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CHAPTER 6:
The Shoulder

The shoulder is a unique joint and is prone to a great many injuries. It's a very shallow ball-and-socket joint. The head, which has little contact with the small socket, can easily slide out of it, which means that the joint is not very stable. The rest of the shoulder socket is formed by ligaments that connect various parts of the bony components of the socket, and cartilage around the small rim of the bony socket.

      The shoulder is the only joint in the body not really held together by ligaments. The few ligaments in the shoulder serve only to keep the shoulder from moving too far in any one direction. The ligaments have little to do with holding the joint in place.

      The shoulder socket also contains three tendons: the tendons of the long and short heads of the biceps muscle and the supraspinatus tendon. The biceps tendons connect the biceps muscle to the bones of the shoulder and help the biceps flex the forearm. The supraspinatus tendon connects the supraspinatus muscle and the bone of the shoulder, and aids the supraspinatus to move the humerus, the bone between the shoulder and the elbow. Directly below the socket is the brachial plexus, which houses all of the nerves that supply the arm.

      The shoulder bones are held together by a group of muscles you read about often in the sports pages: the rotator cuff muscles. These muscles are also responsible for the shoulder's fine movements, such as throwing a ball. Because of the shoulder's shallow socket and lack of ligaments, any weakness of the small rotator cuff muscles makes it easy for the head of the shoulder to slide part way out of the socket, which is a partial dislocation, or subluxation. Or it may slide all the way out, which is a full dislocation.

ROTATOR CUFF INJURY

Sports in which you bring your arm up over your head, such as baseball, tennis, volleyball, and swimming, are the main contributors to overuse injuries of the shoulder. The rotator cuff muscles are not meant to function under stress with the arm above a line parallel to the ground. If the shoulder joint is continually stressed with the arm in this overhead position, the rotator cuff muscles begin to stretch out. This allows the head of the joint to become loose within the shoulder socket.

      If the head of the shoulder is loose, when you extend your arm backward over the shoulder the head will slide forward, catching the tendon of the short head of the biceps between the ball and the socket. The same thing happens if you raise your arm to the side above a line parallel to the ground. The head will drop in the socket, and the tendon of the long head of the biceps will become impinged. The supraspinatus muscle may also become impinged.

      This impingement causes the tendons to become inflamed and painful. Baseball pitchers tend to feel the pain in both the long and short heads of the biceps, and tennis players feel the pain particularly in the long head of the biceps. Athletes such as free-style and butterfly swimmers who feel pain deep in the shoulder are impinging the supraspinatus tendon.

      Tennis players with this injury tell me they can hit their ground strokes effortlessly, but when they try an overhead stroke or serve, their shoulder hurts. The same thing can happen to golfers in both the backswing and the follow-through, when their arms are above parallel to the ground.

How Not to Treat Rotator Cuff Problems

Many doctors overlook the true problem with a shoulder impingement. They treat the tendinitis (inflamed tendons) with anti-inflammatory agents or cortisone (steroid) injections. But the anti-inflammatories soon wear off, and the next time the individual throws a ball, the tendon is pinched or impinged again. The pain returns, requiring another injection or more anti-inflammatories.

      All too often I see a high school or college baseball pitcher with a sore shoulder whose doctor has told him not to throw for a while, just to rest it. So the pitcher stops throwing, the pain subsides, and by the end of the season he's fine. During the off-season, he continues to rest his shoulder. The next spring, after three or four days of throwing, the pitcher's arm hurts again, and he's right back where he started. Consequently, he has to miss the entire season while he restrengthens his rotator cuff muscles.

      I have seen untreated impingements ruin the careers of many young, promising athletes. Surprisingly, many of them are swimmers. Swimming is often called the perfect form of exercise because it works both the upper- and lower-body muscles to improve conditioning with little pounding on the joints. However, most young, competitive swimmers who train at great distances end up with rotator cuff problems. The overhead motion of pulling the arm through the water hour after hour, day after day, eventually causes an impingement of the rotator cuff.

The Right Treatment for Rotator Cuff Injuries

The proper way to treat a shoulder impingement is through an exercise program to strengthen the rotator cuff muscles sufficiently so that the head of the shoulder is held firmly in place and will not slip out of the socket. With no slipping, the tendons will no longer be inflamed or irritated.

Rotator-Cuff-Strengthening Exercises

You can restrengthen your rotator cuff muscles initially at home with a free-weight program. Using 15 pounds as the absolute maximum weight, do the following exercises until fatigue sets in or for 50 repetitions once a day.

      Your doctor may prescribe physical therapy, in which case a physical therapist can design an exercise program for you. Three out of every four rotator cuff problems can be cured with simple exercises.

      If the problem has not begun to disappear in six to eight weeks, you may need to use special isokinetic exercise machines, such as Cybex® machines. These machines use a computerized system that senses your effort and, at any given millisecond, adjusts the resistance to meet your force. Also, for some movements of the shoulder, such as the follow-through for a pitcher, muscles are hard to rehabilitate with free weights. Unless you stand on your head, the weight is coming down from the force of gravity and offers no resistance. A Cybex machine provides the proper resistance for any motion.

      Some people do not respond to rehabilitation, even with physical therapy, and will require surgery to repair the shoulder joint.

The Pro's Rotator Cuff Injury

The professional athletes with rotator cuff problems that you read about usually have a slightly different injury. For a baseball pitcher such as the Mets' Dwight Gooden, who has thrown millions of pitches over the years, the rotator cuff muscles can become so overdeveloped that they no longer fit into the shoulder socket. As a consequence, they rub along the outside of the socket, and eventually some of the muscle fibers are sawed through as they ride back and forth against the rim of the socket. The only way to correct this is through surgery to enlarge the socket and repair the damaged muscle fibers.

      About 1 in 200 people is born with naturally narrow shoulder sockets. For such a person, even when the rotator cuff muscles are not built up, as a professional athlete's are, they can ride outside the socket and become sawed through. If you have shoulder pain, your doctor must diagnose the type of rotator cuff problem you may have. This has proved to be difficult in the past, but with the advent of MRI it is much easier now.

A Rotator Cuff Tear

A torn rotator cuff used to mean the end of a baseball pitcher's career or of weekend tennis matches. Tearing these muscles left the shoulder weak. Today, tearing the rotator cuff muscles is not as much of a problem because of improved rehabilitation programs and much better surgery.

      A torn rotator cuff receives the same initial treatment as a stretched one--a good rehabilitation program. Some tears will heal without surgery. The surgery is difficult and should be avoided if at all possible. Consider surgery only if you don't respond well to rehabilitation.

      If the tear is not too large, a simpler surgery through a lighted tube, or arthroscope, may be possible. Arthroscopic surgery, which has revolutionized treatment of the knee, is coming into more widespread use for the shoulder. Repairing the rotator cuff muscles through the arthroscope provides a new, less invasive way to treat this injury.

      Another potential problem with a rotator cuff tear develops during the recovery period after surgery. When you rest a shoulder, as you must for four to six weeks after rotator cuff surgery, and avoid moving it in certain ways, the shoulder loses its ability to make those movements. The result may be a partially "frozen" shoulder with limited motion. This requires a diligent rehabilitation program, and it can be a long, painful process to get the shoulder to move through its full range of motion.

WEIGHT LIFTER'S SHOULDER

Weight lifters also suffer from overuse injuries of the shoulder. In particular, the bench press often leads to shoulder pain in the joint where the collarbone meets the shoulder blade, called the acromioclavicular (AC) joint. The small amount of cartilage between these two bones can tear or degenerate from the stress of weight lifting. When the cartilage is damaged, bone rubs on bone, causing pain.

      This injury is not common among well-trained or world-class weight lifters. In fact, I have never seen it in any of the Giants' players, even though bench pressing is an important part of their training. That's because our players are coached in the proper lifting technique.

      People who work out on their own are the ones most likely to develop weight lifter's shoulder. They typically do not space their hands correctly on the bar and try to lift too much too soon. Usually, rest for a few weeks and an injection of cortisone provides temporary relief. If the pain becomes chronic, then a small piece of the outer end of the collarbone can be removed surgically. This widens the space between the two bones and relieves the pressure in the joint, enabling you to return to full, pain-free weight lifting.

SHOULDER MUSCLE PULLS

Like any area of the body, the shoulder is subject to muscle pulls. The mechanism is the same: the muscle overcontracts or overstretches, causing muscle fibers to tear. This is typical among wrestlers and in the throwing sports.

      The proper treatment is a short rest period, about three to seven days, followed by stretching and then strengthening exercises. As with all muscle pulls, you should warm up and then stretch and lengthen the shoulder muscles to prevent pulling them again.

      Because of the complexity and number of muscles around the shoulder that can pull, you need to see a physician to get a diagnosis of which muscles are involved and then a physical therapist for a program specifically designed for those muscles. You cannot rehabilitate torn shoulder muscles yourself. Find out which ones are torn and what to do for them.

THE OTHER SHOULDER PAIN: BURSITIS

Some doctors call any kind of shoulder pain "bursitis." However, true bursitis occurs only in the pillowlike sacs of fluid, called bursas, found throughout the body. These sacs vary in size tremendously, from the size of a lemon pit to that of a large lemon. Bursas occur where a tendon has to turn a corner and go around a bone; they allow the tendon to slide freely without wearing itself out as it rubs against the bone. Overstressing these sacs causes them to become inflamed. Once they swell up, they become extremely painful.

      Bursitis is different from tendinitis, although both can be very painful. Usually, you don't feel the pain of tendinitis unless you use the tender body part. With bursitis, the body part is painful whether you move it or not. Also, you feel the tenderness of tendinitis all along the length of the tendon, but you feel it in one specific spot with bursitis.

      The usual treatment for bursitis is a cortisone injection. You may have heard horror stories about having an injection for bursitis and how painful it is. Unfortunately, most of those stories are true. Putting more fluid into an alreadyinflamed sac causes a flare-up of severe pain for about a day. Once the cortisone takes effect, however, it cools down the inflammation, and the pain subsides.

      I have found that the more humane way to treat bursitis is with cortisone by mouth for the first few days. The pills almost always provide rapid relief, and in many cases the bursitis calms down completely without any need for injections. Some bursitis sufferers, however, may still need injections because of the discomfort. These later injections do not cause as much pain since the inflammation and swelling in the bursa have already been reduced.

SHOULDER "POPS": PARTIAL DISLOCATION

Jill's shoulder was so loose that she could dislocate her joint at will. In my office, I saw the 11-year-old gymnast slide it in and out by herself. The damage was so extensive that I knew she would require surgery. However, no doctor wanted to perform surgery because her muscles had not yet fully developed. So I put Jill on a weight-training program. Fortunately, she worked so hard at rehabilitating her shoulder that she never needed that operation.

      A sudden force exerted against the shoulder can cause the head to slip momentarily out of the socket, that is, become partially dislocated, or subluxated. The shoulder's structures and shallow socket may allow the head to slip part way up onto the rim of the socket, and then the shoulder snaps back into place spontaneously. It feels as if your shoulder has "popped" out and then "popped" back in. But that's not really what happens. If the shoulder were truly dislocated, with the head all of the way out of the socket, it wouldn't "pop" back in spontaneously. Most people can't put a dislocated shoulder back in place by themselves the way Jill could. Often, it's difficult for even an experienced physician to get it back in place.

      Many of the Giants' players have had partially dislocated shoulders. We would like their shoulder muscles to be strong enough that this doesn't happen, but the forces generated on the football field are so great that the players tend to have slippery shoulder sockets. Tight end Mark Bavaro had multiple problems with his shoulders, both of which had to be repaired surgically.

      When the shoulder head slides partially out and then snaps back in, it stretches the rotator cuff muscles, and you have the same problem as an overuse injury. The shoulder begins to slide around, causing an impingement and tendinitis. Because the rotator cuff muscles are stretched, the next time the shoulder takes a blow, the head is likely to slide out again. With each blow you take, the rotator cuff gets looser and looser until finally your shoulder is in danger of truly dislocating.

      The standard treatment for a subluxated shoulder is rest. But that's not enough. Your resting shoulder may not hurt, but the rotator cuff muscles are not getting any stronger. If the muscles stay loose, the shoulder joint can still slip later on. You must use the exercise program described earlier to strengthen the rotator cuff muscles to prevent future slipping.

      These muscles are slow healers. The strengthening program usually takes 6 to 12 weeks, and the shoulder may not be back to full strength for six months or more.

FULL DISLOCATION

A shoulder becomes fully dislocated when the head comes all the way out of the socket. This requires a much greater force than that needed for a partial dislocation.

      A dislocation may stretch or tear the rotator cuff muscles. Usually, these muscles are just stretched, particularly among younger athletes. Older athletes, who have more brittle rotator cuffs, are more likely to tear the muscles. The only time I see a tear in a young athlete is in response to a high-impact injury, such as a fall while skiing on snow or water at high speed.

      When I started practicing sports medicine, the standard treatment was to immobilize a dislocated shoulder for six weeks. But even after six weeks the shoulder never really worked well again, so we cut the immobilization time to three weeks. Now we know that rest is effective only when the rotator cuff muscles are also restrengthened. I can't emphasize enough that if you have shoulder pain or discomfort, even though it will go away with rest, you must restrengthen your rotator cuff muscles through an exercise program to regain full use of your shoulder.

      It used to be that two shoulder dislocations meant surgery. And without rehabilitation after one dislocation, a second one happened quite frequently. Today, even with multiple dislocations, a good rehabilitation program can often tighten the shoulder muscles so that no surgery is necessary.

      The problem with rehabilitation is that there is no way to tell beforehand whether it's going to work. A competitive volleyball player who bangs her shoulder diving for a ball may have minimal shoulder slipping or only one dislocation. She may rehabilitate her shoulder with exercise and yet still need surgery. A high school football player can have many dislocations and recover fully through rehabilitation alone.

SHOULDER SEPARATION

"Separation" of the AC joint, where the end of collarbone meets the shoulder blade, is actually a sprain of the ligaments that connect the two bones. "Separation" is an old medical term that has been applied to the widening of the space between the bones. Since this problem involves ligaments, it really should be called a sprain.

      As with all sprains, there are three degrees of severity. A mild, or first-degree, sprain causes a minimal stretching of the ligaments without much tearing of fibers, and the joint remains stable. There will be pain and swelling around the joint.

      In a moderate, or second-degree, sprain, the ligaments are stretched more and partially torn, and the outer end of the collarbone will partially snap in and out of the joint. I diagnose this type of sprain by first taking an x-ray of both shoulders. Then I have my patient hold a 25-pound weight in each hand, and I take another x-ray. Because the weight pulls the two bones apart, the joint of the affected shoulder will be visibly wider on the second x-ray.

      It's much easier to diagnose a severe, or third-degree, sprain. The complete disruption of all of the ligaments around the joint causes the collarbone to stand straight up.

      The treatment for first- and second-degree shoulder sprains is rest. You will have to put the shoulder in a sling for one to three weeks, depending on the severity of the injury. Also, in addition to resting the shoulder, you must ice it for 20 to 30 minutes a few times a day in the beginning to ease the pain. These are particularly frustrating injuries because they can take six to eight weeks to heal. You may not be able to raise your arm laterally beyond 90° until the injury has healed.

      For a third-degree shoulder sprain, surgical repair of the ligaments is necessary to fix the joint. Up to six weeks of recovery from surgery are necessary before you can begin a restrengthening program. This program consists of range-of-motion and strengthening exercises similar to those used to rehabilitate a shoulder impingement.

BRUISED COLLARBONE

When I was with the Westchester Bulls, we had the only Japanese-American quarterback ever to play professional football. We always had a problem with Sieki Morono, better known as Zeke, because he was a reserve officer in the Marines. Every spring he had to miss two weeks of training camp while he put in his Marine training time.

      In our last game of the 1970 Continental League season, Zeke took an extremely late hit and fell hard on his shoulder, severely bruising his collarbone. The injury became complicated when he began to lose calcium in the collarbone. We took an x-ray, which showed a terrible-looking deterioration of the collarbone, and sent it to the Marines, who gave him an immediate medical discharge. What they never knew was that, within six months, Zeke's shoulder had healed completely, and he played for several more seasons without any interruptions for Marine training.

      A blow on the head of the collarbone can cause an ugly bruise. The blow causes a painful bone bruise, or contusion, but does not actually sprain the AC joint.

      The injury usually heals without difficulty but may lead to a second condition called osteolysis. This condition causes the bone to dissolve and deteriorate due to a loss of calcium. On an x-ray the collarbone has a frightening, mosslike appearance, and the physician can see the bone loss on the outer end of the bone.

      Although this can be quite painful, the bone usually heals and becomes healthy again in 6 to 12 months, as Zeke's did, and the pain subsides. Otherwise, the outer edge of the collarbone can be shaved off surgically to relieve the pain.

BROKEN COLLARBONE

The collarbone has an unusual restorative ability. If it is broken, it does not need to be set perfectly, as other broken bones do. As long as the pieces of the bone are in close proximity, they will bridge any gaps, heal, and form a new collarbone even stronger than the old one. As the bone heals, it grows over the site of the break, which will become somewhat thicker than the rest of the bone.

      A broken collarbone is usually a concern only because it prevents you from functioning. However, in severe cases sharp fragments can cause damage to the surrounding tissue. If you feel a sharp pain aggravated by pressure or movement of the shoulder, see a physician. Proper treatment for a broken collarbone is immobilization to allow it to heal. A brace is used to pull the shoulders back and hold the ends of the bone in line. This injury takes six to eight weeks to heal completely, but there is usually enough early healing that the brace can be removed in about three weeks. Since the shoulder joints are not involved in the bracing, you have full use of your arms and shoulders, and no shoulder rehabilitation program is necessary.

      The decision of when it's okay to return to activity has changed in recent years. Modern professional football players have the advantage of better protection with better-made shoulder pads, so we try to get them back into action quickly. Wide receiver Mark Ingram broke his collarbone early in the 1988 season, and he came back and played well six weeks later.

      Since the healing rate and type of break differs widely, no amateur athlete should return to activity until a physician feels it's safe to do so. This will vary depending on the sport and how much trauma may be sustained from that sport. A tennis player may get back to her regular game before a flag football player gets back to his.




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