A few weeks ago, I was working with a female runner who asked me, “Will I ever run pain-free again?”…
The shoulder is amazing, it really is! It is so complex and so interesting. (I know, as an orthopedic surgeon, I am expected to say uncool things like that, but it’s true.)
If you have ever experienced shoulder pain when trying to lift weights, practice yoga, box, swim, surf, or simply brush your hair, you know how much you rely on your shoulders functioning well.
A better grasp of the anatomy of the shoulder will help you understand how and when injuries occur.
The shoulder is a ball-and-socket joint that consists in two bones: the humerus (upper arm bone) and the scapula (the shoulder blade). The humerus is the long bone with a rounded top that acts as the ball of the ball-and-socket joint. There is a part of the shoulder blade, called the glenoid, that acts as the very shallow socket of the joint.
The analogy that works for me is a golf ball sitting on a golf tee, turned on its side. The humerus is not very stable in the shallow glenoid, just like the golf ball is not stable sitting atop the golf tee.
The joint is designed that way to allow a larger range of motion. The more stable or constrained a joint is, the less motion is possible. Our bodies have developed static and dynamic shoulder stabilizers to allow for that amazing amount of range of motion and strength while maintaining the stability required to prevent the joint from dislocating constantly.
The static stabilizers of the shoulder are the ligaments, the capsule — which forms a tight balloon around the bones to keep them in place — and the labrum. The labrum is the gasket that lines the socket to make it deeper. The analogy I like to use for this is the bumper placed in the bowling alley gutter to keep the bowling ball in the lane.
The dynamic stabilizers include the rotator cuff muscles and tendons. There are four of them that originate on the shoulder blade and insert around the joint. When they are kept strong and contract, they compress and depresses the ball onto the socket, stabilizing it, raising the arm overhead, and rotating it.
All of the muscles that attach to the shoulder blade also act as dynamic stabilizers — and there are 17 of them! Some more important than others. We have to remember that the socket of the joint is on the shoulder blade so when the shoulder blade is stable and functioning well, the socket is stable and functioning well.
Since the shoulder is so intricate, there are quite a few things that can cause pain. For the purposes of this article, I am going to focus on the rotator cuff and the continuum of issues associated with its dysfunction.
This is the first stage in the continuum. The rotator cuff tendons get compressed between the humerus and another part of the scapula called the acromion. We use the word impingement because the rotator cuff tendons are being impinged between two bones when a person lifts their arm above their shoulder. This causes discomfort and the pain worsens the more the rotator cuff gets caught between the two bones.
So why does the rotator cuff get caught between two bones all of a sudden? Well the answer is in the anatomy. As we talked about before, a strong, healthy rotator cuff depresses the humerus. This increases the space for the rotator cuff to function freely.
Over time, if we allow the muscles associated with the rotator cuff to weaken, the impingement pain occurs. This is usually what is going on if you can lift your arm above your shoulder but it hurts. It will happen when you are drying your hair, putting dishes up in cabinets, on a pull-up bar, doing push presses, etc.
The bursitis, or inflammation in the area as the rotator cuff, is a result of the same impingement. Rotator cuff impingement rarely occurs without bursitis, so they are often considered to be the same thing.
Further down on the spectrum of rotator cuff dysfunction are the partial and complete tears. The tendon ends of the four rotator cuff muscles can be torn from where they attach to the humerus ball. I liken the tendon to a rope that can pop suddenly from a fall or high energy injury, or slowly unravel over time from the wear and tear of impingement.
Once torn, the tendons cannot heal themselves but they are not always painful. Many people don’t even know they have a tear: some will only have weakness in certain movements of the shoulder, while others can lose range of motion but maintain their strength.
The symptoms experienced as a result of a rotator cuff tear can not only vary between different people, but also in the same person from one day to the next. This can make it more challenging to figure out what is going on with your body.
Impingement, bursitis, and partial rotator cuff tears can be treated with stretching, postural modifications, and strengthening of the muscles linked with the shoulder blade, which include the rotator cuff muscles. Many doctors will suggest going to physical therapy to learn the correct way to do the exercises. Everything prescribed is meant to give a strong shoulder more space to move.
These exercises can easily be incorporated into a daily routine or workout (after you get the hang of them). Remember that it may take a while for symptoms to be completely relieved, as muscle strength takes time to build.
Occasionally, anti-inflammatory medications, including cortisone injections, are offered to help relieve the pain in the short term while the patient is doing the physical therapy required for the symptoms to fade and stay away. By continuing the stretches and exercises after the symptoms are gone, you can usually prevent them from ever returning.
Less often, these stretches and exercises help with the symptoms of a complete rotator cuff tear. An orthopedic surgeon can also reattach the torn tendon in order to relieve the pain and weakness. Nowadays, this procedure is most often done through shoulder arthroscopy, a type of less invasive surgery that’s performed with a camera and small instruments. This is followed by the same type of physical therapy to prevent the problem from returning.
Yes! The good news is that the same stretches and exercises that treat the injury can also prevent the injury. If you keep the shoulder blade muscles efficient and strong — most importantly the four rotator cuff muscles — the shoulder will remain healthy.
Another key secret to healthy shoulders — while it may seem unrelated at first — is maintaining strong hips, glutes and core muscles. If these areas remain strong and engaged during activities, the smaller muscles of the shoulder are less likely to wear out or weaken as quickly — or at all.
The following videos showcase a few exercises that can be used a few times a week to combat pain associated with the rotator cuff or to maintain rotator cuff health after the symptoms have resolved. These same exercises can also be added to a routine to help prevent or stave off the problems.
The shoulder is incredibly dynamic and the rotator cuff is just one piece of the puzzle, but a very important piece. It services the shoulder in countless ways, the most crucial being maintenance of the joint’s stability to help us stay active and pain-free in our daily life. Setting aside a small amount of time needed to recruit and strengthen the muscles involved in healthy shoulder function can be invaluable and should be a part of everyone’s life.
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