common muscles whose referral pattern goes into the shoulder Another important difference is the type of pain you will feel with a trigger point is different than nerve pain Trigger point pain is more of a dull ache or a sharp/stabbing pain, whereas something neurological in nature would elicit prickling, tingling, or numbness
- More symptoms are: Pain becomes amplified with: Muscle activity Passive stretch of the muscle Direct pressure Prolonged stationary periods followed by moving
- What puts you more at risk? Working at a desk that has not been ergonomically assessed Constant overhead activity Working out in short, overly intense, manner Not giving muscles time to relax after a workout Poor posture
- Next I w ill go over some of the things we look for in the examination process Check for improper posture : forward head tilt, rounded shoulders Check for muscular imbalance (a muscle that is more hypertrophied or bigger in nature compared to the surrounding muscles may mean you are using this muscle more often that you should be and can have trigger points) Check bilateral ROM (affected side can have less ROM) Palpate the area to locate any possible tenderness over what feels like a hard ball within the muscle
- Here are some of the more common trigger points we see that have referral patterns that run into the shoulder The first are trigger points in the rotator cuff: Infra, Supra, Subscap, Teres minor
- Scalenes, levator scapula, Trapezius, and Teres Major
- Now how can we treat trigger points? Well there are 3 ways Spray/Ice-and Stretch Before treatment the muscle is moved throughout its ROM With the muscle anchored at one end, the ice or vapocoolant spray is applied in a sweeping motion in parallel strokes in only one direction over the length of the muscle and then over the referred pain pattern As this is applied a rhythmic, passive, slow, and continual stretch is applied progressively to the muscle
- Ischemic Compression - Pressure is applied slowly and progressively over the trigger point as the tension in the trigger point and its taut band subsides. - This is followed by a stretch of the muscle
- Deep-Stroking Massage A firm pressure is used along the muscle Pressure increases progressively A milking movement from farthest to closest end of muscle When we provide these massages we look for what feels like little tense balls in the muscles and we work that ball until it diminishes Now these kinds of massages are not your typical relaxation massages It is important to note that these treatments when being applied will provide some discomfort and the area being massaged may feel sore for a short period of time, but the results are well worth it. We normally see very quick results such as: immediate increased ROM (if there was a deficit) and relief of pain after such treatments You can apply a massage or compression to some trigger points by yourself using a trigger point ball, which is basically a very dense ball like the balls you used to get at a quarter machine when you were little that would bounce, just a bit bigger (show size comparison with hand)
- If you suspect you may have impingement or a rotator cuff tear try conservative method of rehab first Make sure you focus on strengthening the rotator cuff and scapulothoracic msucles If symptoms do not subside you can always conveniently come and pay us a visit at RehabWorks and we can schedule a consult with you to try and pinpoint the cause of your pain and make a diagnosis
- Remember that some shoulder pain can simply be a trigger point in a tense muscle, which that follows a referral pain pattern that targets the shoulder The pattern it follows and the associated pain is different than nerve pathology associated pain Massages and trigger point balls are very effective ways of controlling and minimizing the pain
- Well that wraps things up for me today Once again thank you all for coming and getting more informed on some of the more common shoulder pathologies we see here at KSC! Does anyone have any further questions they would like to ask me?