Shoulder complaints cause, symptoms and treatment

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The most common complaints among athletes are shoulder complaints. There can be many different causes for these complaints, although thankfully the treatment methods often overlap. Yet, it’s useful to know what issue is present and to what extent so that you can work on your recovery as effectively as possible, know when to contribute your own efforts to the doctor and/or physiotherapist, but of course also how to prevent the problem.

Shoulder Complaints

With, among others, handy videos, I not only clearly show how things work within the shoulders but also with which easy tests you can often determine which problem you have. To understand everything, I’ll first explain about the anatomy of the shoulder. The shoulder is complex, so this explanation, despite my attempts to write it understandably, might still be very complicated with many Latin terms, etc. Therefore, you might also choose to go straight to the tests and then to the corresponding treatment methods.

The most common complaints among athletes are shoulder complaints. There can be many different causes for these complaints, although thankfully the treatment methods often overlap. Yet, it’s useful to know what issue is present and to what extent so that you can work on your recovery as effectively as possible, know when to contribute your own efforts to the doctor and/or physiotherapist, but of course also how to prevent the problem. With, among others, handy videos, I not only clearly show how things work within the shoulders but also with which easy tests you can often determine which problem you have. To understand everything, I’ll first explain about the anatomy of the shoulder. The shoulder is complex, so this explanation, despite my attempts to write it understandably, might still be very complicated with many Latin terms, etc. Therefore, you might also choose to go straight to the tests and then to the corresponding treatment methods.

The Anatomy of the Shoulder

The shoulder is the attachment point for the upper arm bone. To allow the arms to move, the head of the upper arm bone (caput humerus) sits in a socket-like part of the shoulder blade. However, the head of the upper arm bone is much larger than this socket, similar to a golf ball on a tee (that wooden or plastic thing you place the ball on for the first hit). Because the “ball” is much larger than the cup, this offers a great deal of mobility, allowing the upper arm to move in almost all directions. This shoulder joint is thus barely hindered by the connection of hard tissue (e.g., one bone tissue keeping another bone tissue in place), but also barely supported. To ensure that the upper arm bone stays in the right place relative to the shoulder blade (scapula) and to stabilize the joint, the shoulder needs the support of a quartet of muscles, the so-called rotator cuff, and the long head of the biceps. On the inside of the capsule is the synovial membrane with the bursae for cushioning.

Cause of Most Shoulder Complaints

The vast majority of shoulder complaints are grouped under the name shoulder impingement. Impingement is a collective term for various shoulder complaints. It involves the pinching of one or more components of the shoulder. The space between the head of the upper arm bone and the acromion (see the image next to it) and the collarbone (subacromial space) is limited and densely populated. In this space, there are attachments, muscles, cartilage, and bursae, among other things. Because this space is limited, pinching of these components can occur under different circumstances. For example, the collarbone and acromion can be pressed in by trauma, such as a fall, reducing the space. Also, the bursae and attachments can become inflamed and swell from (micro)trauma, filling the space more and becoming pinched. I will further elaborate on these different parts and causes.

However, not all of the complaints collected here are necessarily caused by pinching, which is why the official term nowadays is subacromial pain syndrome, which refers more to the location instead of the cause. A vigilant reader pointed this out to me (thanks physiotherapiedokkum). In practice, however, both terms are still used, and sometimes even the term subacromial impingement syndrome is mentioned.

Bursae and Bursitis

One of the potential culprits in shoulder complaints is thus the bursa, but what is a bursa? In animals and humans, two parts of hard tissue that are connected are almost never fixedly connected like a door to a wall via a hinge. They are often bands of connective tissue (ligaments) and tendons that connect the two bones, with synovial tissue filling the cavities. In some places between joints and (attachments of) muscles, there are small openings. Through these openings, the synovial membrane protrudes, forming bursae (bursas). A synovial membrane can thus be seen as a soft piece of tissue between joints that allows the separate parts to move without too much friction. This happens in 3 ways:

1. Providing a distance between the moving parts. Without this distance, they cannot move due to friction. Without this distance, the joint cannot make the movement (such as with a “frozen shoulder”)
2. The tissue can change shape so that the bone tissue can move over the correct path without being hindered.
3. Controlling the distance between the moving parts by determining the amount of synovial fluid in the bursae.

Bursitis

Bursitis in Latin is bursitis, -itis from the bursa. -Itis at the end indicates that it concerns inflammation. Inflammation is a process in the body characterized by warmth, swelling, and redness, and often accompanied by a painful sensation. This process can have multiple causes. Bursitis in the shoulder (bursa subdeltoidea) often has the same cause as other shoulder complaints, namely impingement, usually due to overuse. The main bursa around the shoulder joint is the bursa subacromialis. The bursa subacromialis is the largest ‘bursa’ in the human body. It is located between the tuberculum majus and minus, the arch formed by the acromion above, lig. coracoacromiale, and processus coracoideus. This area is called the subacromial space. The bursa ensures that the tendons of the rotator cuff can pass under the shoulder roof without much resistance. When the space becomes too small and the resistance and pressure too great, inflammation can occur of both the bursa and the tendons whose movement is limited. The bursa then becomes, as it were, pinched, hence the term “Impingement syndrome”. The mentioned overuse often occurs in the shoulder with overhead movements. Risk groups include athletes in general and athletes like swimmers, pitchers (baseball thrower), water polo players, and tennis players, etc., in particular because of the high frequency of overhead movements.

Rotator Cuff

As explained above, the shoulder joint is stabilized by a quartet of muscles that together form the so-called rotator cuff (English: rotary cuff). These 4 muscles (subscapularis, supraspinatus, infraspinatus, and teres minor) ensure that the upper arm bone stays in the right place relative to the shoulder blade. The attachment tendons of these muscles can become pinched and inflamed just like the bursae. In worse cases, they can even tear. In the case of impingement syndrome of the shoulder, it is usually the tendon, or the transition from tendon to muscle, of the supraspinatus that is inflamed. This part of the muscle runs through a narrow tunnel, between the acromion (shoulder roof) of the scapula and the head of the upper arm (caput humerus). Pain is then mainly felt when moving the arm away from the body (“abduction”) between 60 and 120 degrees relative to the body. For example, when bringing the arm forward or sideways up (front raises and side laterals).

AC Joint

The acromioclavicular joint, in English: AC-Joint, is the connection between the collarbone (Clavicula) and a part of the shoulder blade, the acromion. This joint contributes to 20% of the mobility of the shoulder. Hence, these two parts are not fixed. This connection is directly supported/kept together by a ligament (8: ligamentum acromioclavicular) that connects them. In addition, there are 2 ligaments that connect the shoulder blade (at the coracoid process) with the collarbone (2:Ligamentum trapezoidem and conoideum and 3:Ligamentum coracoclaviculare). Finally, there is the ligamentum coracoacromiale (1) that connects the shoulder blade between the coracoid process and the acromion.

Common complaints of the AC joint are instability (acromioclavicular instability) as a result of one or more torn ligaments and arthrosis.

In the case of acromioclavicular instability, one or more ligaments are torn. A first-degree instability means that the ligamentum acromioclavicular (8) is stretched or partially torn. At grade 2, it is actually torn, although this is not always visible to the naked eye. At grade 3, multiple ligaments are torn. The acromion then sags, leading to the piano key phenomenon (see image on the right), a drooping shoulder. Because the treatment of these complaints is different than that of inflamed attachments, I will go into this now. Treatment consists mainly of rest and protection and limiting the range of motion by a sling for the first 2 weeks. Movements forwards to the inside and backwards should be avoided to not increase the space of the two parts of the joint. The bands must be given the chance to heal, where possible scar tissue can support the new stability. The instability is thereby limited. Cosmetically, you are left with a drooping shoulder. In the past, this was sometimes corrected surgically, but this often caused even more problems in the shoulder joint. Besides rest, cooling can help. It should be avoided to sleep on the painful side, not only for the pain but also for better recovery. A sling should be worn high enough so that the arm does not hang too much. After 2 weeks, rehabilitation can slowly begin, still being cautious about adduction (inward movements). After 6 weeks, slowly work towards “normal” load (I say “normal” in quotes because for athletes it is different than for non-athletes).

In the case of osteoarthritis, arthrosis, there is wear and tear of this joint. The AC joint is one of the joints that is more sensitive to wear than others. It mainly occurs between the ages of 30-50 when the degree of wear in combination with the load causes complaints during all overhead activities. Also, direct pressure such as a heavy backpack can then be painful. A difference compared to most other shoulder complaints such as tendon and bursitis inflammation is that arthrosis can also hurt at rest. The area around the joint can be painful, and swelling may be visible. Other possible complaints are radiating pain to the neck and breasts and crepitation (cracking/popping) when moving the joint.

The treatment of arthrosis of the AC joint usually consists of: Anti-inflammatory medication (aspirin, ibuprofen), rest, physiotherapy, injection of Cortisone (only works for short term and must therefore be repeated) and in the worst case removal of the end of the collarbone.

Biceps Attachment as a Cause of Shoulder Complaints

Many complaints experienced in the shoulders are caused by the attachments of the biceps to the shoulder. The name biceps brachii already indicates that this is a so-called two-headed muscle. The heads, the long (caput longus) and the short (caput brevis) attach at two different places on the shoulder capsule and can therefore cause different complaints. However, the majority of complaints are caused by the attachment of the long head. In this article, I will therefore only discuss these complaints.

The attachment of the long head of the biceps.

The attachment of the long head runs from the biceps through a groove in the humerus, the upper arm bone. This is the groove between the tuberculum minus and the tuberculum majus, the two protruding bumps at the top of the humerus (see image). A ligament (a band of connective tissue), the so-called ligamentum transversum humeri (translated: transverse ligament of the humerus) runs over this groove. This ligament must ensure that the attachment does not slide out of the groove. Most pain complaints at the front of the shoulder side are caused by inflammation or irritation of the attachment of the long head. Causes of such inflammation in general are overuse/overtraining. Also, poor or unbalanced nutrition can lead to this. More specifically as a cause of inflammation of this attachment are the same overhead movements that can cause complaints of the bursa and/or rotator cuff that can lead to shoulder impingement.

Indications of inflammation of the long head of the biceps can be:

1. Pain at the front of the shoulder.
2. Sensitivity of the groove between the tuberculum minus and the tuberculum majus
3. Outcome of the speed test.

Other possible complaints of the attachment of the long head of the biceps are:

• (Partial) torn attachment.
• Dislocation of the biceps tendon

The attachment(s) of a biceps can partially or completely tear, leading to the so-called “Popeye muscle”. Because the biceps is no longer attached at the top, the muscle bundle sags down, creating a visible ball. This can only be corrected surgically. The damaged tendon tissue is then removed, and the attachment is reattached, but now to the top of the upper arm bone, the humerus.

Another painful complaint is dislocation of the attachment of the long head of the biceps. As explained, this attachment runs through the groove between the two protrusions of the upper arm bone (intertubercular groove). The attachment is kept in place by: The depth of the groove, the tightness of the attachment, and the tightness of the transverse ligament, the connective tissue band that runs over the groove and under which the attachment runs. If a problem arises in one of these 3, it can cause the attachment to shoot out of the groove. Both complaints occur less frequently than inflammation of attachments and bursae.

What Causes My Shoulder Complaints?

I have now described various possible causes of shoulder complaints. Before you can start working on recovery, you first need to know the cause of your shoulder complaints. There are various tests for this that you can perform yourself. Note! These can give between 80%-95% certainty (depending on the test). For 100% certainty, x-rays and/or MRIs are often needed. In practice, however, a (general) practitioner/physiotherapist will also first make a treatment plan based on these tests and only look further when the treatment does not yield results or if there is another reason to do so. It is also good to know that it can sometimes be a combination of complaints, such as an inflamed attachment that leads to an inflamed bursa and vice versa.

Tests for problems with the rotator cuff, bursae, and attachment of the long head of the biceps:

(For testing, you need a second person who, if necessary, applies pressure by, for example, pushing on the arm or just relieving the load by lifting the arm).

Hawkins-Kennedy test (Supraspinatus and bursa): The Hawkins-Kennedy test can determine if shoulder complaints are possibly caused by an inflamed bursa or inflammation in the rotator cuff, particularly the supraspinatus. The arm is extended about 60 degrees forward and then the forearm is bent inward (as if you’re hugging someone with one arm). Then the hand is pressed down. When pain is felt at the back, this often indicates an inflamed supraspinatus and/or bursa. Click here for the video as an example.

Empty/Full-can test: The Empty-Can Test indicates a possible inflamed or even torn attachment of the supraspinatus. You let someone else lift your arm up straight forward, so 90 degrees relative to your torso, and then 45 degrees outward. The palms are facing inward up to this point. Then you turn your hand with the thumb down as if you’re emptying a can. Then let pressure be applied to the extended hand while you resist the pressure by pushing back. When you feel pain in the back of the shoulder, this can indicate an inflamed attachment of the supraspinatus. It has been shown that the Full-can test better isolates the supraspinatus, making it more certain that it is the supraspinatus and not, for example, the attachment of the biceps. The test is performed in the same way, but now with the thumb pointing up (pronated). For a video with an explanation of both tests, click here.

Neer’s impingement test: With Neer’s impingement test, you also check for inflammation of the supraspinatus, but the outcome can also indicate an inflamed attachment of the long head of the biceps. Extend your arm again in front of you at 60 degrees, but then let the other person lift it further up until the arm is next to the head and pointing straight up. By lifting the arm like this, you simulate the impingement. If pinching indeed causes the complaints, they should now be felt on the side/back of the shoulder. Pain at the front of the shoulder is an indication of an inflamed long head of the biceps. Click here for the video as an example.

Speed test – Attachment of the long head of the biceps: For the speed test, you hold your arm straight down with the palm facing forward and thus thumb outward. Then you bring your arm straight up with resistance (for example, someone pushing against). When you feel pain at the groove between the tuberculum minus and the tuberculum majus (at the front of the shoulder) then you probably have an inflammation of the attachment of the long head of the biceps. Click here for the video as an example.

Drop-arm test: The drop-arm test can be a clear indication of a torn attachment of the rotator cuff, particularly the supraspinatus. Let your arms be brought to the side and up until you have the arms with the palm down, horizontal, parallel to the shoulders. If you can’t keep them there, you probably have a torn attachment of the supraspinatus. Another method is to slowly bring the arms down from the same position while another suddenly gives a push downwards. Click here for the video as an example.

Recovery from Shoulder Inflammations

As you can see, there can be many causes for shoulder complaints, most caused by inflammations. These inflammatory problems often need the same treatment for recovery. For inflamed attachments in general, the English mnemonic R.I.C.E applies: (R)est, (I)ce, (C)ompression, (E)levation.

Rest: An inflamed or irritated attachment often comes from overuse. It is important then to stop this strain. Yes, this means that you won’t be able to train this muscle group for a while, and this is often the worst punishment for an athlete. It is therefore important to know what is inflamed. Even if you feel the pain in the shoulder, it could mean that it is the attachment of the biceps and you must also give the biceps a rest. Rest lowers, among other things, the amount of blood that must pass through the tendon and thereby also reduces the chance of further damage.

Ice: The English word for inflammation is inflammation, literally igniting or burning. This is due to the heating that accompanies an inflammation. By cooling the attachment, you limit this heating. Moreover, it also limits the supply of blood and thereby swellings and pain. For this, you can use a compress, pieces of ice, or for example frozen beans in a bag. Even running cold water can help. Be careful not to place the ice directly on the skin! This can cause damage similar to burns. A moist tea towel around (the bag with) the ice is therefore recommended unless you have a compress that already has a protective layer. It is important that you cool/ice as soon as possible after the first signs of inflammation, for example immediately after the training in which (the first signs of) the inflammation were noticed. After this, it is best to cool for about 20 minutes every 2 hours for 2 to 3 days.

Compression: With compression, you achieve two things. Firstly, it helps reduce blood flow and swelling. Additionally, it provides support for the affected area (thus also protection). For the shoulder, there are special shoulder caps and/or wraps that provide pressure and can cool.

Elevation: Raising the affected area limits the blood flow and thereby the swelling. For an Achilles tendon, this means letting your foot hang higher. For your shoulders/biceps, you can think of a higher pillow so you lie a bit elevated.

Rehabilitation Exercises for Shoulder Complaints

Range-of-motion: Starting with rehabilitation exercises is usually only done when the worst pain complaints have diminished/disappeared through the (P)RICE(R) principle as described above. However, during this time you can already work on increasing the so-called range-of-motion. The mobility of your shoulder is often reduced by the injury. Movements above the head or behind the back can often be painful, causing you to no longer make these movements and the shoulder thereby becomes even stiffer which inhibits recovery. A good exercise is then the pendulum. By bending forward, or lying forward on a desk/table, letting the arm hang and making circles, you ensure that you do not further reduce the mobility. You make the circles first small and then gradually larger, then you make them smaller again. You ensure that you drive the movement from your body (from your legs) and thus do not use your arms to exert force. Repeat this a few times a day. Click here for a video with an explanation of the pendulum as an exercise.

Rehabilitation exercises: The rehabilitation exercises are aimed at strengthening the affected muscles and attachments. By doing strength exercises aimed at the different muscle groups, you build up strength and reduce the chance of complaints in the future. Because you are rehabilitating, you limit the load (compared to the load of a “normal” shoulder training). For the muscles of the rotator cuff, it also applies that these are stabilizing muscles, aimed at endurance. This is also a reason why you do many repetitions with relatively little weight during rehabilitation. The exercises are similar to the exercises you normally do for your shoulder. Normally, however, you train the large shoulder muscle, now you are focused on the underlying rotator cuff muscles. Therefore, you often perform exercises with other rotations of the hands or a different angle of the arm to strengthen the main muscles (such as the supraspinatus). Finally, rehabilitation can also focus on posture. There are various videos on YouTube with rehabilitation exercises aimed at specific complaints and impingement in general. For the latter, I found this a good and clear video.

Prevention, Avoiding Shoulder Complaints

Preventing shoulder complaints is of course not always possible because they are not always caused by circumstances over which you have influence. However, you can prevent many problems by doing the right exercises, maintaining the right posture, and eating the right foods.

Correct Execution of Exercises

As described, it is often overhead movements and overuse due to heavy weights or many repetitions that can lead to impingement. For this reason, it is advisable not to perform shoulder exercises such as side laterals and front raises above shoulder level (but to raise the arms up until they are horizontal). An exception is the shoulder press that actually starts from shoulder level. This can be done with dumbbells or a bar. In principle, any form of shoulder press can cause injuries. However, dumbbells carry a lower risk than a bar because you can bring the dumbbells together at the end of the movement. You thus exercise over a larger and freer range of motion. However, this can cause injuries if you move over the wrong path or lose control when training with a lot of weight. With a shoulder press with a bar, you can also perform the exercise by letting the bar go behind the head instead of in front. Behind the head, however, means a higher risk of injuries to the glenohumeral joint, the connection between the upper arm bone and the shoulder (and a higher risk of neck complaints). Another, maybe even riskier, exercise is the upright row. This exercise is often performed with a narrow grip. This can also cause shoulder injuries. You can perform this exercise, but with two points of attention: 1. keep your hands shoulder-width apart and thus not narrower. 2. Do not lift the stand too high, but until your upper arms are horizontal. So do not let your elbows come above your shoulder.

A shoulder injury does not always occur in the gym. It is a pity if you carefully watch your execution during every training and then cannot train for weeks because you have whitened the ceiling. So also avoid unnecessary overhead movements outside the gym. I’m not saying that the ceiling may remain brown from cigarette smoke, but that you should stand higher on the ladder so you do not have to lift your arm as high.

The Right Load to Prevent Shoulder Complaints.

Muscles grow faster in strength than the attachments of those muscles. That you feel that you can handle more weight and/or more repetitions, therefore, does not always mean that your attachments can also handle this. In general, for attachments, especially for the weight, it applies that you should increase the load within an exercise by a maximum of 10%-20% per month (depending on the muscle group, the extent to which it is trained, and the number of times you train).

Also beware of overtraining!

Overtraining ensures that the recovery process of your body slows down. Not only overtraining of specifically the shoulder but also of the body as a whole. Among other things, your testosterone decreases due to overtraining, while the stress hormone cortisol rises. Less signal to build muscle mass (lower testosterone) and just a greater signal to break down muscle mass in favor of energy (due to higher cortisol). This can mean that muscles are not fully recovered before you heavily load them with the next training. This increases the risk of injuries while your chances of growth only become smaller.

The Right Posture to Prevent Shoulder Complaints

In the picture above, you see the well-known image of the so-called homo digitalis. This image is popular in RSI prevention training because it shows the impact of our current activities and their influence on our posture. Because we are more hunched over, the angle of the torso changes, the arms hang a bit more forward, and the shoulders are pulled more forward. This latter effect is intensified when you work a lot, for example, behind a PC or on a mobile phone or tablet. Because your arms are always working in front of you, this also pulls your shoulder blades forward. Because you then work/train from this incorrect posture, the chance of injuries is increased. Fitness training courses therefore often emphasize posture, both during and outside the exercises. For the shoulders, it applies that they should be down and a bit back. This may initially feel as if you’re excessively pushing your chest forward and as a bodybuilder, you seem to be showing off, but so be it. The video with rehabilitation exercises also starts with a good exercise to correct the posture of your shoulders.

Nutrition and Supplements to Prevent Shoulder Complaints

Finally, there are anti-inflammatory and attachment-strengthening nutrients and supplements that can help prevent and heal. Here you can think of: Turmeric, Ginger, Omega-3 fatty acids (fatty fish, flaxseed, walnuts, Selenium (Brazil nuts), MSM (also for the circulation of attachments), pure chocolate, antioxidants (including cinnamon, cocoa, berries), olive oil (extra virgin), zinc, Borage oil, Vitamin C. Glucosamine and chondroitin work to strengthen the shoulder joint (cartilage). To be used for example in complaints due to the AC joint (such as wear and tear).

Below you will find a selection of supplements that can support you in preventing injuries. It should be noted that all the tips given above about execution, right load, posture, and preventing overtraining have the biggest impact on the chance of injuries. A pill here or a powder there is no remedy for a lousy technique and other mistakes made in the gym or on the sports field.

“Trust me: I’m a pretty smart guy, but I’m no doctor!”

I am just an enthusiastic “hobby builder” and fitness (- and kobudo) instructor with an excessive interest in everything related to bodybuilding, fitness, nutrition, and supplements. I am not a doctor or physiotherapist. This article is not intended as a substitute for visiting a doctor. Because they do not want to go to the doctor for every physical problem immediately, many people wait a long time until the complaints persist and/or worsen before going to the doctor (or until they go away on their own or with rest). This article is intended to help you in the meantime or to make it immediately clear that you need medical supervision and should not wait with this. Good luck with your recovery!