Did you know that once you have had an episode of shoulder pain 40-50% of people will continue to have some symptoms 12 months down the line, even if it doesn’t stop them doing things?
But rehab can be very simple and the earlier you start doing something about it the less time it will take to recover.
So what generally goes wrong with the shoulder?
Most shoulder issues are down to the rotator cuff not doing its job properly. The rotator cuff is made up of four muscles that encompass the glenohumeral (shoulder) joint – the Supraspinatus, Teres Minor, Infraspinatus and the Subscapularis. Together they provide stability for the joint when we move our arm. So, just prior to moving our arm the brain sends an automatic message to the rotator cuff to say there is an intention to move. The cuff then switches on (minus the subscapularis).
One part of the cuff will then work harder than the other depending on what action I make e.g. when I take my arm forwards and up my deltoids and pectoral muscles are moving my arm so the muscles at the back of the shoulder need to work hard. If I take my arm backwards the muscle at the front of the shoulder has to work harder i.e. your subscapularis.
So the cuff is providing the torque or movement muscles with stability. There are situations e.g. when you arm is at shoulder height and you rotate your shoulder, when your cuff has more of a role as torque muscles and other muscles i.e. your deltoids and lats. are working more to stabilize.
So one of three things is generally going on when you have what we call rotator cuff pathology:
- Your cuff doesn’t switch on
- It doesn’t control translation. So when the arm moves, the head of the humerus (your upper arm bone) moves too much in the socket (which can lead to tendons getting impinged)
- It can’t cope with the load
Interestingly, if you look at people with rotator cuff tears and no pain, versus those with pain, in the former the rotator cuff is doing its job better so it compensates.
The most common restricted movements of the glenohumeral cavity (the ball and socket joint) are taking the arm behind the back e.g. to do up your bra strap, and lateral rotation (rotating outwards). It can also be irritated to the point where it wakes you up at night because it is uncomfortable to lie on.
The role of the scapula in the shoulder
The scapula is part of your shoulder. It attaches to your clavicle (collar bone) at the front. The head of your humerus sits in the glenoid cavity of the scapula i.e. the socket. Together these three bones form the shoulder complex. The scapula is the attachment site for sixteen muscles including the rotator cuff. The scapula needs to move correctly in order for the shoulder joint to work properly.
So how do we make the scapula do what it should be doing? We activate the rotator cuff! There are some simple exercises we can do to start activating the rotator cuff but generally they involve shortening the lever (in this case the arm) which reduces the load and makes it easier for the cuff to switch on. A hand grip also facilitates the cuff and scapula, switching it on.
In some people this may be enough and we can then add in some resistance to the movement to encourage the posterior cuff to work harder.
The kinetic chain and shoulder movement
It’s worth mentioning here that the shoulder doesn’t work in isolation from the rest of the body. For example, when we reach up to a cupboard to get something our legs, trunk and shoulder are involved in that movement. The contribution to upper limb power is 50% lower quadrant, 30% trunk and 20% upper limb.
In some circumstances, and especially when we need to get someone back to functioning properly and the issue is with load, we may need to consider off loading the shoulder by getting the rest of the body working harder.
You may be interested to know that there is research that shows a link between ankle or knee injury and subsequent shoulder pathology 2-3 years later!
In people who have had shoulder issues for more than 3-6 months, particularly tendinopathy, the kinetic chain could be a contributor. But also, once the rotator cuff is switched off and other muscles have taken over, it becomes more difficult to get selective control and it’s working harder because it’s either fully on or fully off.
So the message is…….
Don’t put up with a niggling shoulder hoping it will just go away. The earlier you get some treatment including soft tissue work and exercises, the less time it will take to get it back to fully functioning and pain free.
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