Common Shoulder Dysfunction
You may know the shoulder as a single joint that is capable of an amazing range of movements and functions. In reality, it is best considered as a complex. This term is not used because it is a complicated joint, but rather to highlight the fact that there is an orchestra of components all working together to bring about movement and stability of the shoulder region. The shoulder has allowed humans to interact with, and manipulate, the external world. From washing your hair to fastening a bra, the shoulder is called upon to move through a range not seen in any other joint; in sport and exercise these demands increase significantly.
Humans display an emotional connection with the shoulder joint. Notice how the shoulders can rise upwards towards the ears during times of stress, with an uncomfortable tension building up in the surrounding muscles. The shoulder complex can also reflect our mood – the slumped shoulders when we are feeling low or the shoulders pulled back with pride. When painful, the shoulder has an ability that no other joint seems to have to the same degree; it can immobilise itself. Picture the fallen Tour de France rider cradling their immobilised arm after a collarbone (clavicle) injury. It is not unusual to see a patient with a frozen shoulder reaching across their body to grip their painful upper arm and fix it against their body. In this way it can be totally relieved of its functional duties.
By acknowledging the shoulder complex for what it is – a collection of moving and stabilising parts – you will better appreciate the overview of anatomy that follows. This will lead you on to discover how and why some of these structures become dysfunctional, causing pain and restriction of movement.
Functional Anatomy of the Shoulder
Passive Structures. The term passive structures will be used in its very broadest sense throughout this book to refer to any structure in the musculoskeletal system that cannot move itself. That is, its resting state can only be changed by something acting upon it, whether this is gravity, somebody moving it on a person’s behalf, or a muscle and tendon pulling against it.
The passive, or inert, structures are those that give the fundamental shape and inherent stability to the joint; examples are bones, cartilage, ligaments, capsules and bursae. The relationship of these structures can be seen in Figure 5.1.
Common Shoulder Dysfunction
The wide variety of pure movements normally available at the glenohumeral joint combine to create an extensive circular movement, known as circumduction. This can be fully appreciated when you ‘windmill’ your arms. The large degree of movement is facilitated by the scapula as it travels over the posterior ribcage. To fully maximise shoulder function, we therefore also need to consider the position of the ribcage, as this is the ‘stage’ on which the shoulder joint performs. If this is poorly positioned because of posture or trauma, then stress is placed on other structures to compensate.
During a diagnosis of dysfunction at the shoulder, you may hear nonspecific terms such as impingement syndrome or frozen shoulder. Paradoxically, the better our understanding of pathology has become, the looser and more nondescript the diagnoses have been in recent years. This actually reflects a better understanding of shoulder problems – tissue dysfunctions often coexist! It is very difficult to pinpoint the cause of shoulder pain to a single structure, and there has not been a scan invented that can detect pain. Dysfunction, on the other hand, can be obvious to a well-trained health or medical professional. The shoulder is a fairly honest joint that often reveals its secrets through patterns of pain and movement.
Some of the key features of common shoulder problems will be explored next. Subacromial Pain Syndrome. You may hear this condition described as impingement syndrome, rotator cuff disease or even rotator cuff tendinopathy. It is thought to be caused by an entrapment of the soft tissues in the space below the bony shelf of the acromion, hence the term subacromial (Figure 5.5)
This rotator cuff dysfunction may in turn lead to reduced control of the head of the humerus bone and contribute further to the subacromial impingement.
In clinical practice and in the research literature, the term subacromial pain syndrome is becoming more common. This is partly because it is difficult to observe impingement on scans like ultrasound, but also because we cannot be sure of a single structure being the cause of pain. The ‘impingement’ may involve not just the rotator cuff tendons but also the long head of the biceps muscle and the bursa. Thickening of the bursa, the rotator cuff tendons and the shoulder ligaments can further reduce the available space for movement. Add in poor shoulder posture and you have a recipe for pain. According to some research, subacromial impingement syndrome is the most common diagnosis for shoulder pain.
Before we leave the overview of this pathology, it is worth considering the concept of tendinopathy of the rotator cuff tendons. It has often been regarded as an ‘overuse’ tendon disorder, but this has been brought into question more recently. Some evidence suggests that degenerative tendon change is due to many factors, one of which could be a form of underuse; that means not used sufficiently in the context in which the injury may have occurred. This again suggests that loading the tendon in a controlled way with body-weight exercises may make the tendon more robust and restore pain-free function.
Very often, small tears may be found in the rotator cuff tendons; however, these are often treated effectively with nothing more than physiotherapy/loading exercise and modified shoulder movements. The tears may respond well to steroid injections, but this is considered to potentially weaken the tendon further and possibly increase the risk of further tears or rupture. If you are unsure, seek advice from your qualified medical or health professional.
Key Exercise 5.1: Scapula Dip
Primary Target Area: Muscles around the scapulae
Sets: 3 Reps: 10
Rest: 30–45 seconds
This is an exercise for activating the scapula muscles; it uses the same starting position as a triceps dip, but has no movement from the elbows. The scapula dip is a useful exercise for those who are not used to supporting the entirety of their own body weight. You will need access to a dip bar as described in the equipment chapter, or other similar set-up. If you have a kitchen worktop that meets in an internal corner, you may find this a suitable surface for this exercise.
1. To perform the scapula dip, grab the dip bar with both hands facing inwards. Push yourself up until your elbows are straight.
2. From here, draw your shoulder blades downwards, away from your ears, without bending your elbows. Keep going until you cannot rise any further. This is the starting position.
3. Lower yourself down without bending your elbows. It should feel like your ears are dropping to meet your shoulders.
4. Push back up again until you reach the starting position. This counts as one repetition.
The scapula dip is tough not primarily because of the strength required, but because many people struggle to keep their elbows straight when performing the movement. Try to isolate the shoulders as much as possible, and think about keeping the elbows straight to avoid excessive muscular strain here. Watching yourself in a mirror or getting a training partner to help is a good idea.
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