The Rotator Cuff are a group of 4 muscles that attach from the shoulder blade to the arm bone. They are responsible for aiding precise rotation of the arm bone within the shoulder joint.

Because of their origin on the Shoulder Blade, it is crucial to start with Scapular Stabilization exercises first. You can have the strongest Rotator Cuff Muscles in the world but if the Shoulder Blade is not in the correct position it is very difficult for these muscles to work correctly.

Often is the the External Rotating Rotator Cuff Muscle that are weaker than the Internal Rotating ones. That is why I have included two External Rotation exercise to one Internal Rotation.

Click below to view the video.

Please note: These exercises should not cause pain. If you experience pain please stop immediately.

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The reason it is the second video is that it is crucial to first gain good rotation range of motion first.

The Scapular, otherwise known as the Shoulder Blade is the foundation of the shoulder. For a shoulder to function properly you need your shoulder blade to be in the ideal position and move correctly. That can only be achieved by having good working shoulder blade muscles.

Unfortunately, due to our daily activities and poor posture, the muscles of the shoulder blade often become weak.

Please note: If you experience pain with these exercises please stop immediately.

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The first video is about shoulder stretches.

Achieving the correct range of motions is always the first place to start when fixing your shoulder. You can have the strongest shoulder muscles in the world but with out the correct ranges of motion your shoulder will just not function correctly.

The video below contains information on the following:

• Trigger Point Massage
• External Rotation Stretches
• Internal Rotation Stretches
• Sleeper Stretch
• Horizontal Flexion Stretch
• Latissmus Dorsi (Lats) Stretch

Please Note: Both Trigger Point Massage and Stretching can be uncomfortable. There is a difference between discomfort and pain.

With massage, digging in too much can aggravate the symptoms. Likewise with stretching, you want to feel stretch not pain. If in doubt start off easy.

Basically there are three types of exercises what I feel are important for you to do in this order to help improve your shoulder. They include:

1. Stretching
2. Endurance
3. Strengthening

Stretching
In order for the shoulder to work properly it is crucial that the muscles are at the correct length. Without this the shoulder just can’t operate in the manner that it was designed.

You can have the strongest shoulder muscles in the world, but if your muscles are short and/or tight you will still have a poorly functioning shoulder.

This is why stretching exercises is always the first type of exercises I recommend.

The two most important ranges of motion, when it comes to shoulders, are External & Internal Rotation.

I am currently in the process of creating videos to better illustrate all the exercises.

You typically get the best results from stretching by holding a stretch for 10-20 seconds. You also get better results from doing a small amount at a time e.g. 3-5 stretches, but performing them several times during the day e.g. 2-3 times. This is considered more desirable than doing a lot of stretches all at once.

Once good range is achieved, then you can move on to Endurance Exercises.

Endurance Exercises
Many of the important muscles of the shoulders are stabilizing muscles. They are not designed to lift a hundred pounds, they are designed to function well throughout the entire day. This is why I feel it is more important initially to work on endurance rather than strength.

I also think it is important to sequence which muscle groups you work on. Here is the sequence I use with my patients.

1. Scapular Muscles
2. Rotator Cuff
3. Arm and Bigger Torso Muscles

Here is why this sequence works.

The shoulder blade is like the foundation to the shoulder. In order for the shoulder to function properly it must start in the right position and move correctly.

The rotator cuff muscles attach to the shoulder blade. Without a stable and good functioning shoulder blade (scapular) it is more difficult for the rotator cuff muscles to function, i.e. it is hard to build a solid structure without a strong steady foundation.

Once good endurance is established in the shoulder blade muscles then I recommend building the endurance of the Rotator Cuff muscles. These muscles are crucial for controlling the arm bone inside the shoulder joint while it is moving. They help it rotate precisely so not to cause an impingement.

Once the shoulder has good stability in the shoulder blade and the rotator cuff muscles then it is OK to start on the other arm and torso muscles e.g. biceps, triceps, chest lats, etc..

Strengthening Exercises
Once you have built up endurance in the muscles, now it is OK to build strength, speed and power. This is where you can use heavier weights, plyometrics, and more advanced training activities.

As mentioned earlier in this post I am in the process of creating videos for all of these Shoulder Impingement Exercises. I will post them as soon as they are completed. In the meantime if you have any questions or suggestions please feel free to leave a comment.

Painful Arc
When assessing shoulder movement, it is common in an impingement to have what is known as a painful arc.

What this means is that a portion of your shoulder movement is painful but not the full range of motion.

For example you may have no pain when your arm is by your side. You start to lift your arm, still not pain. As your hand approaches shoulder height you start to feel pain but as you continue overhead the pain stops and you are able to extend your arm overhead fully.

Sometimes the pain can be so severe that you can’t push through it to see if you have a painful arc.

Shoulder Tests
Listed below are some common Shoulder Impingement tests used by Orthopedic Surgeons and Physical Therapists.

Neer’s Test

Neer’s impingement sign is elicited when the patient’s rotator cuff tendons are pinched under the coracoacromial arch. The test is performed by placing the arm in forced flexion with the arm fully pronated. The scapula should be stabilized during the maneuver to prevent scapulothoracic motion. Pain with this maneuver is a sign of subacromial impingement.

Hawkin’s Test

The Hawkins’ test is another commonly performed assessment of impingement. It is performed by elevating the patient’s arm forward to 90 degrees while forcibly internally rotating the shoulder. Pain with this maneuver suggests subacromial impingement or rotator cuff tendonitis.

Descriptions are provided by the American Academy of Family Physicians. Click here to visit their web page

Sensitivity & Specificity.
Sensitivity & Specificity are two very important concepts that are crucial to determining the usefulness of diagnostic tests.

Sensitivity refers to how accurate the test is at predicting a positive result, i.e. if one of these tests is positive how confident can one be that shoulder impingement is the problem.

Specificity refers to how accurate is the test in predicting a negative result, i.e. if one of these test is negative how accurately can we predict that impingement is not the cause of your shoulder pain.

Both the Neers and Hawkins tests have high sensitivity, Neers 85% & Hawkins 88%, but low sensitivity. This means that if you are positive for these tests there is a high chance that you have a shoulder impingement. If you test negative, you may still need further assessment to rule out impingement.

The painful arc test is the opposite; it has lower sensitivity but higher specificity (80.5%). This means that if you have a painful arc in your shoulder movement, further tests are needed to confirm you have shoulder impingement e.g. Neers & Hawkins. But if you don’t have a painful arc it is much less likely that your pain is due to an Impingement problem.

As a side note if you would like more information about shoulder physical therapy diagnostic tests for a labrum tear please click here to read some excellent posts by Physical Therapist Mike Reinolds.

In previous posts we have talked about how a incorrectly functioning shoulder can cause impingement and pain.

While thinking it is essential to have a good understanding of what is occurring in your shoulder and why you are getting pain. I also understand that when you are in pain all you want to do is get out of it.

Today’s post is reviewing some of the common ways medical professionals help relief shoulder pain.

Keep in mind, the way to long term relief is correcting the dysfunction in the shoulder by use of shoulder impingement exercises. But when it is 3am and you can’t sleep because your shoulder is aching it is crucial to have some options to give you temporary relief.

Pain Medication
With shoulder impingement it is common to also have a tendonitis or bursitis. Basically that means an irritated or inflamed tendon or bursa. For more information on these terms click here to read the Shoulder Joint post.

For this reason the anti-inflammatory group of medications often give the best relief from shoulder pain. These are commonly referred to as NSAIDs (Non-Steriodal Anti-Inflammatory Drugs). Common over the counter examples are Advil and Aleve. Click here to visit WebMD for more information about NSAIDs

You should always check with your doctor before starting a medication to ensure it is the correct medication for you. Prolonged use of NSAIDs can harm your kidneys.

If your pain is severe you may need a prescription anti-inflammatory from your doctor.

Thermal Relief
Thermal Relief refers to the use of Hot or Cold Packs. Both of these can help with inflammation and pain relief.

Typically cold packs are best in the first 3 weeks after an injury or recent aggravation.

Apply a cold pack directly to the shoulder for 15-20 minutes. Repeat every few hours if pain persists.

Common cold pack options include: wrapping ice in a towel or plastic bag, a frozen bag of vegetables e.g. peas, or a store bought cold pack.

Heat is usually more effective relaxing tight muscles and reducing pain but only if the pain has been present for more than 3 weeks.

Even though it is called a Heat Pack, it is not meant to cook you. The heat should only be a mild comfortable warmth.

Once again 15-20 minutes is ideal.

Common heat pack options are a heating pad, store bought microwavable heat pack, or a hot water bottle wrapped in towels.

Electrical Stimulation
Electrical stimulation is a very effective modality commonly used in Physical Therapy clinics to help relieve shoulder pain.

Here’s how it works. Basically your nerves are like a series of electrical wires. Pain is sent to the brain via the nerves as a series of electrical impulses.

The electrical stimulation sends a current through your shoulder at the same frequency that pain is carried at in the nerves. It interferes with the pain signal and thus the brain doesn’t register the pain.

The electrical stimulation also helps increase localized circulation thus facilitating healing.

When applied properly all you should feel is a pleasant pins & needles, tingly sensation. It should not be painful or too strong.

Ultrasound
Ultrasound is another modality commonly used in Physical Therapy to decrease inflammation, pain and facilitate healing.

Ultrasound is a certain frequency sound wave.

Basically the ultrasound helps increase localized circulation, flushing out the inflammation and bring new nutrients to the area to help with healing.

What you feel with ultrasound is the transmission head moving around on your shoulder and the coldness of the gel. The gel is required to aid penetration of the sound wave into your skin. Sometimes you will feel some warmth from ultrasound but it should never be painful or too hot.

I hope these have provided you with some shoulder pain relief ideas for when you shoulder next plays up.

The next post will review the diagnostic tests to confirm if your shoulder pain is really due to a shoulder impingement.

Now it is time to start putting the pieces together.

One of the common misconceptions that I come across in the clinic in regards to shoulder impingement pain is the concept that “this is where I feel the pain, this must be the problem”.

This introduces the concept of Shoulder Pain Site Vs Shoulder Pain Cause.

Pain Site refers to the structure that has become irritated to cause the pain, e.g. bursa, tendon or ligament.

Pain Cause refers to why has that structure become irritated, e.g. a tight posterior Deltoids may not be letting the arm bone rotate precisely within the shoulder joint and thus impinging the Supraspinatus muscle.

The Supraspinatus tendon may be the site of the pain but it is the tight deltoids that is the cause of the problem.

This may be a subtle but important difference. If we just focus on the pain site, we will be able to reduce the pain and inflammation but we haven’t addressed the root cause, thus there is a very high likelihood that the shoulder pain will return sometime in the future.

To illustrate this more clearly let’s think about the car analogy used in other posts.

Imagine your wheels are out of alignment (this would be the pain cause). As you drive this is going to cause uneven wear and tear on your tires.

At some point down the road it will become necessary to replace your tires due to the abnormal wear (this is the pain site).

Now if you just replace the tires and continue driving you are very likely to have the same problem again and again.

In order to correct the problem properly you not only need a new set of tires but you also need to get a wheel alignment to spread the wear more evenly over the entire tire (treating the pain cause).

That is why when it comes to shoulder pain, for best results it is important to address both the pain site and the pain cause.

Muscles
The shoulder relies on many muscles to function properly. These include the muscles that stabilize and move the shoulder blade, the muscles that stabilize the arm bone within the shoulder joint (also known as the Rotator Cuff muscles) and the muscles that move the arm.

Any of these muscles can become injured through a sprain, strain or tear and therefore cause pain and/or the shoulder to function improperly.

One particular muscle in the shoulder that is especially susceptible to injury is the Supraspintus. It is one of the Rotator Cuff muscles.

It is a small muscle that travels from above the bony protrusion (or spine) of the shoulder blade, through a tunnel of bone and ligaments and attaches to the arm bone.

It is susceptible to injury when the arm bone doesn’t rotate precisely within the shoulder joint. This excess movement can cause pinching of the muscle between the arm bone and the shoulder blade. This is what is commonly referred to as Shoulder Impingement.

Tendonitis
A simple way to think of a muscle is a spring attached to a rope. The spring represents the muscle belly; this is where the shortening, lengthening and production of force comes from.

The tendon is more like the rope. A muscle will turn into tendon prior to attaching into a bone.

The tendon is responsible for transferring the force produced by the muscle belly to the bones for either movement or stability.

Tendonitis refers to inflammation of the tendon. In other words something is irritating the tendon causing it to swell and be painful.

Bursitis
A bursa is a small fluid filled sac that typically lies between a tendon and the bone. Its purpose is to prevent the tendon rubbing directly on the bone.

It too can become irritated, inflamed, and painful.

That concludes the two posts about Understanding a Shoulder Injury. If you have further questions please feel free to leave a comment.

These terms include: rotator cuff tear/strain, labrum tear, adhesive capsulitits, bursitis, impingement, arthritis, separated shoulder, dislocated shoulder, and tendinitis

As discusses in previous posts, the shoulder has many moving parts. To better understand these parts and what can go wrong let’s break things down in to two categories:

1. The structures of the joint
2. The structures that surround the joint

Structures of the shoulder joint include the bones, cartilage, labrum, joint capsule, and ligaments.

The structures around the joint include the muscles, tendons, and bursa.

Let’s start by looking at the structures of the shoulder joint that can commonly be injured.

Labrum
The majority of movement of the shoulder occurs between the arm bone and the shoulder blade. Click here to see shoulder joint post for more information about shoulder anatomy.

You may remember the golf ball and golf a tee analogy, where the golf ball represents the top of the arm bone, the golf tee represents the shoulder blade portion of the shoulder joint.

This bony structure allows great flexibility and movement in the shoulder. Unfortunately it doesn’t provide much stability.

The body’s ingenious design to increase stability of the shoulder while allowing mobility is called the labrum.

The labrum is a ring of fibrocartilage that runs around the cavity of the glenoid fossa (i.e. the golf tee). It basically makes the joint surface deeper so that the bones fit better together.

Since the labrum is fibrocartliage and not bone it make it more susceptible to injury or tearing. Damage to this structure compromises the stability of the shoulder joint.

Common types of labrum tears include SLAP and Bankhart.

Arthritis
There are over 100 different types of arthritis; some of the well known types include Rheumatoid, Psoriatic, and Osteoarthritis. These can all affect the shoulder joint.

Cartilage is typically found where bone meets bone in a joint. Cartilage is like padding for the end of a bone. The cartilage prevents bone rubbing directly on another bone.

The easiest way to think of Osteoarthritis, a common diagnosis of shoulder pain, is wear and tear of the cartilage.

To illustrate this further consider if you drove your car for 60 000 miles, you are going to have wear on your tires. If you’re tires are out of alignment you will have greater wear on some areas of the tire compared to other areas.

The body reacts in a similar way, if you use it for 50-60 years there is going to be wear and tear of some of the joints and thus osteoarthritis.

Separated Shoulder
A separated shoulder refers to an injury of the AC joint (acromionclavicular). This is the place where the collar bone connects to the shoulder blade.

These bones are held together with ligaments and joint capsule.

An impact to this area can cause a sprain or tear of the ligaments.

Dislocated Shoulder
This is similar to the separated shoulder but refers to the arm bone.

An impact can sprain or tear the ligaments and joint capsule that connect the arm bone to the shoulder blade, thus causing the arm bone to pop out of its socket.

Adhesive Capsulitis
Adhesive Capsulitis is more commonly known as frozen shoulder.

The joint capsule is basically a sac that surrounds a joint.

Due to the shoulders great flexibility the joint capsule has the capacity to extend and stretch in many directions.

When it is at rest, i.e. arm by the side, there are small folds in the capsule.

Sometimes these folds can become stuck together thus preventing stretching and extensibility of the capsule during movement. This can be very painful.

This concludes Part 1 of Understanding a Shoulder Injury. Part 2 will go in to greater detail of what structures around the shoulder joint can become injured.

One of the things most people don’t realize about the shoulder joint is that the only place the arm connects to the rest of the skeleton is the SC joint, i.e. where your collar bone meets your sternum.

Basically the shoulder joint is made up of three bones, the collar bone (also known as the clavicle), the shoulder blade (scapula) and the arm bone (humerus).

The shoulder joint is unlike virtually any other joint in the body in regards to the relationship between the surfaces of the joint. i.e. unlike the knee or the hip where one bone stacks directly on top of the other, in the shoulder the joint surfaces are horizontal to one another.

The shoulder joint is often referred to as a ball and socket joint, meaning that the top of the arm bone provides the ball to the joint, while the shoulder blade provides the cup.

Unlike the hip joint, which is also a ball and socket joint, the socket of the shoulder is small in relation to the ball. A good analogy is to think of a golf ball sitting on top of a golf tee.

This design in shoulder anatomy is actually a good thing as it allows great amounts of movement in multiple directions.

Unfortunately this relationship also means that the joint can not rely on gravity or its bony structures to provide support.

Instead the shoulder relies on a remarkable relationship between the joint capsule, ligaments and muscles to provide movement, stability and a coordinated action between the three bones that make up the shoulder joint.

In order to be able to lift you arm overheard, two-thirds of the movement comes from the movement of the arm bone within the shoulder blade, and the other third comes from the rotation upwards of the shoulder blade.

Thus there are three different groups of muscles that you need to be aware of:

1. The muscles that go from the skeleton to the shoulder blade. These provide both stability and movement for the shoulder blade.
2. The muscles that go from the shoulder blade to the arm bone. The muscles are also referred to as the Rotator Cuff Muscles. These muscles are responsible for making sure the arm bones rotates precisely within the shoulder joint while the shoulder blade is moving.
3. The muscles that connect the skeleton to the arm bone. The muscles are responsible for movement, strength and power.

With all these moving parts it is easy for something to go wrong.

In order to determine if your shoulder is in good condition, painful due to a musculoskeletal problem, or heading towards trouble, it is important to be able to assess the functioning of these 3 different muscle groups.

This is why I stress the importance of a good understanding of shoulder anatomy.

My next post will go into greater detail on what structures within the shoulder joint can become injured. Please feel free to leave a comment if you have further questions.