Category Archives: Shoulder

Weight Lifting Injuries

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Statistically, more and more people are working out using weights and weight bearing exercise than ever before.  Whether it’s to achieve those major biceps for men or to tone and stave off the ravages of osteoporosis for women,  fitness with weights is at all an all time high.  So, unfortunately, are serious shoulder injuries, most of which occur with upper arm strengthening.

One common problem  is an injury to the A-C joint  The A-C Joint is the small accessory joint at the top of the shoulder. You can feel it — it is the small bump at the end of your collarbone. A-C stands for Acromio-Clavicular. The acromion is a flat bone at the top end of the shoulder blade. It is nature’s shoulder-pad — a square shaped bone that you can feel at the top of your shoulder.  The clavicle is the collarbone. Between the end of the clavicle and the acromion is the A-C joint which plays a major supporting role in the function of the shoulder.”

Both those who work out and their fitness trainers can stress the A-C joint when they do bench-presses and overheads because any exercise that uses a substantial amount weight to move the arm also involves stress to the shoulder.  Both of these lifts strengthen the powerful deltoid muscle which lies along the acromion and the clavicle and thus, the stress of heavy lifting can be transmitted to the small A-C joint. People who lift weights for years may injure the A-C joint and develop arthritic degeneration in the area. My patients frequently complain of pain and popping  at this joint.   I can even hear the pop on examination before x-ray or MRI confirms the injury or arthritic condition.”

The bad news on A-C  joint degeneration is that  once the damage occurs, it cannot be reversed. There is no cure for arthritis. One solution might be to curtail or give up overhead lifting, but this is usually not an option for dedicated weight lifters.  They may abstain from or limit weight lifting, but usually only for short periods of time and rarely long enough to stabilize a serious joint condition. Anti-inflammatory medicines like Aleve, Celebrex and Advil  may relieve pain but their effects may only be temporary.  A cortisone injection into the A-C  joint may also help, albeit temporarily. And neither will relieve the ‘popping’ of the joint.  That said, both therapies  should be tried prior to surgical intervention.

When A-C joint surgery is indicated, both the pain of the injury and the ‘popping’ sound can be cured with comparatively minor surgery. Quite simply, the end of the collarbone is removed. The painful arthritis and the pressure at the joint are relieved. This often ends both the pain and the popping.  The surgery can be done either arthroscopically or through a very small incision at the top of the shoulder. Recuperation is relatively quick – usually two to three weeksto return to normal activity .  The good news for the gym set is that there is usually little or no postoperative impairment to the shoulder and patients can happily resume weight lifting and other sports. Some lifters may note slight loss of maximum bench press strength, but this will be offset by relief of painful popping.

Weight lifters can also develop muscular injuries from overuse or overdoing it! One common condition is bicepital tendinitis.  “The biceps muscle bends the elbow and it’s long tendon lies in a groove in the front of the shoulder. Tendinitis or inflammation of the tendon can occur with bench presses and ‘dips’.  Treatment consists of pain and/or anti-inflammatory medication ; Physical therapy can be useful.  Sometimes, a cortisone injection. is necessary. 

Older lifters may even rupture the tendon. Sharp pain and a popping sensation may be felt in the front of the shoulder. The pain will eventually subside and usually there will be little or no lasting disability so surgery is rarely necessary.

Another muscle that can tear with excessive stress during bench presses is a tear to the so-called “pecs” – the pectoralis major muscles. A partial tear can be treated with rest and therapy and should heal on it’s own. A complete tear may require surgical repair.

Working out with weights is an important part of many people’s lifestyles. It is, for the most part, an excellent way to help stay fit and an anti-aging boost.  That  said, it must be approached with care in order for people to gain the maximum benefit from work-outs.”  In short, take care of your arms and shoulders and they will help take care of you.  If not, your upper body fitness is at serious and potentially permanent risk due to injury.

 Please note: these articles are for general information. They are not intended to serve as medical advice or treatment for a specific problem. Diagnosis and treatment of a problem can only be accomplished in person by a qualified physician.

Rotator Cuff Injuries

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The Rotator Cuff – not rotary cuff, as some people call it – is a broad tendon that covers the humeral head –or ball of the shoulder joint. The shoulder is a ball and socket joint. Both are very shallow and the joint would be unstable were it not for multiple muscles and ligaments which hold the ball and socket together. The fact that the joint is shallow allows for better and circular motion of the shoulder.

The rotator cuff is actually a broad tendon which, to me, looks like a bathing cap-covering the ball of the shoulder like a cap covers one’s head. Four muscles converge into the cuff –the subscapularis, the supraspinatus, the infraspinatus, and the teres minor. The tendon attachments of the middle two muscles (the supraspinatus and the infraspinatus) are more commonly torn.

These muscles allow internal and external rotation of the shoulder and assist the larger muscle that covers the shoulder-the deltoid – with abduction(raising the arm sideways and upwards). The deltoid abducts the arm, but cannot do so without the assistance of the rotator cuff muscles. This is why patients with a strong, normal deltoid but with a large rotator cuff tear frequently cannot lift their arm.

I mainly see three rotator cuff conditions:

1. TENDONITIS or TENDONOSIS.

Tendonitis means that the cuff tendon is inflamed and clinically there is tenderness and pain on movement. Overhead elevation produces pain –a positive Impingement Sign. Under arthroscopic visualization, the cuff looks scarred and irregular. Calcium deposits may occur.

Depending on the severity of this condition, I try to initially treat this problem with rest, therapy, and anti-inflammatory medications. Frequently, I give a cortisone injection ,which commonly works.

If these conservative measures, fail, the last resort could be arthroscopic surgery to smooth and clean out the scar tissue. This is usually successful and the recovery time is short –most of my patients regain full motion within a week or two.

2. PARTIAL ROTATOR CUFF TEAR

This is commonly associated with tendonitis ( above) and the treatment is the same. I first recommend conservative treatment. If surgery is later performed, I usually smooth and clean out the scar tissue adjacent to the partial tear and it probably heals without surgical repair or opening up the shoulder.

3. COMPLETE ROTATOR CUFF TEAR

This is a full thickness tear – a complete tear: the size of the tear is commonly the size of a dime but frequently larger. Usually, although, not always, the patient cannot raise his or her arm, or if they can, they do so with pain. The tear could be caused by chronic use and wear in an older person. In younger people or in workers who do heavy labor, it can be caused by an acute wrenching injury. Falling directly on the shoulder can tear the rotator cuff. Throwing hard can do it. Or some injury that jams the arm — thus transmitting force towards the shoulder– can tear it.

These are serious injuries. The treatment is frequently surgical –commonly with a skin incision. The tear is stitched together. Sometimes, it can be repaired arthroscopically, but usually a small mini incision is necessary. Post operatively, a sling to rest the arm and to allow the repair to heal is needed for 3-4 weeks. And then, physical therapy to rehab the shoulder –for 2-3 months – or longer. No picnic!

But, the results are frequently good, although there are no guarantees. Much of the success of this surgery depends on the patient. Patients must adhere to their doctor’s orders, lest they re-tear the repair in the vital post-operative period. And, if they do not follow-through with their rehab program, they may develop stiffness, a frozen shoulder, or weakness. And in older patients with poor circulation, the repair may not heal ;  also,  in patients who smoke or have diabetes.

Some people with large tears, paradoxically, have surprisingly decent shoulder motion. If these patients have relatively little pain, they theoretically could avoid surgery if they can live with this condition. But, most people with rotator cuff tears have trouble and require surgery.

Is there treatment besides surgery ?  Probably not.  Physical therapy could be offered for the patient in the paragraph above, but therapy will not heal the tear. Large tears most probably will not heal, so surgery is usually indicated for these.

Please note: these articles are for general information. They are not intended to serve as medical advice or treatment for a specific problem. Diagnosis and treatment of a problem can only be accomplished in person by a qualified physician.

Shoulder Separations

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One common shoulder injury that is frequently confused with a dislocation is the shoulder separation.  Many people believe them to be the same injury, but the two are completely different.

Shoulder separations refer to a disruption of the ligaments which hold the collarbone to the shoulder blade.  When these ligaments are ruptured, the collarbone rises out of place from the shoulder and “separates.”  Medically, this is referred to as an Acromio-Clavicular separation.  As the clavicle (collarbone) attaches to the acromion (side extension of the shoulder blade), it is held by three ligaments.  These ligaments stabilize the clavicle and hold it down toward the top of the chest.  Injury to these ligaments “springs” the collarbone upward from its normal position.

Run your hand along your collarbone; as the shoulder is approached, you will feel a small bump—this is the acromio- clavicular (A-C joint).  A-C separations usually occur from a direct force as one falls violently onto the point of the shoulder.  The shoulder is forced downward as the ligaments holding the collarbone tear.  The injury is common in contact sports, such as football, rugby, hockey, and lacrosse.  Football players who carry the ball, such as backs and ends, are more susceptible because their shoulders are directly hit when they are tackled.  However, the improvement and effectiveness of shoulder pads over the years has diminished the incidence of this injury in football in contrast to rugby where the occurrence rate remains higher.

A shoulder separation is quite painful, and the athlete is unable to lift his arm without discomfort.  The A-C joint is swollen and tender to touch.  Complete separations produce a prominent deformity with an enlarged “bump.”  If there is any doubt about the diagnosis, stress x-rays can be performed to confirm that the joint has separated.  The patient is asked to hold a heavy weight with the arm at the side.  The weight pulls the shoulder blade down, and the collarbone will displace upward.

Like many other orthopaedic injuries, A-C separations are categorized into three degrees of severity.  A first degree separation is merely a sprain without serious ligament damage.  The joint is tender and swollen, but there is no separation.  Treatment consists of ice applications and use of a sling for 3-7 days.  Athletics can later be resumed when the pain subsides, and full shoulder motion is restored.  Little rehabilitation is necessary, and the prognosis is excellent.

In the second degree separation, the injury is greater, and there is complete disruption of the ligaments which surround the A-C joint. However, the ligaments holding the collarbone to the shoulder blade are not torn, and consequently there is only minor displacement of the collarbone.  The A-C “bump” is more prominent, and the separation can be felt.  This injury is also treated with a sling, but immobilization is required for two to three weeks to allow the joint to heal.  During this period, gentle motion exercises are allowed to prevent shoulder stiffness.  Later, shoulder strengthening exercises are recommended.  The athlete can return to sports in four to six weeks if the pain has subsided, and if there is clinical evidence of healing.

A third degree A-C separation represents a complete dislocation of the joint and rupture of all ligaments.  The collarbone displacement produces a large painful deformity.  The treatment of this injury is controversial.  Some orthopaedists believe that no treatment is necessary, and therefore no attempt is made to reduce the separation.  The rationale of this treatment is based on the belief that the separation does not really cause any permanent disability of the shoulder after the initial pain has subsided.  The patient rests with a sling for one to two weeks and later resumes activity when there is no longer any pain.  There is merit to this approach, as many patients regain useful function of their shoulder even with a permanent deformity.

The other school of thought is that the separation must be set and held either with a brace or by surgery.  The brace is a special sling with a pad which exerts pressure over the collarbone, pushing it down.  The sling could be effective, but it is very uncomfortable and must be worn constantly for six weeks.  Unfortunately, this treatment requires a rather stoical and reliable patient and, frequently, this treatment option is not practical.

Surgery consists of returning the collarbone to its normal position and holding it in place with a screw, pin, or wire.  The ruptured ligaments are also repaired.  The athlete will miss competition for approximately 12 weeks.

However, surgery may be performed in certain instances—depending on the severity of the displacement and individual requirements of the athlete relating to his sport.

Please note: these articles are for general information. They are not intended to serve as medical advice or treatment for a specific problem. Diagnosis and treatment of a problem can only be accomplished in person by a qualified physician.

Ski Injuries

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Preventing Common Ski Injuries

Once again, many are heading north to the slopes and most will return invigorated, tanned, and happy.  Some, unfortunately, will return with slings or crutches, pale and unhappy.  Here are some common ski injuries and how to avoid.

Well over half of the ski injuries involve the lower extremities, and most of these favor the knee and leg.

Knee Injuries

Knee sprains are by far the most common injuries.  The ligaments along the inside of the knee are injured when a skier catches the inner edge of a ski in the snow and the foot rotates outward as the body continues forward.  Stress is then placed on the inner side of the knee, which is forced into a “knock-knee” position as the skier falls.  The ligament will be stretched (sprained) if the force is minimal and if the bindings release.  Otherwise, the ligament can be completely torn.  Another potentially dangerous position is the “snow plow”—where both knees are knocked and the body weight is placed on the inner edge of the ski.  A fall will place direct force against the inside of the knee.

Catching the outer edge of the ski may injure the ligament that lies along the outside of the knee.  This can occur if the tips of the skis accidentally cross and the skier falls sideways.  The leg on the side of the fall will twist inward and will remain straight.  Stress is placed on the outer ligaments.

The new shorter, shaped skis place more stress on the knees than the former, longer skis.

Especially stress on the medial collateral ligiment(MCL).

Prevention of these injuries mainly centers around adequate bindings.  It has been reported that a high percentage of lower extremity injuries result from a failure of bindings to release.  Quality bindings properly mounted and maintained will prevent many knee injuries.  Various knee braces can also be worn and, to some extent, can provide protection.  A brace with metal sidings and hinges can comfortably be worn under ski pants and allow an acceptable degree of knee mobility.

Fractures

Another common injury is the tibial fracture—or broken leg.  This occurs when the leg is forced against the hard boot top during a fall.  The leg can also break when the bindings fail to release and the leg is twisted.  This torque can snap the bone.  Again, proper bindings are the best insurance against this unfortunate and incapacitating injury.

Shoulder Dislocations

If inadequate bindings are a cause of knee and leg injuries, faulty pole technique can contribute to upper extremity injuries—specifically the shoulder or thumb.

Shoulder dislocations are very commonly treated at base clinics.  The shoulder can dislocate when a backwards force is applied to the outstretched arm and the shoulder is levered forward.  Thus, a skier who falls on his outstretched (abducted) arm may sustain this injury.  Frequently, however, the arm is levered by a planted pole; as the body continues forward, the arm is forcibly stretched and rotated outward, aggravating the injury and making a dislocation more likely.  Slalom racers who grasp too long on their planted poles are especially susceptible to this type of injury.

A shoulder dislocation is very painful and requires immediate setting to relocate the joint.  Multiple dislocations can eventually produce a damaged, unstable shoulder, and surgery will frequently be required to repair it.  One way to avoid this injury is to be aware of the mechanism and try to eliminate excessive pole planting.  Poles with strapless hand grips, which release better from the skier’s hand, may also prevent this injury.  If a skier has a dislocated shoulder, he or she might consider a brace to check excessive shoulder stretching.  These braces are custom made, but they are light, comfortable, and usually don’t interfere with normal skiing.  They can be worn inconspicuously under the ski jacket. ( I have personal experience on this matter, as I dislocated my shoulder twice while skiing—once on a bunny trail at Stratton-when I first learned to ski—but again, and less embarrassingly, on a real black diamond trail—Nosedive—at Stowe, a few years later. I successfully skied down Nosedive without falling and ,of course, at the bottom on level terrain, slipped and fell. I had a custom made brace made which I wore thereafter and never again dislocated my shoulder.) 

Thumb Injuries 

The other notorious injury caused by ski poles is damage to the ligament on the inside of the thumb.  Since the pole is grasped between the thumb and the index finger, sudden force along the pole can jam the handle of the pole into the base of the thumb and injure the ligament.  This is a serious injury which is treated with a cast and perhaps surgery.   Pole straps incorrectly positioned can result in greater risk of this accident.  A strap held around the palm just below the base of the thumb can be stretched.  The strap should properly lie around the wrist, well away from the thumb.  The risk of thumb injuries may also be decreased—although not eliminated—by using poles with a strapless type of hand grip.

Finally, here are five useful tips for prevention of ski injuries:

  1. Service your bindings at the start of each ski season.
  2. Stay fit prior to the ski vacation.
  3. Do warm-up exercises before you go out.
  4. Quit whenever you feel tired.
  5. Don’t be a daredevil.

Please note: these articles are for general information. They are not intended to serve as medical advice or treatment for a specific problem. Diagnosis and treatment of a problem can only be accomplished in person by a qualified physician.