The population of this study includes athletes of all levels between the ages of 15 and 40. It was decided to focus this study on this group of athletes for several reasons. Shoulder impingement syndrome, which is commonly associated with our subjects, has been shown through studies to be prevalent in the younger population. This occurs due to the repetitive stress placed on the shoulder from overhead activities. Studies have shown that symptoms of SIRP have caused early retirement from sports. By focusing on this age group, the researchers hope to tackle this ailment early, prevent recurrence, and increase the longevity of their athletic careers.
Shoulder internal rotation pain is a common ailment found amongst athletes who partake in throwing sports. This usually occurs in the late cocking or early acceleration phase, and pain is usually felt in the front aspect of the shoulder. The symptom happens due to the excessive load being placed onto the shoulder, especially during the late cocking phase where the shoulder is in maximal external rotation and abduction. This leads to micro-trauma and possibly tears to the static and dynamic restraints of the shoulder. Pain will be felt when the shoulder is in a protracted position and not in the retracted position when the shoulder is off from being in full external rotation.
Understanding Shoulder Internal Rotation Pain
Shoulder internal rotation pain (SIRP) is a condition involving pain in the front of the shoulder. It occurs when there is an impingement of tendons or bursa in the shoulder joint at the front of the shoulder. This can occur either from a specific injury or it can occur over time with repetitive overuse of the shoulder. It is called “internal rotation” pain because this is the movement that reproduces the pain. This impingement leads to a strong sense of catching and pain with certain movements of the shoulder. The pain can be severe and is one of the most common reasons why people seek help for shoulder problems. Activity requiring frequent and repetitive use of the shoulder tends to provoke and aggravate SIRP. This is particularly so with overhead activities and those involving heavy lifting. Because the pain is elicited by movement of the shoulder, people often modify their behavior to avoid painful activities. This can lead to decreased function of the shoulder and can often affect confidence, particularly in those involved in overhead sport or in manual work. This can lead to weakness of the shoulder muscles and a generalized “pattern” of shoulder dysfunction.
Prevalence of Shoulder Internal Rotation Pain in Singapore
Athletes competing in overhead or throwing sports, such as rugby or shot-put, can also develop shoulder internal rotation pain due to increased torque about the humerus which over time can lead to internal impingement and eventually cuff-related tears or SLAP lesions.
Competitive swimmers can sometimes develop shoulder internal rotation pain as a result of adaptive changes to the glenohumeral joint to accommodate the large amount of humeral head elevation during the swimming strokes. Essentially, the increased torque about the axis of the humerus will cause adaptive changes, often in the form of posterior capsule tightness or hypertrophy and glenoid retroversion. This, in turn, will restrict the amount of humeral head spin, causing increased ER torque during functional activities and thus negatively affecting the RI:ER force couple.
Shoulder internal rotation pain is a common problem among athletes and active individuals. The prevalence of this condition in the general population can be quite high and even more so in certain groups of individuals. The etiology is multi-factorial and the problem can be quite difficult to treat if the pain becomes chronic. One study found the prevalence to be as high as 36.9% in the general population and 67% in manual wheelchair users. This is quite significant given how disabling shoulder pain can be. In some cases, it can lead to permanent disability and difficulty in performing routine daily activities. In certain groups of individuals, shoulder internal rotation pain can become quite a debilitating problem.
Causes of Shoulder Internal Rotation Pain
Muscular imbalance, as defined by a MedicineNet.com article, is when “one set of muscles is working hard and the opposing set is less so.” It mentions how this can occur when an individual is attempting to maintain a steady position, such as holding something in place, which involves an awkward posture, thereby fatiguing the muscles. An example of this and how it relates to shoulder internal rotation pain might be a tennis player serving a ball. This involves holding the ball in the hand and hitting it with the tennis racket. This can strain the shoulder and create an internal rotation muscle imbalance as the muscles are constantly being used to deliver a fast and hard serve. If that individual were to serve repeatedly for long periods of time, it’s likely that he will have shoulder pain due to the muscles being fatigued, in addition to leaning towards the side of internal rotation as it is the “power position” for this particular tennis shot. With the fatigue and the constant repetitive motion, there is a high probability that an injury such as a tear or impingement would occur. Overuse or repetitive strain, the Baselinecentral.com article explains internal impingement as occurring when the rotator cuff and/or the labrum are repeatedly pinched at the back of the shoulder joint. It goes on to mention how this occurs during the positioning of the shoulder at the end of the cocking phase and the beginning of the acceleration phase of throwing. (An overhead athlete’s throw is the typical situation.) In simpler terms, this means any sort of throwing motion in which it’s repeated frequently will cause shoulder pain, as explained in the case of the tennis serve. This is a typical situation for any athlete who has done lots of throwing or serves, and it’s relevant in the case of internal rotation pain, as the positioning of the throw is almost always done in the position of internal rotation with the hand behind or above the shoulder. The key point is that due to the repetitive strain, wear and tear on the rotator cuff and labrum, there is likely to be impingement and pain in the shoulder.
Muscular Imbalances
An injury to the supraspinatus will not allow the humerus to be depressor an effective action for abduction. The deltoid acting alone on abduction will further cause impingement of the greater tuberosity on the acromion against the coracoacromial ligament. This too will cause pain and injuries to these mentioned structures.
Another possible mechanism for rotator cuff injury due to a muscular imbalance is a tensile overload on the cuff itself. This often occurs when the deltoid is too strong relative to the supraspinatus. With the deltoid attached to the humerus and the supraspinatus attaching to the greater tuberosity, the deltoid will overpower the supraspinatus, pulling the humerus and the GT superiorly against the acromion process. This action will impinge the supraspinatus and the long head of the biceps tendon against the anterior portion of the acromion. Over time, the increased compressive forces and tension at this area will cause fraying and degeneration of the cuff tendons.
Internal rotation is facilitated by the subscapularis, latissimus dorsi, pectoralis major, teres major, and anterior deltoid. The external rotators that oppose these muscles are the infraspinatus, teres minor, and the posterior deltoid. When the internal rotators become too strong or the external rotators are too weak, the chance for a shoulder impingement or a rotator cuff injury increases. This is due to the fact that when the internal rotators are tight, the head of the humerus glides forward increasing the potential of the humerus grinding into the acromion process or the coracoacromial ligament. With repetitive stress to these structures, pain and injury may occur.
Muscle imbalances present when one muscle is over-utilized relative to its antagonistic muscle. Most of the time, the overutilized muscle becomes shortened and eventually tight. As a result of this, the antagonistic muscle is lengthened to a weakened state attributing to the imbalance.
Overuse or Repetitive Strain
This refers to any movement that is performed too frequently with incorrect shoulder muscle recruitment. This is commonly seen in gym goers who perform an exercise incorrectly, dancers or swimmers. This form of shoulder pain is significantly more chronic than the previous shoulder impingement and is caused by fatigue of the rotator cuff muscles from trying to stabilize the shoulder joint during the aggravating activity. This fatigue leads to the deltoid taking over this role as it is a powerful mobilizer of the shoulder joint. As the deltoid is a prime mover for shoulder flexion and abduction, it will cause an internal rotation force on the shoulder joint. Swimmers are particularly prone to this type of internal rotation pain due to the high amount of shoulder work involved in training and difficulty of avoiding fatigue of the correct rotator cuff muscles in a water environment. This will result in pain which is felt during the activity and also when lifting the arm in day to day tasks. Treatment for this will involve a cessation of the aggravating activity or stroke and specific rotator cuff strengthening to maintain its role as a dynamic stabilizer of the shoulder joint. Due to the nature of the sport, changing the stroke and addressing technique faults is a better long term solution than trying to avoid the same problem with a different stroke.
Traumatic Injuries
A traumatic injury (either acute or chronic) can occur in a single or a series of events and it usually involves the presence of a significant force, high intensity loading (compression, tension, shear, etc.) with some sort of collision or a combination of these mechanisms. This leads to damage of bodily tissues. The traumatic injuries in the shoulder are the most common cause of shoulder internal rotation pain (Jobe et al., 1983; Kvitne et al., 1995; Lintner et al., 2007). Jobe et al. (1983) divided the mechanism of injury for a traumatic shoulder injury into different categories; each has its own specific effect/damage to the shoulder complex. These are external impingement of the shoulder, overhead activity, instability related, and isolated internal impingement. This has been further explained much later in the essay. However, Lintner et al. (2007) simply states “The most common cause of internal impingement is secondary to a traumatic event involving forced abduction and/or forced rotation in an overhead position”. This indicates that there is significant force of damage to the shoulder resulting in a labral or rotator cuff tear. The most common injury which affects the internal rotator muscles is a subluxation or dislocation of the glenohumeral joint. This is often the result of a significant force which the glenohumeral joint cannot withstand, the shoulder gives way and the humeral head is displaced partially (subluxation) or completely (dislocation) out of the glenoid. This can result in a labral tear mainly in the anterior region and possibly a rotator cuff tear or strain. If this happens, there is likely to be significant loss of rotator cuff activation and muscle atrophy of the internal rotator muscles. This will decrease the dynamic stability of the shoulder leading to further instability episodes and an increased risk of further injury.
Treatment Options for Shoulder Internal Rotation Pain
For less severe internal rotation deficits and impingement signs, a structured and supervised physical therapy and rehabilitation program may be sufficient to regain full shoulder motion and reduce pain. This program may be conducted by the physiotherapist or, if you are motivated well enough, you can do the exercise program by yourself at home. The main objective is to restore normal shoulder motion and strength to reduce any associated impingement signs and any causative factors: – Improved shoulder and shoulder blade (scapula) posture – Soft tissue treatment to tight or shortened muscles that may be the cause of the reduced internal rotation, such as the posterior shoulder capsule, pectoralis major, and subscapularis – Rotator cuff and shoulder blade muscle strength and endurance training – A gradual stretching and return to normal overhead and throwing/serving sports activities.
There are four treatment approaches possible for the painful shoulder rotational deficit. According to the severity of the present internal rotation deficit and impingement sign, your age, other associated pathologies, and your personal goals, the physiotherapist can help guide you to decide which is the best approach for you.
Physical Therapy and Rehabilitation
Manual therapy can be employed to improve flexibility and assist in decreasing pain. Techniques such as mobilization and manipulation can be beneficial for tight shoulders or shoulders with restricted mobility. A recent study published in the Journal of Orthopaedic and Sports Physical Therapy suggests that a combination of manual therapy and exercise is superior to only exercise for individuals with impingement. The scapula and shoulder musculature, including the rotator cuff, responds well to strengthening, and exercises can be modified to gradually load the healing tissue.
Physical therapy and rehabilitation are very effective treatments for relieving shoulder internal rotation pain. An effective program should address flexibility, strength, and occasionally retraining control of the scapula and shoulder complex. A detailed description of specific treatments for shoulder impingement can be found at the physical therapy for shoulder impingement page.
Medication and Pain Management
Medications can be useful in controlling shoulder internal rotation pain, especially in the acute inflammatory stage. Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, aspirin, and naproxen are effective in reducing pain and inflammation. These drugs can be obtained over the counter, but it is wise to consult with a physician because long-term use can lead to gastrointestinal ulcers and bleeding. If pain persists, consult with a physician, as they may be able to prescribe a stronger NSAID or another class of drug to provide pain relief. Oral steroids such as prednisone are very effective in reducing inflammation and pain, but the side effects can be significant and include weight gain, mood swings, and immunosuppression. It is important to discuss the risk/benefit ratio of this medication with a healthcare provider. In cases of significant pain, narcotics may be prescribed, but these should be used cautiously and for a limited duration due to the potential for addiction and abuse. Topical or local NSAIDs and anesthetics can also ease shoulder pain, often with fewer side effects than their oral counterparts.
Alternative Therapies
Acupuncture Acupuncture is based on oriental philosophy and aims to restore the body’s normalcy. It involves the gentle insertion of thin needles into the skin at the meridians. A meridian is defined as an anatomic area which is under the skin and through which there is potential access to deeper structures. According to traditional oriental medicine, the body is made up of both positive and negative principles – yin and yang, and health is a state of balance between the two. Illness results from an imbalance. The meridians are the pathways through which the life energy – qi flows. In illness, the flow of qi is disrupted and acupuncture is believed to correct this imbalance by removing the blockage and re-establishing the regular flow through the meridians. According to western theories of acupuncture, the stimulation of the body at acupoints causes a release of endorphins or opiate-like compounds which relieve pain. It is this analgesic mechanism that is most likely why acupuncture seems to be effective in warm shoulder pain and impingement syndrome cases. Electro-acupuncture involves the use of a TENS unit attached to the needles to create an electrical pulse. This may be more effective than simple acupuncture in chronic pain management. Electro-acupuncture has been found to increase beta-endorphin in the plasma and for a shorter time, ACTH and cortisol levels. High-frequency 2Hz electroacupuncture has been shown to have a faster onset and longer duration of pain relief compared to conventional drugs such as morphine.
Surgical Interventions
Surgical options should be considered when shoulder internal rotation pain fails to respond to non-operative treatment methods. Surgery is considered a last resort in the management of shoulder internal rotation pain, as it is associated with more risks and a longer recovery period. However, it is often the only effective means of treating shoulder internal rotation pain in a select group of patients. There are three main surgical options available, which include subacromial decompression, frozen shoulder release, and internal impingement repair. Subacromial decompression involves arthroscopic removal of the coracoacromial ligament and the acromial osteophytes. This procedure is indicated when there is concomitant subacromial impingement. Frozen shoulder release is performed arthroscopically, involving release of the coracohumeral ligament and the rotator interval. This procedure is indicated for patients with primary and secondary frozen shoulder. Internal impingement repair is usually carried out through an open procedure. This procedure involves repair of the superior glenoid and humeral head lesion, as well as subpectoralis tenodesis of the lesioned biceps tendon. This procedure is only indicated in overhead athletes with dominance in overhead throwing sports.
Finding the Right Shoulder Internal Rotation Pain Treatment in Singapore
The first thing to consider when seeking treatment is to find the right person to diagnose and treat the injury effectively. This is important as being misdiagnosed or having the injury treated incorrectly can result in a chronic condition or further injury. Some of the healthcare professions qualified to diagnose and treat musculoskeletal conditions can include primary care physicians, sports medicine doctors, physiotherapists, and chiropractors. It would be to your benefit to find a healthcare professional experienced in the diagnosis an shoulder internal rotation pain treatment. This could involve asking the professional what proportion of cases they have seen and successfully treated. An effective way to diagnose the problem can also involve medical imaging, which can include x-ray, MRI, or CT scans. This can help to rule out other conditions that may be causing the shoulder pain and also effectively identify the site and nature of a soft tissue injury.
After identifying shoulder internal rotation pain and seeking information on its correct treatment, it is time to move to the next stage in getting the right treatment. Essentially, there are three main goals to be achieved in finding the right treatment. The first is to find the right qualified healthcare professional to effectively diagnose and treat the injury. The second is to consider the cost of treatment and insurance coverage. The final step would be to find the right doctor, physiotherapist, chiropractor, etc. who is effective in treating the condition as well as being reputable and trusted.
Researching Qualified Healthcare Professionals
Generally, the expertise of the healthcare professional is reflected by their knowledge and how they manage the case. It can be difficult to assess the knowledge of the healthcare professional, and it may be subjective. However, asking for the detailed plan of management and the rationale behind it should give a fair idea of the knowledge and expertise of the healthcare professional. A knowledgeable healthcare professional would have a systematic approach to managing the condition and would offer a detailed and plausible explanation.
Identifying the cause of the shoulder internal rotation pain is a priority, as receiving inappropriate treatment due to misdiagnosis can result in prolonged pain, worsening symptoms, and various side effects. Typically, healthcare professionals such as physiotherapists, sports physicians, and orthopaedic surgeons have experience in managing such cases. Finding a healthcare professional who has the relevant experience in dealing with the condition is important, and it might be beneficial to seek recommendations from friends, relatives, or other healthcare professionals. Otherwise, do not hesitate to ask the healthcare professional about the number of similar cases that they have managed and their rate of success.
Considering Treatment Costs and Insurance Coverage
Across different healthcare institutions, fees can vary greatly for the same treatment procedures. Common treatments for shoulder pain that may vary in cost include steroid injections and physiotherapy, as well as surgical treatment for more severe shoulder injuries. Patients are encouraged to inquire about the specific cost of their intended treatment and clarify whether this cost includes follow-up consultations and treatments.
Patients must note that an examination and consultation of a shoulder injury usually includes a physical examination and a review of the patient’s medical history. Most of these initial consultations usually last no more than 15 minutes, albeit being charged the fee for a 30-minute consultation. During which, some orthopedic surgeons may order imaging tests such as an x-ray, MRI, or ultrasound to accurately diagnose the nature of the injury. Any imaging tests done are usually charged separately and are not part of the initial consultation.
All treatment fees can vary greatly depending on the hospital, the specific treatment given, and even just between individual doctors. If you are insured, then you will want to consult your insurance provider to know exactly what is covered and what is not. Different insurance policies cover different treatments, and you might find that even some of the more common treatments for shoulder pain may not be covered by your policy. If you are not covered by insurance, find out an estimated cost of the entire treatment process and take some time to think about whether this will put too much of a financial strain on you or your family. If it will, you may want to reconsider going through the public healthcare system, as the waiting time, although long, will cost significantly less than a private consultation.
Seeking Recommendations and Reading Reviews
Physicians may prescribe anti-inflammatory medicine for the shoulder rotator cuff. This is accomplished so that inflammation and pain go down for the next stages of healing. It may be beneficial to receive an injection on the shoulder. There is a greater chance of pain going away faster after the injection. In some cases where a great deal of strength is lost, a physician will go as far as to prescribe an MRI to make sure that there are no tears in the rotator cuff. This is to be done once all the inflammation and pain is down so that the MRI will show a clearer result. If the rotator cuff is partially or completely torn, the shoulder rotator cuff tear will be recommended for surgery. This is usually the last resort in cases of shoulder internal rotation pain. Surgery involves re-attaching the torn tendon to the bone. A high rate of success has had many patients satisfied with the results of this procedure. This surgery is followed by an extensive amount of rehabilitation. This stage is most crucial as it is retraining the shoulder on how to function properly again. The success of the surgery can, however, depend on the size and the location of the tear. If it is determined that the rotator cuff is not completely torn through a physical examination, the shoulder internal rotation pain patient will be recommended to undergo a strength training program in hopes to build enough strength to relieve the pain and inflammation. This is why it is important to go to the doctor early on to prevent the loss of strength in the rotator cuff.
