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Physiotherapist And Doctors Services - Shoulder Pain

Shoulder Pain

Types of Shoulder Injuries
- Instability (traumatic vs. a-traumatic) - often in gymnastics ‘hypermobile’
shoulder
- SLAP lesions
- Internal impingement (SLAP/instability?)
- Os Acromiale/AC joint
- SICK shoulders (general ‘crowding’)
- Impingement/tendinopathy
Presentation
- Pain in shoulder. Site of pain, and direction of loading causing aggravating
symptoms generally most helpful in identifying contributors causing overload of
shoulder structures. Can be a number of structures affected – most important to
identify contributing factors (may be a mix)
Contributing factors
- Hanging or support activity
- Wider levers contribute huge expectations on scapula and cuff stability to
protect shoulder (e.g. cross, Maltese, planch etc).
- Presses in any position of support + increased numbers
- Scapula dyskinesia _ inability of scapula stabilisers to either keep scapula
stable as base of support for rotator cuff (may appear as ‘winging’ in
support positions), or scapula mobility not sufficient for end range
loading (scapula to provide stable base in all positions - but should move
into overhead and reaching positions to continue to provide base of support
for cuff activation (often via flexibility limitations in any of the following _
pectoralis minor, posterior cuff/shoulder internal rotation, triceps, lat dorsi,
thoracic spine extension).
- Shoulder internal rotation deficits (GIRD > 25°) – can contribute of overload
of shoulder structures during loading at end ranges, and pull scapula out of
stable positions during these activities
- Shoulder instabilities (laxity of ligaments of shoulder combined with
deficiency of stabilising muscles fail protect shoulder structures from
excessive loading) causing overload of shoulder structures _ commonly
shoulder labrum/cartilage (e.g. SLAP lesions) and rotator cuff tendinopathy.
- Female and male athletes
- Flexibility deficits anywhere in upper limb or trunk chain (e.g. wrist, forearm,
muscles listed above, thoracic spine, hips) – shoulder may compensate
- Muscular/neuromuscular stability at forearm, shoulder/scapula or trunk may
cause overload of shoulder
- Occurs more frequently around periods of increased athlete growth and
any weight changes
- Increasing in specific shoulder loading during strength or skills training
Key management points
- Reduce all loading of shoulder (aggravating activity) until follow up with
health professional (gymnastic Sports Physiotherapist)
- If suspicion of instability or resistant progress of physiotherapy
management – referral to Sports Physician for review and investigation
(MRI)
- Beware cuff pathology – often co-exists with instability
- Management specific to contributing factors (flexibility, scapula stability in
different positions of support and hang, rotator cuff activation)
- Training within pain limits only
Management strategy
- Identify periods of increased growth (spurts) and reduce overall training
loads until spurt over
- Remove or Reduce numbers of skills/drills which are aggravating
symptoms
- Seek advice from gymnastic Sports Physiotherapist – rehab outline,
training loads and progressions
- Keep diary of activity levels _ if symptoms increasing, remove aggravating
activity until pain begins to subside
- If continuing shoulder symptoms, unload completely from aggravating
activity until appropriate professional advice sought
- Address all areas of flexibility and conditioning to minimise loads on
shoulder (e.g. if ‘stiff’ or tight at shoulders, wrist may attempt to
compensate to make up deficit causing overload at shoulder - pectoralis
minor, posterior cuff/shoulder internal rotation, triceps, lat dorsi, thoracic
spine extension, hip extension).
- Rehab progression and training loads as per Sports Physiotherapist advice
- Assess technique and body posture during static and dynamic skills/drills to
determine contributing factors (global flexibility,
pelvic/trunk/scapula/forearm control)
- Ice post training if symptomatic
- Continue modified (as necessary) mid body and lower body programs
Flexibility
- Emphasise regions above and below potentially contributing to overload
- Thoracic extension flexibility
- Scapula external rotation (pectoralis minor)
- Hip flexors
- Wrist flexors
- Triceps
- Lat dorsi
- Shoulder internal rotation
Strength/conditioning
- Trunk control all directions
- Shoulder exercises _ ‘pulls’ before ‘pushes’ within pain and inner range
(arm closer to side) before increasing range
- scapula and shoulder stability particularly in support (front, side, back,
handstand) and hang, triceps and forearm condition to assist control in
support _ inner range then progressing to outer range as control and
condition improves
- Ensure keep up lower limb strength to ensure power development during
dynamic support skills to minimise upper limb contact time and range of
motion expectations.
- Wrist/forearm conditioning
- Continue modified (as necessary) mid body and lower body programs
CV fitness
- Normal program
Physiotherapy
- Mobilisation of any joints above and below shoulder possibly contributing
towards overload
- Soft tissue mobilisation of any muscular/fascial structures identified as
contributing factors
- Shoulder mobilisation if any capsular limitations/AC/SC joints etc.
- Prescription of rehab targeting conditioning deficits
- Review of suitable training progressions and timelines
Return to sport
- Dependent on ability to complete skills/drills/training loads etc within acceptable and
improving pain parameters and technique
Key management points
- Seek gymnastic sports physio advice for confirmation of diagnosis,
identification of possible contributing factors, management outline (Sports
Physician review particularly is concerns regarding instability of shoulder)
- Unload shoulder as per management advice doctor/physio
- Rehab to identify contributing factors to overload (see ‘Management
Strategy’)
- Coaches to monitor ‘growth spurts’, training loads, improve condition of
surrounding and global muscles groups in support to assist shoulder share
upper limb loads. Report any concerns to Sports Medicine support.

 
 
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