Shoulder Pain: It’s An “Under-Use” Syndrome

July 29, 2019

head shot of doctorOne of the most common conditions that I treat as an orthopedic surgeon is shoulder pain. Daily activities such as reaching overhead, doing yard work, and various sleep positions can potentially aggravate our shoulders. Upper body lifting exercises and sports that require overhead motions increase our risk for shoulder pain or injury.  

Of all the shoulder conditions that I treat, rotator cuff issues are the most frequent. Common rotator cuff problems include bursitis and tendonitis, which are commonly referred to as “impingement.”

The rotator cuff is a group of four muscles and tendons that coalesce together to form a common insertion onto the humeral head, or ball of the shoulder (Figure 1).image of shoulder ligaments

As the name implies, the rotator cuff rotates the shoulder. However, the rotator cuff’s main function is to stabilize the ball on the socket during movement, especially when raising the arm overhead.  

Raising your arm overhead is a complex motion requiring that the scapular (shoulder blade), deltoid and rotator cuff muscles all work in unison. Rotator cuff problems occur when there is an imbalance between these muscle groups. This muscular imbalance leads to excessive strain or pressure on the rotator cuff, resulting in inflammation, pain and a limitation in motion (Figure 2).shoulder socket with inflamation

So where do the problems begin? In the absence of an acute injury or change in their exercise regimen, patients typically do not recall a specific activity that precipitated the onset of their pain. Patients have a hard time accepting that they have an “overuse” injury when they haven’t changed their exercise routine. I prefer to describe rotator cuff issues as an “under-use” injury.

Most upper body exercises focus on strengthening the surrounding large shoulder (pectoralis, latissimus and deltoid) muscles. As a result, the smaller rotator cuff muscles become overpowered and are relatively weak from “under-use.” Unfortunately, most patients either do not perform rotator cuff-specific exercises or do not perform them correctly, which leads to the muscular imbalance around the shoulder as described.

When I have this discussion with my patients, I often get the same response: “Why now? I have been doing the same exercise program for the past five or 10 or 15 years!” While I hate to pull the aging card, the reality is that our bodies do change with time — and when it comes to our tendons, these changes can occur as early as in our 30s.

There are age-related changes that occur within our tendons that decrease pliability, which can lead to injury. To make matters worse, the blood supply to the rotator cuff tendons becomes less robust with aging and can inhibit our ability to recover from the usual stresses placed on our tendons when we exercise.

Rather than deal with bursitis or tendonitis after it has already developed, be proactive. Minimize your risks of a rotator cuff injury by exercising (no pun intended!) good rotator cuff health:

  1. Focused rotator cuff exercises. Talk to one of the trainers. Search on YouTube or Google for exercises. The most common mistake is performing the exercises with too much resistance. The rotator cuff muscles are small muscles designed for endurance. Think of light weights and high repetitions. Dumbbells weighing less than eight pounds or light resistance bands at high repetitions (three sets of 10 repetitions) are best. 

    Common mistake: Using a cable machine for rotator cuff strengthening. Using more than 10 pounds on a cable machine is a great exercise for the deltoids but does very little to isolate the rotator cuff muscles. 
  1. Postural and scapular exercises. Poor posture leads to forward tilt of the scapula, which limits the rotator cuff’s ability to lift the arm. As with rotator cuff exercises, there are plenty of resources available for postural and scapular stabilizing exercises.
  2. Aerobic conditioning. As mentioned above, the blood supply to the rotator cuff diminishes with age. Maximize blood flow and oxygen delivery to aid in recovery through aerobic exercise. 

As with many medical conditions, the key is prevention. Consider adding a rotator cuff strengthening program to your exercise routine to optimize rotator cuff health. In addition to the well documented cardiovascular benefits of aerobic exercise, aerobic conditioning is an important component of maintaining rotator cuff health as well.

Joseph Layug, M.D. is a board-certified orthopedic surgeon with Orthopedic Solutions and a member of Columbia Association’s Medical Advisory Board.

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