What are the two most common shoulder injuries?

In recent months, due to lockdowns and gym closures, creating your own ‘Home Gym’ has become commonplace, but has this resulted in an increase in shoulder injuries?

The shoulder is particularly prone to injuries due to the fact that it’s not a very stable joint. The shoulder relies on lots of ligaments & muscles to keep it stable. This anatomy of the shoulder makes it prone to injuries that can easily happen from stretching, overloading & repetitive movements.

Part of the problem with exercising in a Home Gym is that for many people:

• you have very little space to move freely
• your exercise equipment is inadequate
• you don’t have supervision from an expert (e.g. personal trainer).

All of these factors can leave yourself at risk of injury due to inappropriate or improper technique, particularly around the shoulder area.

Looking at the patients I’ve seen in my clinic stream over the last 12 months, I’ve noticed two common shoulder injuries caused by working out in a home gym, namely:

1. rotator cuff injuries and
2. AC Joint injuries.

So, what are the main causes of these injuries, how do you accurately diagnose and what are the best treatment options?

What are the most common causes of rotator cuff tendon injuries?

Rotator cuff injuries are one of the most common injuries that I see in my practice. Rotator cuff problems tend to occur because of repetitive overhead activities.

Training the deltoid is one of the most common ways to injure the rotator cuff. The main lifting exercises include:

• the upright row,
• weightlifting above the head,
• bench dips and
• behind the head neck pull down.

The way your arms are positioned while lifting the weights results in maximal rotation of the shoulders, and so it’s not surprising that there is a risk of potential rotator cuff problems.

I’ve seen a trend of younger patients presenting with recurring rotator cuff problems that simply don’t settle. That’s because it gets inflamed and stays slack, and so the humeral head doesn’t stay fully in the glenoid (see hand drawn pictures below).  When the arm moves up slightly, the cuff tendons can impinge against the acromion and this then leads to further inflammation…  and more inflammation leads to further weakness. It’s a vicious circle that won’t go away and which can result in ongoing symptoms.

 

How to diagnose rotator cuff tendon injuries?

It’s really very simple. You use the classical painful arc test, as illustrated in the diagram below.

Ask the patient to raise their arm, but ask them to do so slowly. (NB If they do it quickly, they can bypass the tendon). Then watch their face or ask them to say when any pain or clicking is felt (N.B: clicking is a very common feeling patients describe, and this is due to the humeral head migrating upwards and then relocating itself in the glenoid).  The pain won’t be present when the arm is high up in the air (if it does, or it gets worse with the arm high up, this could suggest possible AC joint pain, so always ask the patient to point to where the pain is being felt). Again, as the arm is moving back down, the pain is felt again, and it can be more uncomfortable on the way down. This is the painful arc, which is classic for the diagnosis of rotator cuff pain.

The impingement testing involves rotation of the arm internally whilst the arm is abducted. It’s important to ask the patient where the pain is, which is usually on the side of the arm. This is a sign of impingement or tendonitis.

Of course, there is a role for Ultrasound and/or MRI scan when the clinical presentation is equivocal.

How to treat rotator cuff tendon injuries?

Prevention is key

If patients are lifting heavy weights, you need to tell them to stop!  If they’re getting pain, then they need to go down a bit and lift lighter weights.  It’s fine for them to do more repetitions, but the weights have to be lighter.

Physiotherapy

This is genuinely the key to successful treatment, and I always recommend that the patient sees a physio that specialises in shoulder physiotherapy and who has the expertise to work on the rotator cuff tendon, specifically.

When you have a tendon that isn’t torn, but just needs to be tightened, then this is where physiotherapy can succeed greatly: particular by focusing on isometric exercises. The aim is to tighten the rotator cuff tendon and to recruit outer muscles (Lat D, Pec) as they insert on the neck of the humerus, so that they act as a depressor, assisting the supraspinatus muscle.  When patients present with pain under the armpit, this is often from compensatory mechanisms, and this tends to disappear when the rotator cuff gets better.

Steroid injections

If the patient isn’t improving because it’s too painful for the patient to do rehabilitation exercises, there is a role for steroid injections.

Once I’ve injected a patient, I’ll then send them back to their physio. I explain to the patient that there’s no point in me injecting them if they won’t pursue regular rehabilitation with a physiotherapist. I insist that the patient sees a therapist, because when they say “I exercise regularly”, hinting that they don’t need the help of a specialist therapist, I say “you could be exercising the outer big muscles wrongly and thus unbalancing your shoulder, and this can aggravate the problem!”.

Surgery: Arthroscopic Subacromial Decompression

If all of the above conservative treatments fail, then it usually means that the tendon has gone into a phase where the amount of bursitis & scarring above it is now very thick and this is making the space tight for the tendon (bear in mind that some patients have a smaller subacromial space compared to others, and this is why some might be more prone to impingement). For me, surgery will always be a last resort, and I will only recommend surgery if the patient has failed to improve after 6 months of physio (& or injection) and the space is still tight.

What are the most common causes of AC Joint Injuries?

Injury to the AC joint is something that I commonly see in younger patients, and is usually caused by:

• Bench press with dumbbell

• Deltoid above head workout

With the last few degrees of that push, you’re basically jamming your acromion against your clavicle, and this is where you cause continuous nodding between your clavicle and acromion, stressing your AC joint.

Dumbbells are worse, as it’s easy to lose control on the last few degrees when you bring the arms together and the dumbbells drop away from your hands, and this is one of the contributing factors in jamming the AC joint, crushing the small cartilage inside the AC joint and causing trouble.

How to diagnose AC Joint Injuries?

Pain in AC joint could be from a sprain; inflammations in capsule (capsulitis) or tear of the cartilage

I always ask patients to tell me where/when is it painful? For a positive diagnosis, this is what I most commonly hear:

• I get painful movement when trying to get my seatbelt on
• Moving my hand behind (trying to reach behind my back)
• When I’m sleeping on my affected side
• I just can’t get my arm high up as straight as the other one, it feels it gets stuck
• Women will always point to the bra strap area

How to treat AC Joint Injuries?

Physiotherapy

I always recommend at least 3 months’ physiotherapy, and including work on posture is also very important.

The AC joint is a very small & shallow joint. Proven effective rehab is therefore based around the following:

• ice therapy, gentle massage soft tissue stimulation – i.e. working on the surrounding muscles that are firing & aggravating the pain (e.g. trapezius, pec, clavicle),
• addressing posture, balancing movements and working on the trapezius and scapular muscles, and
• pain management, including gentle massage, ultrasound and soft tissue massage devices.

Steroid Injection

Ultrasound steroid injection into the AC joint can provide relief and then I send the patient back to the physio to continue with their rehab.

Surgery: Arthroscopic excision

If all of the above fails, then I’ll recommend surgery.  If the patient responds well to an injection (which also confirms the diagnosis), then they’ll usually respond well to surgery. The latter is done arthroscopically, whereby I shave about 5mm off the end of the clavicle and some bone from the acromion, along with debridement the inflamed tissues under the AC joint.

In Summary / Conclusion

The two most common shoulder injuries I’ve seen in recent months caused by home gym workouts have been to the rotator cuff tendons & to the AC joint.

For both these injuries, I will always recommend that physiotherapy is the first treatment option. That can involve:

• taping/strapping,
• soft tissue therapy (I believe in this a lot, including US & others),
• gentle massage (but there is a fine line between not going in too deep and thereby triggering inflammation) and
• focusing on muscle recruitment, which is the basis of any rehabilitation.

If after 3 months the patient doesn’t improve with physiotherapy, then as a next step I will often recommend giving the patient a steroid injection. This will usually reduce the pain, and consequently the patient can then continue with physiotherapy.

Surgery will always be the last resort.  Surgical options include Arthroscopic Subacromial Decompression and Arthroscopic Excision.

I’m a firm believer that the majority of shoulder problems will benefit from physiotherapy as the main first-line treatment option. The aim is to make the shoulder stronger. Even if the patient eventually has to have an operation, having physio first will still make the post-op rehabilitation easier.

Being a full-time NHS consultant and also working in private practice too, I’ve seen such a huge difference between my patients who have received physio within a week, by going privately, compared to those who often end up having to wait about 6 weeks or longer for a physio appointment within NHS. The progress I tend to see for private patients at 2 weeks is often equivalent to where many NHS patients are only just beginning to reach by 8 to 10 weeks!

I’m a big fan of physiotherapists and the value of trying appropriate conservative treatment options first. I continue to learn from my specialist physiotherapy colleagues that I am lucky to work closely with, and I greatly value the tips and tricks that they give to my patients! That’s why I’ll nearly always recommend that my patients see a physio first, and I’ll only offer surgical treatments when conservative measures have first been tried but have failed.

Mr Daoud Makki, Consultant Upper Limb Surgeon

This article was written following a CPD webinar presentation given by Mr Makki to physiotherapists, which was part of HCA Healthcare UK’s Online Physio Education Programme.  If you’d like to view the presentation, click here

For more information visit, Mr Daoud Makki – London Sports Orthopaedics

To arrange an appointment: Tel: 020 7496 3552 or Email: makki.admin@sportsortho.co.uk

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If you are a GP, physio/AHP and would like Mr Makki to lead a CPD session on shoulder injuries, then please email: mary.wolff.ingham@sportsortho.co.uk

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