shoulder joint is capable of a wider and more
varied range of motion than any other joint in
the human body. This extraordinary flexibility
has allowed human beings to do everything from
pitch a baseball to paint the Sistine Chapel.
Unfortunately, because the shoulder is so
flexible, it also tends to be unstable. This
instability contributes to a variety of
problems, some of which can be treated with
rest, and others may require the expertise of a
licensed physical therapist.
Certain athletes (throwers, tennis players,
swimmers) are at especially high risk for
shoulder problems, though they can occur in
anyone. And in most cases- even those requiring
surgery- a physical therapist plays an integral
role in the rehabilitation process. The physical
therapist's expertise can help you recover
function as quickly as possible and get you back
in the swing.
The shoulder has three major joints: the
glenohumeral (GH) joint, the acromioclavicular
(AC) joint, and the scapulothoracic (ST) joint.
Each joint can become dysfunctional and painful.
The glenohumeral joint is a ball and
socket joint. This joint has been compared to a
golf ball sitting on a tee: the large, rounded
end of the humerus (upper arm bone) moves
within the shallow, scooped-out glenoid
(golf tee). The anatomy of the glenohumeral
joint permits the greatest flexibility and range
of motion of any joint in the human body.
However, because of the shoulders make up it can
also become unstable.
The acromioclavicular joint, more
commonly called the AC joint, joins the scapula
(shoulder blade) to the clavicle. The AC joint
can become separated; this commonly occurs in
contact sports, such as when a football player
falls on the tip of the shoulder.
The third shoulder joint is the
scapulothoracic or ST joint, which is
the scapula as it lies over the thorax (back of
the rib cage). The ST joint is attached to the
thorax by muscles and tendons. Neck and upper
back posture directly affect the position of the
ST joint on the rib cage. Postural abnormalities
will affect the function of the shoulder. In
addition to these three joints, an intricate
system of muscles, tendons, ligaments, and bursa
sacs work in precise harmony with each other to
provide the amazing amount of mobility of the
The rotator cuff is made up of four
muscles that encircles the shoulder joint. This
muscles are a major source of muscular stability
in the shoulder. The rotator cuff can be prone
to tears and weakening due to a number of
causes, including strain and overuse. When the
tendons become inflamed it is called tendonitis.
Tendons are strong fibrous cords that
attach muscles to bones. An additional structure
essential to the shoulder is the bursa sac.
Bursa sacs are fluid-filled membranes within
and around the shoulder; they cushion the joints
and help minimize friction. Inflammation of the
bursae is known as bursitis.
What Causes Shoulder Problems?
There are several factors involved in shoulder
• the aging process, including disuse and
• strain and overuse;
It's not unusual for many of the common shoulder
problems described below to develop from a
combination of these factors.
The Aging Process
Whether you're 15 or 75, age has a profound
impact on how the body responds to shoulder
strain or trauma. As young people, the tissue
around our shoulder joints is soft and
resilient. Before age 30, if we "overdo it"
through sports or physical labor, the most we're
likely to suffer is a slight, short-lived
soreness or stiffness in the tendons. This
Tendonitis is the most common of all shoulder
problems. It rarely requires treatment in young
people. However, as a person grows older, the
cumulative effects of having an ongoing problem
of tendonitis can result in a more serious
ailments. After the age of 30 our muscles and
tendons begin to undergo a structural weakening
because of the aging process. The simple
tendonitis can degenerate into actual tearing of
the muscle tissue.
Each episode of tendonitis weakens the muscles
further. Therefore, the cumulative damage can
lead to larger tears in the muscles and tendons.
This is why conservative treatment of tendonitis
at an early stage, along with education about
the way the shoulder works and proper exercise,
is crucial to preventing further injury.
Rotator Cuff Injuries. Tears in the
rotator cuff can result from the progressive
worsening of tendonitis, repetitive strain
through overuse, or trauma- especially as a
result of athletics. The gradual tearing of the
rotator cuff is a process similar to a shirt
wearing out- it gets more and more threadbare
until the edges fray or a hole appears. This
sort of rotator cuff injury can be difficult to
repair surgically, and conservative treatment
under the direction of a physical therapist is
often the best course of action. A "clean" tear
to the rotator cuff (due to trauma) can often be
repaired surgically. Whether or not surgery is
indicated, a physical therapist will almost
certainly be involved in all stages of the
recovery process. Researchers have found that
rotator cuff tears occur more often in people
who rarely exercise or who participate in sports
only sporadically. People who keep in shape
through regular exercise are more likely
to maintain strong bones and rotator cuff
strength, and to diminish the chance of future
Bursitis goes hand-in-hand with
tendonitis. Inflamed bursa sacs may become
thickened and reduce the "free" space in the
joint, thus restricting movement. In extreme
cases some of the bursa sacs can be removed
surgically; otherwise, the therapeutic approach
to treating bursitis and tendonitis is similar.
Osteoarthritis is a condition in which
the joint cartilage deteriorates and the joint
becomes gritty and rough. It can be caused by a
number of factors, including disease, trauma,
and infection. Degenerative arthritis is
often associated with wear-and-tear in the
joints over a long period of time. The AC joint
is particularly susceptible because it
degenerates faster than any other joint in the
body as we age. Arthritis in the glenohumeral
joint usually appears somewhat later, and may be
related to trauma earlier in life or rotator
Besides being painful, arthritis can lead to the
inability to fully move the arm due to tightness
in the joint; attempts at movement in the later
stages of the condition are usually painful. In
advanced cases of arthritis involving the
glenohumeral joint, arthroplasty- surgical
replacement of the joint- is an option that can
bring pain relief and greater mobility. The
rehabilitation period, however, is crucial, with
both the patient and the physical therapist
playing active roles.
Subluxation is a quick, spontaneous
"pop-in/pop-out" or partial dislocation of the
shoulder joint. Subluxations can occur while
playing "overhead" (throwing, tennis, swimming)
sports, though the activity need not be
strenuous to cause an occurrence. Subluxations
usually happen to people who are approximately
14 to 30 years of age. Although they may not be
painful, subluxations may, over time, contribute
to problems of wear and tear in the shoulder
A dislocation is far more serious,
involving tissue damage, stretching, and
tearing. Unlike a subluxation, the shoulder
doesn't "pop back in." The first step in
treating a dislocated shoulder is almost always
a trip to the emergency department. People under
20 and over 50 are most prone to dislocations,
with younger individuals more prone to
experience further dislocations in the future.
Impingement refers to a condition,
sometimes painful, in which the shoulder joint
lacks enough room to function properly.
Structural impingement is a "built-in"
organic condition, e.g., a bone spur in the
shoulder joint. This situation is usually the
result of years of tendonitis, rotator cuff
injuries, and wear-and-tear. Functional
impingements often result from occupational
situations (such as being hunched over a
computer keyboard all day). Brief stretching and
exercise breaks, along with proper posture, can
help prevent and alleviate functional
Trauma comes in two varieties: microtrauma
and macrotrauma. Microtrauma is common in
everyday life- it can occur while lugging an
overstuffed suitcase, or straining to reach a
can of spaghetti sauce on the top shelf. In both
cases we're inflicting microscopic tears to the
soft tissue around our shoulders. Although a
single episode of microtrauma in itself is
rarely serious, over time it can set the stage
for shoulder ailments such as tendonitis,
bursitis, and rotator cuff injuries.
Macrotrauma is the result of violent
force, with falls and sports injuries being the
most common causes. Depending on what position
your arm is in when you fall or get hit, you can
fracture your collarbone, dislocate your
shoulder, or tear your rotator cuff.
An evaluation of the shoulder, neck, thoracic,
and upper extremity will performed to determine
what the cause or driving force of the shoulder
pain. The evaluation will look at posture, joint
mobility, strength and coordination. After a
thorough evaluation is performed a treatment
plan is developed to eliminate or decreased the
causes of the shoulder problem.
The following tips may prevent shoulder problems
General prevention tips
• Stay in good overall physical shape.
Strengthen your wrist, arm, shoulder, neck, and
back muscles to help protect and decrease stress
on your shoulder. Do stretching and
range-of-motion (ROM) exercises for your arms
• Maintain good posture. Stand straight and
relaxed, without slumping.
• Warm up well and stretch before any activity.
Stretch after exercise to keep hot muscles from
shortening and cramping.
• Avoid catching falling objects.
• Use a step stool. Do not stand on chairs or
other unsteady objects.
• Use the correct body movements or positions
during activities, such as lifting, so that you
do not strain your shoulder. Do not lift objects
that are too heavy for you.
• Avoid overusing your arm doing repeated
movements that can injure your bursa or tendons.
In daily routines or hobbies, think about the
activities in which you make repeated arm
movements. Try alternating hands during
activities such as gardening, cooking, or
playing musical instruments.
• Avoid keeping your arms out to the side or
raised overhead for long periods of time, such
as when painting a ceiling. If you must do these
things, take frequent breaks, and use rest, ice,
compression, and elevation (RICE) for home
• Make sure your child's backpack is the right
size with good support. Carrying heavy backpacks
may increase his or her risk of shoulder
problems or injury.
• If you feel that activities at your workplace
are causing pain or soreness from overuse, call
your human resources department for information
on alternative ways of doing your job or to
discuss equipment modifications or other job