Understanding and planning your pathway to a strong and mobile shoulder
Shoulder pain can be a very troublesome and tiring considering how much we use our arms and hands on a daily basis. In this blog we'll talk about the
To understand what can happen to the shoulder we need to understand some of the basic anatomy of the area to ensure we can accurately diagnose the issues.
The shoulder joint is made up from the humerus and the shoulder blade (scapula). The amount of 'bone on bone' contact is much smaller than the hip for example, meaning that the shoulder joint's stability is largely based upon the soft tissue surrounding the area.
Most people have heard about the rotator cuff, but not sure what that means. The cuff is a collection on 4 muscles that create not just rotation in the shoulder. They support pretty much all of the movements through a direct action or a stability role; meaning whilst the joint is moving these muscles ensure the ball and socket are kept in a 'biomechanically useful' position.
There are also a wide range of muscles attaching as far away as the low back. The latissimus dorsi is one of the most powerful muscles in the body. It attaches to the low back, shoulder blade and the humerus. The biomechanics of just this one muscle is hard to understand let alone the whole shoulder complex.
Ligaments and Bursa
The shoulder's stability is also relies on the ligament surrounding the ball and socket. People who struggle with instability in the shoulder may have some laxity in these ligaments, which can allow the bones to move more than they should.
Bursa are a small 'sack' of tissue that helps prevent friction at key points around joints. For example in the shoulder the Sub-acromial bursa help prevent the ball compressing the muscle/tendon that runs along the top of the ball inside the joint. These tissue, with the right conditions can become inflamed causing surprisingly large amounts of pain and debilitation.
Tendons are tough! They deal with a large amount of load on a regular basis. When muscles have a much wider area of tissue to spread load through. In tendons these forces are directed through a much smaller area so relatively have a much harder job than muscles.
Tendinopathy is the collective term used nower days for an issue with the tendon, rather than trying to be specific with exactly what type of inflammation and what stage of injury the tissue is at.
Typically, the tendons or the sheath around the tendons become inflamed from an imbalance between tissue healing and tissue loading. If you are training relatively harder than your body can deal with then you're higher risk of developing a tendinopathy. Similarly if you are performing a movement that's new to the body e.g. new running shoes that move your feet and legs slightly differently, you can develop the same issue.
Calcific tendinopathy is classed within this section but is different to a typical tendon issue. Calcium crystals are deposited in the tendon causing an inflammatory reaction therefore pain. These are most common in the supraspinatus muscle in the upper shoulder area. Depending the stage of the presentation the issue can be quite painful and debilitating.
These are much simpler to manage than most of the injury type in the shoulder. Depending the system of classification your therapist uses you'll have an injury classified into a scale.
We use the British Athletics muscle injury classification (BAMIC/BAC) in our clinics, as they offer more depth to the previous scale systems.
- grade 0a: focal neuromuscular injury with normal MRI
- grade 0b: generalised muscle soreness with normal MRI or MRI findings typical of delayed onset muscle soreness (DOMS)
Grade 1 (mild): high STIR signal that is <10% cross-section or longitudinal length <5 cm with <1 cm fibre disruption
Grade 2 (moderate): high STIR signal that is 10-50% cross-section; longitudinal length 5-15 cm with <5 cm fibre disruption
Grade 3 (extensive): high STIR signal that is >50% cross-section or longitudinal length >15 cm with >5 cm fibre disruption
Grade 4: complete tear
This is all a bit technical but essentially quantifies the amount of tissue disruption in a scale. We can then predict your recovery time and rehab needed.
MRI scans can be used in this situation but they are normally costly and typically not needed to make an accurate diagnosis.
These little sacks of fluid are very important to ensure that tissues like tendons are not becoming irritated and inflamed from excessive friction and pressure. Common areas of issues are in the hip underneath the gluteal muscles and in the knee. However, bursa are found throughout the body.
Albeit these are less common especially in the sports and fitness communities they can't be overlooked, especially if you have recently fallen off your bike or during a run. Humeral head fractures are the most common type, particularly in people over 60. The risk of this type fracture increases with age.
Stress fractures are much more common in our clinic, mainly as fullf ractures are normally managed in a hospital setting initially, but people come to us when the cast or boot is due off. They are not very common in the shoulder however, but cant be excluded just for that reason.
These issues are not overly simple to detect. Pain is not constant, symptoms do not always present immediately and you can still be active on a stress fracture without a sudden onset of pain.
Here's a great example of an ultra runner with a heel stress fracture.
They were running 3-4 times up to 100 km over the week. They were experiencing pain that would be consistent but only appear after 5-6 km. The pain wouldn't go above 3/10 and there were no other symptoms.
As other treatment plans were not working we explored the low likelihood of a bone issue and low and behold there it was. For context, this is a significant stress fracture.
How we can help
Shoulder problems account for ~35% of people we see in clinic. This is a high number seeing at least 10 people per week symptoms in this area.
The trick to understanding and setting the right diagnosis is based upon two key areas:
- Case history
- Physical examination
The case history allows us to understand not just about your pain, but the reasons why this can exist. We look into your activity and exercise levels, explore your training patterns and times for periodisation. We also explore what your do for you work or other hobbies. We need to know what your body is going through each day. This perspective creates an excellent basis for our physical examination.
Where our team excel compared to other practitioners is our ability to look beyond where the pain is. Being able to assess other parts of the body and explore how they relate to the area of pain is key to understanding THE WHY for pain's presence.
If you don't explore and treat the why then issues tend to return
The simplest way to see if we can help is speak to us. We pride ourselves on not up selling, not misleading and offering a no nonsense approach to managing pain and injury.
What you can do to help yourself
You are in a great position to support your health and performance. There are a range of online and in-person support services around that can give you what you need.
Google tends to be the first port of call for people with pain. The trouble with google is that it's great when you know what you're looking for. We use it for a range of information gathering and rehab info, but because we know what we're looking for.
The next issue is sifting through the click baits and "fix this" posts. These aren't specific enough typically and we have seen some wild claims and assumptions. It's not worth the risk!
Two main questions to ask yourself:
- Am I mobile enough?
- Am I strong enough?
Mobility of tissues and joints is key to ensure your body has less risk of being injured. People who are less mobile tend to be less 'fit' as well. Keeping your body 'stretched out' helps to move your body in a variety of positions and helps create and exercise effect. There is also the mechanical advantage of being able to move your body to meet the demands of your environment.
If your his have restrictions in extension (moving backwards) then other joints need to create the movement that's missing. This typically moves to the low back and in itself create low back pain. This has very little to do with the back and can lead to focusing on misleading areas of issue.
We definitely recommend a more structured form of mobility work. It helps keeps your programme regular and regimented. Mainly as the tissues and joints take weeks and months to show a significant change. This is so important to understand and one of the reasons why people feel stretching an issue doesn't work.
Strength is an area that has been neglected over the years with too many people focusing on separating their sport and traditional gym work. More and more people are understanding that strength and conditioning work is not important but essential to any sports.
If you want to be better at tennis it's not just about making your arms and shoulders stronger, you need to make your whole body stronger as you use your whole body when playing. We recommend you speak with us about a training plan and how this can meet your aims and objectives for your sports or lifestyle.
There are almost too many ways to train, some with higher or lower risks of injury. We won't go into this now as this is whole different topic in itself, but like with the mobility work it needs to be consistent.