It’s the same mistakes…
Shoulder pain while golfing comes arises from the same mistakes:
- Poor swing mechanics
- Poor lower body/core function
- Poor shoulder blade stabilization
- Poor shoulder external rotation
I am going to break that this time because many of the conditions that can cause shoulder pain while golfing are from the same root reasons.
There are a few different shoulder pain injuries that golfers usually go down with, but they are usually from these same root reasons.
Here are the 6 most common shoulder injuries in golf:
- Rotator Cuff Tear
- Rotator Cuff Tendonitis
- Shoulder Impingement
- Glenoid Labral Tear
- Shoulder Instability
This article will go into each of the most common shoulder injuries in golf, but let’s first go over the reason shoulder pain develops at all in golfers….
The Major Cause
The shoulders go through a lot of external rotation in a complete golf swing.. In order to do this, your shoulder needs to be aligned properly. Improper alignment of the shoulder and shoulder blade leads to many shoulder injuries. Here’s a great video by a TPI trainer I respect in the SoCal area:
Increasing external rotation and proper shoulder blade endurance allows the shoulders to move freely through a golf swing.
There are some common faults people have in their golf swing that leads to shoulder injury…
Swing Faults To Look For
- Early extending
- Loss of posture
- Reverse spine angle
- Flat shoulder plane
- Hanging back
- Chicken winging
Gosh, that seems like almost everything doesn’t it?! Lack of ability to use the lower body leads to swing faults that cause shoulder pain. Don’t know what some of these swing faults are? Here are some great videos of me from my Golf YouTube channel:
Reverse Spine Angle
Loss of Posture
Things to consider regarding your shoulder
Shoulder blade strength is the shoulder blade’s ability to keep its proper position and move well when needed. Wondering what the right position is?
It depends on where you are in the swing, so it’s a complicated answer, but I can tell you what the wrong position is.
Imagine someone sitting with poor posture.
This is the wrong position, and it results in shoulder injury.
Here’s a great shoulder routine that is simple and easy to do do before you play. It’s not only targeting shoulder blade strength, but rotator cuff strength too.
Another one I like to do to increase shoulder external rotation is:
This should not be done before playing. Make sure you do not blow through any shoulder pinch points. Consult your doc before trying this.
Now, I’llgo into hip mobilization techniques since many shoulder issues come from the lower body not doing its job. The hips are at the top of the suspect list.
Increased hip motion can be attained by putting the work in during the week. It won’t happen overnight. It could take months.
Here is one series I start my golfers off with:
ROTATOR CUFF TEAR
What Is A Rotator Cuff Tear?
The rotator cuff is the four muscles holding the shoulder ball and socket together.
- Teres Minor
The most commonly torn muscle is the supraspinatus, but any can be torn both with orwithout trauma. You read that correctly.
You don’t have to fall to have a rotator cuff tear. Keep swinging like a weekend warrior and one could develop over the years.
Tears happen in all grades and directions. Check out the infographic above. You should get tons of information from that.
Share it with your friends. It’s a great learning tool.
Rotator Cuff Tear Treatment Options
If the tear is a large one, you’ll need surgery. I have a very large article on rotator cuff tears that you should read if you have one.
This article relates to baseball, but the part about rehab and surgery covers everything you need to know.
ROTATOR CUFF TENDONITIS
What is Rotator Cuff Tendonitis?
The same information you just read on rotator cuff tears can be applied here. Tendonitis is just a smaller tear. The tendon attaches the muscle to the bone. In this case, the tendon becomes irritated.
Why is it irritated? It could be overused, smashed or partially torn. Tendonitis leads to larger tears. It’s just a matter of time.
Rotator Cuff Tendonitis Treatment Options
Oftentimes as the tendon injury heals, there is scar tissue formation that hardens the area of injury. These treatments model that scar tissue into healthier tissue over time, which decreases chance of reinjury.
• Active Release Technique
• Deep tissue massage
• Anti-inflammatory injections
• Chiropractic adjustments or mobilizations
• PRICE therapy
Rehab and therapy exercises are still needed. Shoulder rehab can be extremely confusing, but it’s easily done with proper guidance. Rather than recommend a blanket exercise, I’d suggest going to our online shoulder rehab course.
What is Shoulder Impingement?
Shoulder impingement is when something is being crushed under two bony structures in the shoulder.
The two bony structures involved are the humeral head and the acromion process of the scapula.
Between these two structures are tendons and a bursa. If they become crushed, they can create a pinching pain with shoulder elevation…hence the name “impingement.” The funny thing is that shoulder impingement leads to rotator cuff tendonitis, which leads to a rotator cuff tear.
Why is that funny to me?
Because we are looking at virtually the same mechanism of injury, but it’s just in different stages. Why confuse patients? Just call them stages of each other. Regardless, the take home message is that all three come from the same situation we addressed in the beginning of this article.
Shoulder Impingement Treatment Options
Just like rotator cuff tendonitis, impingement will respond to the same types of treatments and rehab.
• Active Release Technique
• Deep tissue massage
• Anti-inflammatory injections
• Chiropractic adjustments or mobilizations
• PRICE therapy
The labrum is a cartilage “O-ring” that the ball of the shoulder joint sits on. It creates stabilization of the shoulder (roughly 70%), and when damaged, it does not regenerate as well as bone, muscle or tendon.
The labrum can be frayed or torn to different degrees. A Grade I tear is a fraying, and it can be rehabbed to some degree. Grade II (and higher) labral tears will normally end in surgery to regain full golf function.
Glenoid Labral Treatment Options
Normally with labrums, I like to rehab and strengthen the heck out of them. Not to say treatments don’t help, but they don’t make the shoulder more stable.
For pain management, my choices are:
• Active Release Technique
• Deep tissue massage
• Anti-inflammatory injections
• Chiropractic adjustments or mobilizations
• PRICE therapy
For rehab, here are some educational videos. We do have an online course coming as well if it’s not currently live by the time you read this.
Here’s another series of exercises. These are very entry-level. A program that is more specific can be put together if you have an evaluation in person.
Note: In this video, her back is rounded. I would have suggested a flatter back. Overall, a good demo though Dr. Jo!
OSTEOARTHRITIS OF THE SHOULDER
What is Osteoarthritis of the Shoulder?
Osteoarthritis is basically “old age” arthritis. There are many types of arthritis. This is important to know because the inflammatory types of arthritis actually require medication to decrease their progression.
In this type of arthritis, medication is normally recommended for pain management, but it is not mandatory.
Osteoarthritis doesn’t always occur in the shoulder because it is not a weight-bearing joint, but it can develop if you have had past trauma.
• Do you ever dislocate it?
• Ever fall on it?
• Break your collarbone?
These are all situations where the joint mechanics change and an abnormal load is placed on parts of the joint leading to abnormal bone growth and thinning of cartilages.
Osteoarthritis Treatment Options
Let’s be clear: once you have arthritis, you will always have it.
We are not changing the arthritis, but we can improve how the joint moves.
If you want to keep playing golf, you will need use one of these techniques, in addition to rehab.
I love all of these pain relief methods for arthritis.
• Active Release Technique
• Deep tissue massage
• Anti-inflammatory injections
• Chiropractic adjustments or mobilizations
• PRICE therapy
What is Shoulder Instability?
Shoulder instability is where the shoulder is “looser” than it should be.
Sounds like a good thing, right?
Think of a loose car wheel… too loose is bad right? You can be too “loose” or too “tight” in any joint. More flexibility is not always the answer.
In conditions of “looseness”, we need to strengthen, tighten, and rehab the muscles and tendons as well as re-establishing joint control to make sure the “looseness” is not the death of the joint.
Extra loose” shoulders will lead to rotator cuff tears, labral tear and impingement.
Just like MacGyver, if something’s too loose, you need to make it tighter and vice versa.
Shoulder Instability Treatment Options
Rewind this article and you will find many examples of exercises for adding strength to the shoulder complex (the glenohumeral joint and the scapulothoracic joint).
Note: with shoulder instability, a doctor should really evaluate you because some types of instability are surgical cases while others respond really well to rehab. As a general rule, if there was trauma involved and you’re a young person, then you’re most likely going to be a surgical case.
Shoulder Rehab Podcast
The Shoulder: Literally Everything a Patient should know before Rehab
This is Performance Place Sports Care Session #41.
Yeah, I don’t believe in like ages and numbers, but if I had to put an age on me, I’d say 35.
Welcome to the Performance Place Sports Care Podcast where you can learn about sports injury theory, rehab, diagnosis, and how to understand the doctor lingo you didn’t understand at your appointment, and now your host, Dr. Sebastian Gonzales.
Hey everybody, it’s Dr. Sebastian Gonzales again with Performance Place Sports Care. Thank you for tuning in and wanting to learn something about your body today.
This one, if you look at the title of this podcast, it’s actually going to be more of a boring one, and I’ll tell you the reasons why. It’s because we are going to go into some anatomy, as well as some light mechanics on how the shoulder works. Then we are going to talk a little bit about how it applies to throwing sports as well.
The reason why I actually wanted to do this boring topic all by myself, not having an expert or anybody else, was because when I was talking to a friend who is going to be the expert on the shoulder, he actually gave really, really good research at one of the seminars that I went to about shoulder mechanic,s and what’s right and what’s wrong, and how to rehab it and so on, but I realize that without a basic understanding of how the shoulder is put together from a muscle, ligament, bone standpoint, then you guys might not be getting everything you could.
So, I was thinking as we go through some of these injuries in joints, even knees to come, I really should probably spend some time talking about the bony anatomy, the ligaments, the cartilage, the muscles, and just some light teaser stuff that I think you guys should know.
Honestly, a lot of this stuff that I start talking about with some of my patients when they come into the office, it’s a lot of the same questions. I’m starting to realize that everyone needs to have a better understanding of how stuff is put together.
Now you may not need to know all of the technical, technical terms, and like we’re even going to go into some of the rotator cuff muscles today, what their actual names are. Now if you wanted to be a super-nerd and remember all these terms, by all means, go ahead and listen to this podcast like five times, but it’s not super, super important to realize what all the muscles are, just kind of know roughly where they go, be familiar, that you’ve heard them before, understand why the shoulder hurts and when, and blah, blah, blah, and so on.
I wanted to start off with letting you know that there are a few types of shoulder diagnoses typically. This goes along with … I actually did a great article, I think, a really long article on pitching shoulder pain on my website. If you want to read along a little bit, I’m taking some of the information off there. It’s p2sportscare.com/shoulderpain and you could probably Google that and find it. It’s a really, really long article. There’s lot of pictures and so on, but in there, I actually was astounded about when I was looking at all this research because I think I had about 30 different research articles to validate this article I was writing.
One of the facts that stuck out to me, because I did not realize the need for this type of article until I actually researched it, was that the estimate was that around 66% of rotator cuffs do not actually have pain. I think it’s amazing to see that because there are a lot of rotator cuff tears out there, by the way, tears can be varying different degrees, but there are a lot of them out there without pain, and there’s more out there without pain than with pain.
Of that 33%, that 1/3 who still remains that still have pain, they say only 20% of these people actually report for medical attention. That’s a startling number as well. I mean obviously, there are a lot of rotator cuffs out there and if they’re not painful, that’s cool, great and everything, by the way, I will talk about expansion in a second, which I think is an interesting part why you should know if you have a tear in the first place or realize that even if you have a non-symptomatic or non-painful tear, you should probably know a little bit about the shoulder anyway, because at some point, it could become painful.
One of the reasons that I went so gung-ho on this article was because about 20% that seek medical attention, most really get it, or they have some type of drive or need to make the shoulder feel better. Now the other 80%, again of that 1/3 of all the rotator cuffs walking around the street, did not care enough to seek attention or thought it would go away on its own, or if it does go away on its own, like really is it any better? They didn’t completely understand and as we go into the topic of expansion, I think you will start to really understand why I am so passionate about this.
Expansion is really where a previously sustained tear becomes larger. Now, I know I have said the word “tear” a lot, but consider the fact that impingement or bursitis, a lot of these go hand-in-hand with tears. Tears can also go synonymously with tendonitis or tendonosis, usually different types of tears of varying different grades that we kind of categorize and get all these different types of terminology surrounding them, but I can tell you this from personal experience with working with a lot of tendonitis, tendonosis, tears, or whatever you want to call them, that the majority of the time when someone comes in with a shoulder condition, if they have impingement, a tendonitis, or some type of bursitis, we are looking for some type of small, even partial, tear.
Now if they can raise their arm or there is a large amount of disability involved, then we are looking for a large, basically torn off muscle, which a lot of times, you will find on imaging, but again, knowing that there’s different types of tears and grades of tears really leads us into this idea of expansion. That 66% of people that have tears walking around the street, I guess they could be rehabbing it on their own, they could be doing some type of preventative program, and they could be using their shoulder and the rest of their body really well, which would be awesome, but I really doubt it, and that’s why I am talking about this today.
Expansion is when tears get larger over time. So a “tendonitis” will turn into a partial tear. A partial tear will turn into a full tear. A full tear can turn into basically a ripped off and torn one. I know those sound like the same thing. I have a whole infographic to describe different types of tears and sometimes 3-dimensional structures are a little bit harder to explain, but for the most part, just in this section, just understand the tears will expand.
What you have to understand is that rehab is an ongoing process a lot of times. The overall long-term goal is to not allow these tears to expand further. Because in one of the studies they did actually, it showed that these tears, when they became painful or when the shoulder finally became painful, it was because of the expansion.
So, let me say that again: They actually had a whole series of people and they imaged them prior to them actually developing pain, and they asked them, “Hey, when this area develops pain, when the shoulder develops pain, I want you to come back.” When they came back, they imaged them, and they already had a prior standing image, so they wanted to see if it got any bigger, changed, and so on. The overall consensus of the study was that when someone reported back for pain, pretty much a lot of the time, it was because the tear expanded. That was the thing that happened, so it’s a freshly developed injury basically.
Understand that first off, and sure you can have a rotator cuff surgery, but if we’re talking about baseball players, just know that there is very low probability if you have a rotator cuff tear, especially a complete tear, I believe the estimate is around 8%, ever get to pitch again (if we’re talking about pitchers). It’s really, really dismal. I even interviewed a strength coach from Major League Baseball and they said it is actually very, very, very low as well. So, the best thing to do is really just prevent these things from happening in the first place.
I know there are probably some surgeons listening to this at some point, so just to let you know, obviously I’m not a surgeon. This is just from what I read in research to make sure. I know there are so many complications that could be with surgery of a rotator cuff tear, and mainly, talking about this from a standpoint of pitching because the return to play is a little lower obviously.
The thing we have to consider is that the ligaments in the area, or even the pliability of the muscles and tendons around the rotator cuff; it’s a very dynamic structure and you see a large amount of range of motion and whipping effect that goes into a baseball pitch, or a throwing sport, these muscles and tendons have to be really, really dynamic, pliable, and resistant to tearing. The rigidity and firmness that comes along with it, and even the third point, is that the loss of range of motion is very detrimental.
I’ve actually heard stories, though I’ve never personally had this experience, but sometimes when you work with pitchers to increase range of motion, you actually mess up their pitching too. Because with pitching or throwing, by the way, I know I am diverting a little bit down the throwing or pitching path, but I will come back I promise, hang in there, I’ll go into the anatomy and will cater to everybody, but with pitchers or the poster boys of laxity of the shoulder, you have what we call greater external rotation than internal. We call this phenomenon GHIRD (glenohumeral internal rotation deficit).
So, the greater range of motion is actually, if you look at a pitcher pitching, when they are all the way back and their arm is behind their head or their hands are behind their head, this cocked-back position is the great external rotation that they have that is an accommodation that the body makes over time to make the velocity higher. It is not always a bad thing. A lot of times, it is a good thing and actually they’ve shown that when you have greater external rotation in combination with a few other things, that you actually throw at a higher velocity. So, through a surgery on a pitcher who throws hard, you’re going to lose some of that. It’s almost like you have to learn to pitch all over again.
Now, going into anatomy, there are a few different types of anatomical structures in the shoulder and I will break down the basics of them first. We have bones, cartilage, ligaments, and muscles. I will say that again; bones, cartilage, ligaments, and muscles.
The bones are kind of just like the rough architecture. If you are building like an office building, all that rough framework of iron and what-not, is kind of similar to the bones in the area. There are not too many bones in the shoulder, granted it’s not like the ankle or the wrist, but the bones do provide some structure.
Ligaments: Imagine that same analogy and now we are bolting or welding those iron I-beams, I guess, that cross to the other one that keep this thing from falling over or apart, ligaments basically do that. They hold bones together. They are very rigid structures. They do have a little bit of pliability. Within the shoulder, there are ones that go around the ball and socket and there are also other ones that hold the clavicle together with the shoulder blade and what-not (I’ll go into that in a second).
Cartilages are interesting structures. When damaged, they are very, very hard to deal with, just from a rehab standpoint, because they don’t repair extremely well. Some of the cartilages in the shoulders are like the labrum, the articular cartilage (which is on top of the ball of the humerus, which is the arm bone–I’m trying to break these down easily), but the labrum is on the part of the socket of the shoulder blade, which deepens it and provides some stabilization there.
Then there are muscles. Muscles can be broken down into a couple of different categories in the shoulder. To make it simple, we will start with rotator cuff and non-rotator cuff, and even getting further than that, muscles of the trunk, the legs, and hips, and so on, are very important in decreasing the possibility of shoulder conditions. The reason for that is actually with throwing, they estimate that only about 13% of force or velocity comes from the shoulder, so the remainder comes from somewhere, and it’s pretty much going to be the torso and below, so a lot of it is hip related.
In the case of pitchers, if you’re not using your hips well, technically the shoulder prevents you to make sure you are using your hips well and you’re strong down there if you have to throw at a high velocity, so if you’re not doing that, and we’re just patching together the shoulder and rehabbing, we’re preventing things up there with the shoulder blade exercises, etc, are ones that aren’t doing you any favors either.
Now, going into bones. We have a few different bones of the shoulder. So, the shoulder blade is also known as the scapula (that is the technical term of it). The shoulder blade is located on the back side of the body, it’s like the wing that you have back there. Actually, what most people don’t realize if you put hand on top of your shoulder and kind of inch your fingers back you will actually find this bony area right there (it feels like a ridge). That is still part of the shoulder blade. When you follow that thing all the way out to the shoulder, just to the tip, there is a spot right there called the acromion process and that too is still part of the shoulder blade. On the front part of the shoulder, like where you grab someone on their shoulder from behind, and you kind of sink your fingertips in there just because it hurts, that’s called the coracoid process, and that is also part of the shoulder.
The actual arm itself is called the humerus. The humerus and shoulder blade come together to make a ball and socket. Now something that people don’t recall either is the shoulder (like you’re taking apart a chicken, you will kind of see like this wing and the shoulder girdle just kind of falls off the rest of the body), with shoulders with humans, there is only really one bony attachment of the shoulder to the remainder of the body and that is where the clavicle comes in and attaches to the sternum. It’s kind of right up by your throat. This area right here does develop some conditions on people like arthritis and what-not, but the overall thought with it is that since that’s the only bony spot that’s holding the whole shoulder, hand, elbow, wrist on the rest of the body, we have to consider what the other parts are, right? If we are considering how unstable this whole region is, if we’re going to keep it on there well and keep it functioning well, we have to make it so the rest of those stabilizing structures that attach the rest of the body to the shoulder are working. Those structures are muscle which attach the spine or trunk to the shoulder blade.
I will say that again because I know I rambled a little bit. So, the muscles which hold the shoulder blade on come from the spine. The shoulder and the shoulder blade together would be known as the shoulder complex. So, from this point forward, everyone stop thinking of the shoulder as the ball and socket. Start thinking of the shoulder as cumulation of the shoulder blade, the torso, and the shoulder or the ball and socket itself; they cannot work independently well of each other.
There was a seminar I watched, it was awesome. It was put on by a biomechanics professor. He was a real, real smart dude and he was going over shoulder mechanics and what-not, and he put up this shoulder blade picture, and he said, “I’m in a love relationship with the shoulder blade or the scapula.” He was saying how important it is to decrease the possibility of actual shoulder injuries. He explained all this away and you’ve got to believe me from here on out, the shoulder blade is a large part of the key to making it so you’re actual shoulder doesn’t hurt, so from a non-traumatic standpoint.
By the way, before I go any further, the shoulder can be hurt from trauma. Trauma is falling on it, gosh, falling on it is the major thing. I remember there was a friend that I snowboarded with and he actually broke his clavicle because he fell snowboarding, but non-traumatic or cumulative trauma is basically doing poor motions over and over and over again. It’s not always that you’re doing the repetitive motion itself, because the body is amazing. It has the ability to change its structures, and to strengthen things, and reinforce things, to make it so we are not going to overuse a structure, but sometimes if you took like a knife and just scraped it across a table (assuming you can hear my pen) then at some point, you’re going to get through the table. My analogy to this as normal mechanics of the shoulder would be let’s make it so this knife doesn’t scrape through this table, that’s not normal mechanics, but doing the motion back and forth across the table is.
So we went over the bones of the shoulder; we have the humerus, the scapula, the clavicle. Those are the major ones. Arguably again, we can say the body works as a whole unit and that we can go down to the rib cage, torso, and blah, blah, blah, but for the sake of this podcast, we’re going to keep this a little bit more tight.
Now the ligaments of the shoulder … Again, the point of the ligaments is to hold the bones together. Now I’m not even going to go into the names of these ligaments of the shoulder because I even wrote them down here just to make sure that I was going to serve them well for you guys because they are a little bit complex in name. I can honestly say going through school, I thought, “Dear God, why did they name these things this way? Why couldn’t they make it really simple like the Achilles tendon of the ankle?” But they didn’t, they made it really, really complex for people to understand, but for the most part, understand that there’s ligaments forming roofs in there for things to pass through. There are ones attaching the clavicle to the shoulder blade. There are ones attaching the shoulder blade to the humerus. There are ones that forms the joint capsule on the shoulder so it doesn’t fall off because it is a very loose joint period. Sometimes these ligaments are damaged through trauma and sometimes I guess, we won’t go too deep into it right now, but they theorize that abnormal motions, especially with pitching, tightens certain ligaments up, which create ambient or compensatory motion to the shoulder leading to some type of tear, impingement, labral tears, and so on.
Now cartilages: I alluded to the fact that cartilages are a mystery. They are not a complete mystery to us, but they are frustrating for the patients. They are frustrating to the provider. I don’t know about the surgeons, I’ve never talked to one about this, but I really would love to actually. If anybody knows one who would love to be on a podcast, feel free to refer them over to me at p2sportscare.com.
With the cartilage of the shoulder, there is the labrum, there is the glenoid fossa, and there is articular cartilage. I will recap on those right here. The labrum is made of what we call fibrocartilage. There are a few different types of cartilage in the body. The fibrocartilage is gosh, think of this like a gasket, like an O-ring, and in the O-ring at least the way I’m thinking of using it, it’s kind of deep in the contact of one thing on another. Let’s think of it like you’re screwing a bolt onto a nut, and you need some type of bracket/gasket, let’s just say we’re in a watertight environment and we don’t water to leak out of whatever we’re tightening together, now that gasket as you put them together, it will start to mash and gum up, but it will form a seal is the point. In the labrum in the shoulder, it kind of deepens and secures the ball within the socket and so on.
Now the articular cartilage and the glenoid fossa, those are a different type of cartilage. They go together and it’s the bottom of the socket and the head of the humerus. These cartilages, they just kind of make it so things like move around smoothly. The interesting thing about cartilages is they are avascular (or they don’t have blood vessel supply). That’s just the nature of the beast. They are unique in that fashion, but because of that, they are really hard to repair.
I know that with knees, over the years, they’ve considered perforation, or regeneration of the cartilage and so on, because if it’s a cartilage injury, then we have to try to repair the cartilage. I mean that would be the best thing to do, but it’s really, really hard to repair. Obviously, if anyone has any groundbreaking stuff on cartilage that’s listening, feel free to contact me; I’d love to hear about that as well. I don’t spend a lot of my time figuring out those types of realms yet. I will spend some time in the future.
Now rotator cuffs … So we are now getting into stuff that you guys probably have a little bit higher interest in because you’ve heard of it. The rotator cuff is really only floor muscles. It’s the supraspinatus, the infraspinatus, the teres minor … (gosh sorry, I think about that every time), and the subscapularis. Now the reason I stuttered on the teres minor is because there is a teres major as well. The teres major is technically not part of the rotator cuff. There are only four muscles, but it doesn’t mean the teres major is not important. There are other muscles around the shoulder as well, and they also help the shoulder with function, but they are not technically the rotator cuff.
You might be wondering, “Well, why is the rotator cuff such a special little group?” It’s because they are the ones which drive the head or the ball and the socket together. They are the ones which keep it centralized and they are the ones which often get damaged as well, especially the supraspinatus. It’s one probably, I don’t know the style on this, but I would say of rotator cuff tears, I’d say it’s 80% to 90%. I mean the majority of the time, you see the supraspinatus injured, sometimes you see the subscapularis, other times you see the infraspinatus. I don’t think I’ve seen the teres minor, but I have seen people point to pain there, so possibly, but you really would have to investigate on ultrasound or MRI to see which one has really been damaged. Again, that’s the infatuation with the rotator cuff, but the muscles which move the shoulder are really not the rotator cuff. They are the ones which are surrounding it and if you listened to my podcast on the 3 P’s of the Shoulder, I’ll be recapping a little bit of that, but for the most part, the rotator cuff is the protectors, it’s the protector group of the shoulder. They are responsible for keeping the ball and socket from coming apart, as well as with those passive structures such as the cartilage, ligaments, and so on, but also the protector, it’s the rotator cuff, as well as the biceps long head tendon.
The bicep, obviously, it’s that muscle which the big one that Popeye has. If you have been working with sports injury, you might have heard of the term “Popeye arm” and Popeye arm is actually where they have had a rupture of the biceps long head tendon, and actually, you end up looking like Popeye because the muscle kind of slides down, but the biceps long head tendon is the stabilizer of the actual ball and socket.
Again, just to recap, I will come back again … So, the rotator cuff holds stuff together in that small joint. The non-cuff ones are the ones I’m going to go into right now.
The next group of the 3 P’s is the pivoters. They are responsible for putting the shoulder blade into the correct position to decrease shoulder impingement and then further on with rotator cuff tears. These encompass the trapezius, the rhomboids, the levator scapulae, serratus anterior; I know you are probably not going to remember these right now, which is totally okay, I do have a whole infographic on the 3 P’s of the shoulder on that same page at p2sportscare.com/shoulderpainpitching. Those are the ones which move the shoulder blade.
Now the reason why again the shoulder blade is important is because it holds the entire shoulder girdle on the body, besides that one bony contact point. I know that when you look at someone if they are in front of you, hopefully, they are raising the arm and asking a question, and when they raise their arm, you’re going to see that when their arm hits about parallel to the ground, it’s mainly the shoulder, the ball and socket, which moves. After that, you will start to see this big wing come out and they’ll start looking like Bruce Lee if they’re really muscular, but you’ll see the actual blade start to come out, like flare out from the midline of the body. This is how the shoulder blade works. It clears the space where the rotator cuff goes through this small tunnel called the subacromial space.
So the subacromial space is below (so there is sub or below) the acromion (again the acromion if you go back and listen to the portion on the bones of the shoulder) the acromion is a bony prominence or almost like a narrowed projection of the shoulder blade. It sits over the top of the ball and socket. I strongly encourage, if you’re listening to this, if you’re driving a car you don’t have a choice, but if you’re at home or have access to a computer, you should be looking up and Googling pictures of the subacromial space because that will start to make this real to you and make it more interesting.
So it raises that space and also, the rotator cuff produces what we call a roll and slide maneuver, where when the shoulder or ball and socket comes up to a certain point, it starts to depress or push down the ball in the socket to also clear space too. So there’s a few way we can clear space.
The reason why I am bringing this up is the subacromial space is the magic to if you have pain in regards to impingement or bursitis, and I will tell you why. It is because this space is really small, and there’s not a lot of room for error. So let’s just imagine the ball rises, or the ball of the shoulder rises, as you raise your arm rather than depressing, it narrows the space even more. I honestly don’t remember what the space is supposed to be, but let’s just make an arbitrary number, let’s just say 5 mm. So there’s this thing at 5 mm and I want you to actually take your fingers, your index and thumb, and I want you to put them out in front of you and form an inch (make it easy).
Now I want you to take your other hand and I want you to slide two fingers in there, nah, let’s go three. You’re going to see that it barely fits through this space, but it still does. Now, here’s the problem. Let’s just say these fingers between that left hand spreads, so spread them out a little bit, put some space between your fingers, and now, you’re going to see that you’re putting pressure on your actual tunnel or the finger which was making the inch. This is an analogy of expansion of a structure. Now, what can expand in there? It can be the bursa. It can be one of the tendons. It could be a bony prominence, which could be like an arthritic findings. So now that’s one way you can pinge things.
The second thing is instead of making an inch, make it half an inch. Now we have a narrower space. Obviously you can’t fit three fingers in there, make it two. So everything is absolutely going to be crushed in there and you are eventually going to tear something up. That is how these injuries present themselves. It doesn’t mean you actually have to clear the space. It means you have to improve the mechanics that are creating it in the first place. Maybe we can get that half inch to a full inch, right? Maybe we can decrease the size of those things that are inflated in there, such as the tendon and bursa.
But for this reason, I have to pull up the research that I have here, let’s see if I can find it … So actually this is one of the fun facts I had in that article; 12 weeks is the number of weeks of physiotherapy found that rivals subacromial decompression surgery success rate. Now if I have this, I would rather rehab it than surgically change the structures first. Don’t get me wrong, I’m not opposed to surgery, and I have sent people to surgery when they have nothing else working for them, or they have the conditions which dictate it. I know there has been a push so much for over the last, I feel like 5 years, from what I’ve heard people absolutely not wanting surgery, and XYZ, but sometimes you need it. Sometimes you do, but it really depends on the case.
Now in my opinion, on a lot of the shoulder cases that I see, they don’t need it yet. I would rather them put the hard work in, learn the education, and start to make their body move better, so they don’t have to take that space and shape it up.
Again, if we’re talking about tears again, if there is a large tear, then you might have to put it back on. That’s just the name of the game. I know that some people don’t want to. My mom was actually one of them. She had a completely full through-and-through tear, detached, just hanging there. There was a gap where the tendon was and was supposed to attach, and she didn’t have any pain, which was really surprising. It made me really reevaluate how I look at shoulder conditions in cases that come in now, because she didn’t have any pain … I’m telling you, I’m not even joking … She had no pain, full range of motion, and we really had to isolate it down to be able to see that she had a lack of functionality.
The question she asked me was, “Should I have this repaired?” I’m like, “Gosh, I mean, you don’t hurt. If you go in and it comes out worse …” I know from my standpoint, with a normal patient, I would say, “Yeah, here’s the pros and cons and so on,” but it’s a little different when it’s your family because you’re going to see them all the time. At some point, if you make the wrong call, I don’t want to put anyone into the position where they would blame my judgement call because I made the call for them. It’s the patient’s call. It’s not life or death, so it’s the patient’s call.
I think this went through the majority of what we needed to for understanding the shoulder. I want to reiterate that with shoulder conditions, it’s not always trauma; you might sleep on that side and all of sudden it starts hurting, or you might throw a baseball with your son for a couple of times and then that irritates it as well. Remember, it’s not that it is a new thing typically, it has been happening a lot over time, and it expands, okay? It’s the expansion.
So I consider that if anyone knows they have a condition and they’re not doing anything about it, they’re really negligent on themselves. I hate to say you know, but being realistic, if you know you have it and you’re doing nothing about it, it’s not top on your priority list. That’s just how it goes.
I tell people all the time, “Like, I know you’re busy. I know you have a busy life. It happens. But it’s not my shoulder, it’s not my back, it’s not my knee, and I will give you as much information as you want, but I can’t do the work for you.” It’s as simple as that. There is no easy way out of this stuff. If you want to take the less invasive route on these things, then you have to put the work in.
I hope this was helpful. I think I went through everything. The only other thing there is, which I might go into in the next podcast is some of the movements of the shoulder, but I don’t want to bore you too much in there, but make sure you go onto my website, p2sportscare.com/shoulderpainpitching, or you can just go through p2sportscare.com and you will see when you start scrolling down, you’ll see some pictures of a runner, a golfer, a baseball player. Just go into the baseball player shoulder and click on it, and you will see this entire article pop up, and it’s going to be longer than you are going to want to read at the time, so I’d suggest … I think there is a pop-up that comes on that says you can download it through PDF, so just save it, put it on your phone, and read it at your leisure.
This is where you should go to learn about how to rehab it, and other stuff I didn’t hit on today. I will bring in an expert to talk about it, but for all I know .. He’s a friend of mind and he might hem and haw and kind of go back and forth on different topics and joke around and miss something. Typically, on a podcast, I hope it’s entertaining, but also educational too, so sometimes we don’t get to everything, so I will have to do it again.
Thank you for listening. Again, my name is Dr. Sebastian Gonzales. Please go to my website and share it. I made it really easy to share with the links on the bottom with Facebook, Pinterest, Google Plus, Twitter. The reason I spent so much time on this is so people can share it. I don’t write for my health. I proofread and have grammar like I’ve never been to school at all. Actually, English was one of my worst grades in high school and college, it was terrible. So, I have to send these things out to get proofread honestly because I’m terrible at writing I think, but I know the ideas I want to put out there.
So, please do share. I have great pictures, great infographics, and if you go through there, and you want to see what we do for rehab in our office, we are putting together a course. There is a course link on the website and you can see what we have there. We are trying to build one for patients in office because we do have a lot of people who have questions on the rehab that we suggest, as well as to repeat stuff like this, you know understanding their pathology or their injury, but also too, I have a couple of different injuries that I really want to hone in on and are rotator cuff health for pitchers and knees for runners. I have a huge passion for both of these. I played baseball. I have run recreationally, not in college or high school, actually track was during baseball season so our coach really wouldn’t let us go over there. But it’s so common and such an easy thing to understand that with runner’s knee or injuries of the knee to runners that I don’t see any reason why I can’t put a course on for it.
So again, if you guys have a personal question that you want answered on the air, then go to the site again, there should be a voicemail button right there, it’s super easy to do, and I think that’s all I have for you.
Take care and listen in to an expert next time.