CHRONIC SHOULDER PAIN

INFLAMMATION OF A TENDON OR A BURSA

A bursa is a fluid-filled sac that acts as a cushion to reduce friction between bones and tendons, muscles, or joints. Excessive ball throwing or other overhead activities may cause inflammation and swelling of the bursae or tendons. The most affected bursa is the one between the rotator cuff and a part of the shoulder blade known as the acromion. The most affected tendons are the rotator cuff and biceps tendons.

Sometimes, the inflammation may result from the “impingement syndrome” (Figure 4): whenever the arm is lifted, the acromion rubs (impinges) on the rotator cuff tendon or bursa. The rotator cuff tendon can also impinge on the socket/humeral head at the back of the shoulder. This may occur when the tissues at the front of the shoulders become loose over time, while the tissues at the back are tight. Bursitis and tendinitis manifest as pain, weakness, and limited range of motion.

Figure 4: Impingement of bursa and tendon https://physioworks.com.au/injuries-conditions-1/rotator-cuff-impingement

SHOULDER INSTABILITY

Instability occurs when the head of the humerus is forced out of its socket. The head may either come all the way out of the socket (= complete dislocation or luxation) or only do so partially (subluxation). Once the ligaments, tendons, and muscles around the shoulder become loose or torn, recurrent dislocations, either partial or complete, may occur and cause pain and unsteadiness whenever you raise your arm.

DYSFUNCTION OF THE SHOULDER BLADE (SICK SCAPULA)

Since the shoulder blade is only connected to the collar bone, its position and stability are highly dependent on its muscles. Repetitive use of these muscles may cause changes that result in drooping or abnormal movements of the shoulder blade. In some athletes, the chest muscles may tighten in response to the changes in the back muscles. You may feel pain in the front of your shoulder near the collar bone.

HOW CAN YOU PREVENT CHRONIC SHOULDER PAIN?

As a throwing athlete, you need to maintain a delicate balance between mobility and functional stability of your shoulder. Your shoulder must be flexible enough to allow excessive external rotation, but also stable to prevent dislocation or subluxation of the humeral head. The most important factors for all overhead athletes are shoulder range of motion, rotator cuff strength/imbalance, and position and movement of the shoulder blade.

Although we need more research to provide evidence for optimal prevention, what we currently know supports the following suggestions:

USE PROPER THROWING MECHANICS

You have to be aware that you can generate considerable force when your arm performs a throwing movement by using your core and leg muscles. That means, as odd as it may sound, a good range of motion and strength in your hip and a stable core are a critical foundation in the kinetic chain of throwing. Always use your legs and trunk during throwing.

GIVE YOUR SHOULDER ENOUGH REST

When you are tired, this may alter your throwing mechanics and predispose you to injury. Try to get enough rest between training sessions or games. For young pitchers, there are specific recommendations to limit the number of throws per session. Less than 76 pitches per game and 600 pitches per season are suggested.

IMPROVE YOUR SHOULDER RANGE OF MOTION

Raise your arm to be horizontal, bend the elbow to 90°, and then turn the forearm and hand forward as far as possible while keeping the elbow in position. This movement is called internal rotation. You should have about the same range of motion on both sides. Many throwing athletes, however, have a deficit in the internal rotation of their throwing arm. This can predispose you to injury. Learn how to stretch the tight structures in the back of your shoulder. The Sleeper stretch is a good stretching exercise—as long as it is pain-free. If it causes you pain, stop doing it!

STRENGTHEN YOUR ROTATOR CUFF MUSCLES

Throwing athletes frequently have a muscular imbalance in their rotator cuff. Most often, their external rotators may be weaker than their internal rotators. The external rotators should have 66-75% of the strength of the internal rotators to maintain stability during throwing. Doing eccentric exercises of the external rotators using elastic bands may be helpful to obtain more strength in the external rotators.

RESTORE THE BALANCE OF YOUR SHOULDER BLADE MUSCLES

Throwing athletes may develop abnormal motion patterns of their shoulder blades. Most often, one shoulder blade stands lower than the other, or the inferior part of the blade may be prominent. I recommend the consequent strengthening of the middle and lower parts of the trapezius muscle, rhomboids, and the serratus anterior. You can easily find exercises that strengthen these muscles.

INCREASE THE NEUROMUSCULAR CONTROL OF YOUR SHOULDER

Neuromuscular exercises stimulate the centers in the brain that control movement. They help you to learn how your shoulders were meant to move and pay more attention to the position of your shoulder joint. You can perform Dynamic Neuromuscular (DNS) exercises on stable or unstable surfaces with an elastic band or a Swiss or medicine ball. Slow and fast catching ball exercises with heavy balls cannot only increase muscle endurance but also the plyometric capacity (meaning the ability to exert maximum force in short intervals of time) of your shoulder.

It may be daunting to do all these exercises by yourself. But this is not necessary. There are some well-designed programmes for preventing shoulder injuries and chronic shoulder pain. I suggest these two:

The Oslo Sports Trauma Research Center (OSTRC)’s “Fit to Play” website is a fantastic resource: Check their shoulder injury prevention programme. They also offer sport-specific programmes: Check the one for handball (applies to baseball, too); volleyball; lacrosse; tennis; and judo.