Managing Persistent Shoulder Pain
4 Possible Reasons Your Shoulder Pain is NOT the Fault of Your Shoulder!
Shoulder pain is a common problem with much variability. Shoulder pain can come in many forms across a wide range of sports, and can have a variety of causes. When coupled with the complexity of the shoulder itself and the required balance between mobility and stability it is easy to understand why it can be difficult to initially pinpoint the cause of an athletes shoulder pain. Certainly we traumatic shoulder injuries in sports like football, hockey, MMA, or wrestling where an athlete ends up with a dislocation of the humeral head, a "separated shoulder" or sprain of the AC joint, etc. These types of traumatic injuries are fairly easy to identify and understand.
For the purpose of this discussion, we are going to focus on the non-traumatic injuries. The chronic, achy, nagging pain that seems to develop over time, or the sharp, pinching pain that occurs with certain movements or positions. These are the descriptions most often given by our athletes. They may or may not have an event to attribute them to, and usually have not responded to the athlete's self-management strategies of ice, ibuprofen, self-soft tissue work with a foam roll or tennis ball. These are the low to moderate level pains that seem to creep up out of nowhere with each workout or as the training volume increases. Sometimes the athlete has had a label slapped on it: rotator cuff tendonitis or tendonosis, impingement, bursitis, rotator cuff strain. While these may be the tissues that are painful and irritated, focusing treatment only on the painful area will rarely yield a lasting result. You may achieve the initial goal of pain relief in the short run, but most often there are other variables to consider which may be contributing to the athletes shoulder pain, and they are not a the local painful area.
"Wait, so you're saying my shoulder pain may not be because of my shoulder? Because, I had an MRI, and they said that clearly my rotator cuff is 'inflamed'. And my shoulder is what hurts! Isn't that the shoulder's fault?"
Yes. That is exactly what I am saying. No, it may not be 'the shoulders fault' (though statements like that will be the topic of future discussion, as the shoulder is a body part, not a separate outside entity for which blame or other qualities can be asserted...).
Certainly chemical pain at the tissue level needs to be addressed, but what the MRI doesn't tell us is WHY the rotator cuff is so 'inflamed'. What is causing that tissue be respond in such a way? Sure pain is an output from the brain, so what is it that's tripped the threat alarm and gained the brain's focused attention?
First let's dive into 4 possible variables that may be contributing to your symptoms, the potential Source of the problem, which may be presenting as pain and irritation of the rotator curff, the Site of the problem.
4 Possible Contributors to Shoulder Pain
1. Inadequate Scapular Stabilization
The scapula, or shoulder blade, is a key component of the shoulder girdle. It is a point of attachment for muscle that connect scapula to humerus, scapula to thoracic spine & rib cage, scapula to cervical spine, and scapula to strenum. It is also provides the stable base and dynamically controls and positions the glenohumeral joint during movement. The rhythm or coordination of motion which takes place between the rotation of the humeral head & glenoid (the ball & socket) and the rotation of the scapula itself has been the topic of much attention over the years.
Inadequate scapular stabilization, usually seen as weakness or deficiency of function of the serratus anterior, middle & lower trapezius, rhomboids, also puts the rotator cuff at a disadvantage by preventing optimal activation and force production of the rotator cuff. Clinically, chronic tension in muscles like the levator, upper trapezius, cervical & thoracic paraspinals, pec minor, and rotator cuff muscles are often seen as a compensation for inadequate stabilization of the scapula. This may also be a contributing factor in issues related to lack of motion in the cervical and thoracic spine. Often times it is not stretching or mobilization that needs to occur at the thoracic or cervical spine, but rather strengthening & development of neuromuscular control to improve scapular stability.
2. Inadequate Thoracic Mobility
Your scapula, discussed above, has a rather intimate relationship with the thoracic spine. The scapula must be able to slide and rotate on the thoracic spine and rib cage, so a quicker way of discussing this is simply saying: 'Posture & position matters.' The skeletal relationships between the spine, rib cage, and scapula can change the available range of motion at the glenohumeral joint, and places tissues in on stretch or slack which creates insufficiency. These deviations in both joint mobility and tissue extensibility can limited the available motion of the scapula, which then places the glenohumeral joint at risk. This concept has been researched and discussed in the analysis of a tennis serve, volleyball serve, and with overhead throwing / pitching in baseball (though the mechanics are different in throwing).
Note also that we are saying 'inadequate thoracic mobility' and not 'inadequate thoracic extension.' Certainly lack of thoracic extension can be a common finding, and has received a lot of attention with mobility drills aimed at mobilizing and moving into extension or rotation. It is also important to recognize that there are instances where an athlete is actually living in thoracic extension, so adding more extension is unlikely to be helpful...or pleasant for the athlete. These are the athletes that often present with very flat thoracic curves, increased tone of the thoracic paraspinals, and visible winging or tilting of the scapula. The winging or tilting may not be a result of weak serratus anterior, but perhaps is a positional fault by having a curved scapula on a flat thoracic curve which decreases the congruence of the articulation.
3. Inadequate Lower Extremity Mobility.
Keep in mind that athletic movement requires integration of the entire kinetic chain. For an overhead athlete, transfer of force from the lower extremity, through the trunk, and through the upper extremity is necessary to achieve the goal of trowing a 100+ mph fastball or serving in tennis or volleyball. Lack of mobility at the hips, knees, and even foot & ankle have been shown to contribute to increased stress at the shoulder. The same can be said for a highly rotational sports like hockey, golf, tennis, and baseball / softball.
Without repeating what has already been said earlier, assessment of the entire kinetic chain should be performed to identify potential areas that are contributing to the increased stress on the shoulder via a lack of mobility or stability. Studies have shown that lack of mobility at the hip or knee can increase stress on the shoulder in throwing athletes. Additionally, we must look at joints both above and below meaning that limitations at the wrist and elbow can have just as much impact as issues at the lower extremity. This is easy to conceptualize in sports like weightlifting, where lack of wrist and elbow motion may be easier to see when the athlete is trying to achieve the rack position in a clean, but perhaps less so in a combat athlete with sports like judo.
4. Your Program Sucks.
You can't out rehab a poor strength & conditioning program. If with every workout the athlete is continually popping up with shoulder, hip, or back pain and the variables discussed in 1-3 are a non-issue, then it's time to look at the training program itself. What's your volume like? Is there a balance between pushing & pulling? Are you doing multi-joint, multi-planar movements and gaining ownership of the transverse plan? What kind of work/rest cycle are you using for the intensity & goal of the exercise? What are you doing for recovery?
Two focuses here:
1) Form matters. Whether you are doing push ups, working with light dumbbells, working with bands, performing explosive med ball throws, or moving big weights overhead in a movement like the snatch, one thing is certain -- form is everything. If you can't get your body into the proper position to perform an exercise, then there is no point in loading that movement with external resistance as this will just drive compensation and open you up to development of problems over time. Poor form may not stem solely from lack of mobility, but can also come from a lack of neuromuscular control, inexperience with the exercise in question, or onset of fatigue. In any case, continued loading through both load or volume with poor form may lead to injury sooner than later.
2) You need to have balance. Balance between Right and Left sides of the body, balance between pushing and pulling motions, and a balance in strength to offset the forces or loads that the body will have to endure.
Here's a real example of a past patient, we'll give you the short version: High school softball player, potential D1 candidate as a catcher, with a cannon for an arm. She developed shoulder pain in her throwing arm with confirmed small infraspinatus tear and labral pathology via MRI. Went through a course of PT and was no better. Was referred to me by her Orthopedic Surgeon. On evaluation she had a number of finds, a few of which included a significant deficit in Total Range of Motion and presence of GIRD on her affected shoulder as compared to the non-throwing shoulder, deficits in thoracic mobility, and deficits in ankle mobility.
One piece of information I wanted to gather was what kind of strength & conditioning program was she or her team doing. The response was, unfortunately, one we hear all too often -- they had a program that they were given to do in the weight room. Minimal supervision, and obviously created by someone without a S&C background. She walked me through her basic program, which consisted of chest press, lat pull down, chest flies, bicep curls, triceps extensions, a bit of shoulder external rotation with a theraband, and leg work consisting of your basic machine based leg press, leg extension, and leg curl.
Hmmm. No rowing? "Nope." No rear delt or reverse flies? "Nope". No side laying external rotation with a dumbbell? "Nope." You see the pattern emerging...
Their program sucked. All pushing and mostly internal rotation dominant exercises. Very little focus on external rotation or eccentrics, no real scapular stability exercises, and no pulling. No amount physical therapy will combat a program like that...unless you change the program, and that is what we did.
Get Yourself Assessed!
It is worth recognizing that these are just four of many possible contributors to shoulder pain. As an athlete, the first step should be to recognize there is a problem. If your are stretching, massaging, foam rolling, lacrosse ball mashing and taking a regular regimen of vitamin I, yet still having the same pain each day and with each workout over a period of weeks or months --- it's time to get assessed, preferably by a healthcare professional who understands your sport and needs as an athlete. Seeking out this type of clinician is about to get much easier for athletes & coaches, and I am excited for what is to come, so be on the lookout for our announcements during the next week!
A thorough evaluation and movement assessment will yield a great deal of information on how to best address what is affecting your performance. Targeted interventions can then allow you to minimize lost training or practice time, improve your overall movement capacity, and allow you maximize the results of your strength and conditioning program.
Feel free to get in touch with any questions by emailing me at firstname.lastname@example.org or contact me through our website here.
Athletes Physiotherapy, Las Vegas, NV
Thank you for stopping by the Athletes Physiotherapy Blog! Kristopher Bosch founded Athletes Physiotherapy in Las Vegas, NV. He is a Father, physical therapist, athletic trainer, pilates teacher, & perpetual student!
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