FAQ Category: Shoulder

It’s important to measure before and after results any time treatment is administered for orthopedic injuries. That’s especially true with athletes who are eager to get back into the game. Orthopedic surgeons and physical therapists testing this patient group must make sure they are safe to return-to-sport at a competitive level. Avoiding reinjuries is one reason assessment of motion, strength, and function must be performed.

Whereas the surgeon might say the case has been successful because motion and strength are restored, the patient who can’t return to sports play (swimming in your case) remains unhappy and feels the treatment was a failure.

Your own report that speed and endurance have not returned to normal is an important subjective (self-assessed) report of results. Providing a record of timed trials provides objective data (evidence) help your surgeon see that there’s still a problem.

You may just need additional rehab to get back what you’ve lost in terms of strength and function. Start with a return follow-up visit with your surgeon and this new information and see what he or she recommends. There’s no need to be satisfied with less than you expected until further evaluation is done.

Anyone who has had a shoulder dislocation is understandably concerned that it might happen again. Your question is a good one: is there any way to predict who might have a second (recurrent) shoulder dislocation?

The answer to this question is important because if someone is at increased risk of a recurrent shoulder dislocation, they might want to consider having surgery early on. Surgical repair can stabilize the joint and spare you from waiting to see if the joint will dislocate a second time. On the other hand, if you aren’t at risk for a recurrence, you’ll probably want to avoid unnecessary surgery.

In a recent study, a group of Israeli surgeons evaluated the benefit of a specific test called the anterior apprehension test. This test is used in predicting shoulder redislocation after a first traumatic shoulder dislocation. As it turns out – no, that particular test wasn’t sensitive enough. But let’s step back and see how they came to that conclusion.

First, what is the anterior apprehension test? This is a clinical test performed after someone has had a traumatic shoulder dislocation to see if the shoulder is unstable. The patient lies on a table face up. The shoulder is placed in a position of 90 degrees of abduction (arm is away from the body). The elbow is bent 90 degrees. The palm of the hand is facing the feet. The examiner holds the elbow with one hand and uses the other hand to rotate the shoulder back (external rotation) while moving the hand toward the patient’s head on the table.

The test is positive if the patient makes a face of pain or apprehension and says it feels as if the shoulder is going to pop out of the socket. The test was done in this study six weeks after the first dislocation after the patient had completed a program of physical therapy to restore normal shoulder motion, strength, and function. If shoulder motion needed for the apprehension test was still limited after six weeks, the patient completed another two to three weeks of therapy before undergoing testing.

There were 52 men who participated in this study. Most were Israeli soldiers or soldiers-in-training. The first dislocation occurred during combat training or while playing soccer or basketball. Everyone was placed in a protective sling for four weeks and then attended physical therapy for two weeks before being tested.

With such a low sensitivity rating, this test isn’t really a good way to predict who would benefit from surgery after conservative care (nonoperative treatment) for the first dislocation. It misses too many of the patients who would benefit from surgical repair. It is not a useful diagnostic method for testing shoulder instability after a primary (first) shoulder dislocation.

When it comes to figuring out who should have surgery right away to repair the damage after a first traumatic shoulder dislocation, the anterior apprehension test may not be the best tool to use. Avoiding unnecessary and unsuccessful surgeries is the goal, especially for an active individuals.

At best, the test results can divide patients into two groups: those who have a higher risk for redislocation after the first dislocation and those who have a lower risk. And based on how the study was conducted, that information is accurate if the patient has been immobilized for four weeks and received two weeks of standard post-shoulder dislocation therapy.

But it sounds like that might be your situation so the test might give you some valuable information but it can’t provide an absolute definitive answer as a stand-alone test.

Shoulder dislocations can be very complex and unforgiving when it comes to rehab and return-to-work. A simple, straightforward dislocation can be vastly different from a traumatic injury with soft tissue, cartilage, and capsular damage in and around the joint.

For someone to complete a conservative (nonoperative) treatment program in eight weeks and get back on-the-job is pretty good. Most patients with clinically stable shoulders (i.e., who have a negative apprehension test) are able to resume full physical activity about three months after the injury.

There is always a risk of recurrence after a traumatic dislocation. This may not happen at first while you are being cautious in how you use the arm. If the shoulder dislocates a second time, studies show this is most likely 10 to 17 months after the first injury.

Age is a factor in second (recurrent) shoulder dislocations. Younger adults tend to have the highest rate of shoulder redislocations. Older (perhaps less active) adults have a lower risk of redislocation.

Any time the rotator cuff is torn and surgery is required to repair or reconstruct the damage, patients are placed in a sling postoperatively to protect the healing tissue. Patients are then given a standard set of shoulder exercises called Codman’s or pendulum exercises to keep the shoulder joint from getting stiff or freezing up.

It’s understandable that you want to progress your exercise program and resume more activity and motion. But we must caution you to follow your surgeon’s and your physical therapist’s counsel.

And here’s why. There’s evidence to show that with large tears (complete rupture), the retear rate is as high as 75 per cent. That’s three out of every four patients! Are these retears in any way linked with doing too much — perhaps even performing the prescribed shoulder exercises incorrectly?

Researchers from the Department of Orthopaedic Surgery at the University of Michigan think so. They tested a group of healthy, young adults (with no shoulder injuries) using surface electrodes (over the skin) of the muscles in question. They found that even doing the pendulum exercises can activate the shoulder muscles.

For someone who had rotator cuff surgery as recently as two weeks ago, the force of that muscle contracting may be enough to disrupt the healing tissues. In this same study, they even found that lifting a simple water bottle to the lips caused the supraspinatus (most common rotator cuff tendon to be injured) to be activated.

Until scientists are able to sort out how much force each activity generates, you are better off listening to the sound advice of your doctor. It makes sense to progress slowly enough to allow the tissues to heal without a retear so that you are able to get back to your daily activities without a second surgery.

Any time the rotator cuff is torn and surgery is required to repair or reconstruct the damage, patients are placed in a sling postoperatively to protect the healing tissue. Patients are then given a standard set of shoulder exercises called Codman’s or pendulum exercises to keep the shoulder joint from getting stiff or freezing up.

When performed right, these exercises are done by using the trunk to generate motion of the arm. The patient is standing holding on to a supportive surface with the uninvolved hand while leaning forward and allowing the involved arm to dangle.

The trunk and hips are rocked forward and back, side-to-side or in a circular motion. Overflow of motion from the trunk moves the arm forward and back, side-to-side, and in circles clockwise and counterclockwise. The motions can be large or small depending on how much swing the person puts into the hips and trunk.

When done incorrectly, the shoulder generates the motion. This makes the exercises active (using the rotator cuff muscles) instead of passive (protecting the muscles). In the past, there has been some concern that these exercises could put too much tension on the repair.

A recent study from the University of Michigan supports the notion that these exercises may not be as passive as we once thought. And it’s the use of large circles that seems most likely to fire up the supraspinatus (rotator cuff) muscle injured most often.

If it’s been two weeks, it may be a good idea to make a follow-up appointment with the therapist to recheck the exercises. That gets you off the hook trying to correct Dad when you’re not sure yourself what to expect and the therapist can answer any other questions or concerns you (or your father) may have.

The rotator cuff is a group of four muscles and tendons that surround the shoulder joint. Together, these muscles, tendons, and their connective tissue covering keep the shoulder both stable (in the socket) and mobile (moving in all directions). A tear in any one or more of the tendons can cause pain, loss of motion, decreased strength, and reduced function.

Rotator cuff tears come in all sizes from small to large. Sometimes the larger, more severe tears are referred to as massive tears. For some patients, the tears can’t be repaired. But for those who are good candidates for surgery, surgeons have quite a wide range of choices when it comes to surgical approach and technique. Studies are ongoing to find out which approach and technique has the best results.

And results/success can be measured in many different ways. The surgeon may be thinking of success in terms of retear rates. Success means the repair or reconstruction holds, the tear doesn’t retear, and no further operations are necessary. The patient on the other hand is thinking more in terms of being pain free and able to regain strength and perform all former activities.

Surgery for the shoulder has changed over the years. A wide incision and open surgery has given way now to minimally invasive procedures using arthroscopic techniques. Arthroscopic approaches can be all-arthroscopic or arthroscopic combined with a small incision called mini-open. Surgeons choose the approach and the repair method based on the type of tear, size of tear, location of tear, and their own experience and expertise with repair techniques.

Surgery for the shoulder has changed over the years. A wide incision and open surgery has given way now to minimally invasive procedures using arthroscopic techniques. Arthroscopic approaches can be all-arthroscopic or arthroscopic combined with a small incision called mini-open.

Even the type of sutures used has evolved from single-row repairs to double-row stitches. Among suture techniques there’s the transosseous, single-row suture anchor, combined transosseous/suture anchor, double-row suture anchor, and suture bridge to choose from. Some of these techniques were first introduced and studied just in the last 5 years.

Surgeons have found that the repair method affects the structural healing rate. In a systematic review of 23 studies where MRIs were used to see how well the healing was coming along, patients repaired with the double-row technique had the best results with the lowest rate of retears. It seems the double-row suture improves the biomechanical performance and contact area and pressure of the healing tissue. The double-row technique also applies less tension to the healing tissue, which is important during the rehab phase after surgery.

Experienced surgeons get the most consistent results. In the case of double-row sutures, the technique requires more extensive releases of the surrounding soft tissue. Getting the right tension on the healing tissue can be a fine art. There is evidence that selecting a surgeon who has done a large number of these procedures in a hospital that also reports a high volume of surgeries yields the best overall results.

The older we get, the more things can go wrong with the body. Rotator cuff tears in the shoulder is one of those problems that seems to go hand-in-hand with the aging process. The rotator cuff is a group of four muscles, tendons, and the connective tissue covering them that surround the shoulder joint. The cuff helps keep the shoulder in the socket as well as moves the shoulder in all directions.

If aging affects the rotator cuff, what’s the effect of older age on recovery after surgery to repair a rotator cuff tear? Is it always true that age is a risk factor for a poor healing and less than optimal outcomes after surgery? There are some studies that suggest age is a risk factor, while still others show mixed results. Surgeons from the Seoul National University College of Medicine in Korea say, No — age isn’t as much of a problem as we once thought.

According to the work they have done in this area, it looks like there are two other factors that may be more important than age when it comes to predicting the results. One of those is tendon retraction (how far the tendon has pulled away from the bone) and the amount of fatty degeneration is present between the retracted tendon and bone. Fatty degeneration refers to the body filling in the damaged area with fat instead of normal, healthy tendon cells.

Once you see your orthopedic surgeon and have a full assessment, he or she can give you a better idea what can be done and what to expect. Don’t hesitate to ask about age as a potential risk factor as well as any other factors you may be concerned about.

Your level of sports activity and how much demand you place on the shoulder will definitely be a guide to your rehab program. The first variable is how badly was the tendon injured — full-tears take longer to rehab compared with partial tears.

Your surgeon will be able to give you a better idea what to expect now that the procedure has been completed. Sometimes, it’s only after they get in there and see how much and what kind of damage has been done before they even know what type of surgery must be done and then what kind of rehab is needed.

For the first four to six weeks, the arm is held in a sling with a special abduction pillow to keep the arm out slightly from the body. This places the shoulder joint in the best position to encourage tendon healing. If there is a massive tear, this time might be extended up to six or seven weeks.

As you have probably found out already, certain motions are allowed and even encouraged right away. Usually, a physical therapist shows patients how to move in such a way as to avoid losing motion in the elbow, forearm, wrist and fingers.

The therapist performs passive motions of the shoulder joint in order to help keep you from getting a stuck or frozen shoulder. Passive movements means the therapist guides the patient in keeping the healing tendon relaxes and does all the motion(s) for you. Gradually, you will be allowed to assist with these motions until eventually, you’ll be doing them actively (i.e., all by yourself).

When the tendon is healed and there’s full motion in the joint, muscle strengthening is started. That doesn’t usually begin for at least two, sometimes three months after the procedure. For patients who are involved in sports recreationally or competitively, sports-specific exercises are added to the program toward the end of rehab.

Most patients are able to return to the sport of their choice about four to six months after rotator cuff repair or reconstruction. This can vary depending on the amount of damage, type of surgery, patient compliance (don’t do anything you aren’t supposed to; do what you are told to do!), and any complications that might arise during the post-operative period.

Ask lots of questions and make sure you know what you are supposed to do, when to do it, and how to do it. Be consistent with your rehab and home program and you shouldn’t have any problems getting back to the activities you love.

You wouldn’t know it without being told, but raising the arm overhead requires complex coordinated interactions of the clavicle (collar bone), glenohumeral (shoulder) joint, and scapula. The entire scapulohumeral structure is held together by muscles, tendons, and ligaments. Protective pads called bursa (bursae when referring to more than one) make it possible for smooth, gliding movements of all the parts.

Sometimes people (especially athletes) develop grinding, snapping, crunching, or popping called crepitus that can be felt by the affected person and even heard by others. When crepitus affects the scapula as it moves over the rib cage (thorax), it is referred to as scapulothoracic crepitus or snapping scapula.

What causes scapulothoracic bursitis or crepitus? Normal variations in the shape, size, and position of the scapula can cause muscle and tendon to rub the wrong way. There are those protective pads (bursae) to help ease the tension between muscle and bone or even muscle and muscle. But if there’s a bony bump on the scapula or an extra long end of the bone, the extra wear and tear of muscle/tendon flipping back and forth over the prominence can result in crepitus.

Now, crepitus isn’t always a problem. It turns out that one-third of all adults notice some snapping, grinding, or popping as they move their arm. It never results in painful symptoms or loss of function. What we are talking about here are those people who either suffer some injury to the arm (trauma) or overuse the arm (repetitive irritation of the bursa). Either one can cause inflammation of the bursa (bursitis) and eventually crepitus from scarring and fibrosis.

In a smaller number of people, there are other potential causes of scapulothoracic bursitis and crepitus besides trauma and overuse. For example, bone tumors or bone spurs may result in a reactive bursa. A bursa forms where no bursa normally exists. Muscle tears, muscle atrophy, structural spinal deformities like scoliosis (curvature of the spine), and rib or scapula fractures that don’t heal properly can also create these types of problems.

It may be a good idea to have your physician take a look and make sure there isn’t a serious cause of this problem. If there’s nothing seriously wrong requiring surgical treatment, you may benefit from a program of specific exercises to balance the muscular action that helps move the scapula and shoulder. A physical therapist can evaluate you and give you a program to follow at home with some supervision. This type of rehab may save you some trouble later if it is addressed early on.

Athletes involved in repetitive sports that include overhead throwing motions are more susceptible to snapping scapula than anyone else. Scapula refers to the shoulder blade. In this condition, pain and tenderness under and/or around the scapula is accompanied by grinding, snapping, crunching, or popping called crepitus. Crepitus can be felt by the affected person and often heard by others.

When crepitus affects the scapula as it moves over the rib cage (thorax), it is referred to as scapulothoracic crepitus or snapping scapula. What can be done to fix the problem? Well, first an examination should be done to find out exactly what’s going on. How is the scapula moving over the thorax? Are there obvious alterations in the normal movement patterns and biomechanics? What muscles are too tight, too loose, or weak? Are there any changes in the person’s posture that might be contributing to the problem?

Clinical testing of motion, mobility, and strength along with imaging studies and possibly electrodiagnostic tests help confirm the diagnosis. The examiner, whether an orthopedic surgeon, sports physician, or physical therapist, will also check to see if the symptoms are really coming from the cervical spine (neck).

Once all the information has been collected, a program of nonoperative rehab is the first step. The physical therapist works with the patient to restore normal posture, scapular movement, strength, and endurance. It can take up to six months to create the form and function needed to a return to normal scapulothoracic and scapulohumeral motion. In some cases, the bursa is injected with a steroid to reduce swelling and irritation from the inflammatory process.

When conservative (nonoperative) care doesn’t solve the problem, then the surgeon gives some thought to operating. The inflamed bursae may be removed or alternately, a portion of the scapula may be cut out. Either one of these procedures takes pressure off the soft tissues that are getting pinched or rubbed against.

In a young athlete like your daughter, it may only require a few changes in the way she pitches to correct the underlying cause. Once any postural or muscular problems are addressed, the snapping or other symptoms disappear. Most of the time, the athlete can continue playing while working through the rehab program, so they don’t lose any time sitting on the bench.

Information on injuries is collected each year from emergency departments across the United States. Shoulder dislocations is one of those injuries data is reported on. Age, sex, and race are fairly typical patient characteristics included. Cause of injury is another feature added to the database.

The majority of the shoulder dislocations reported occurred as a result of a sudden fall. Two age groups were represented: between 20 and 29 and between 80 and 89. The younger group were more likely to fall during a sports or recreational activity. They were either athletes or military personnel (and sometimes military participating in sports). Football and basketball accounted for the majority of dislocations. Falls at home were more likely to be reported by the older adults.

In the younger group, men were represented two and a half times more often than women. A closer look at whether or not shoulder dislocations occur more or less often by race shows that more whites report shoulder dislocations. But when the data is analyzed further the results show that no individual race (white, black, Hispanic, Native American, Asian) have more cases of shoulder dislocation than the others.

According to the Consumer Product Safety Commission (CPSC) the number of reported cases of shoulder dislocation has more than doubled in the last 20 years. They base their statistics on a National Electronic Injury Surveillance System (NEISS). The information is collected from the emergency departments of 100 hospitals across the United States.

The hospitals selected are supposed to represent a broad range of hospitals from small to large, rural to urban, and include children as well as adults. Over a four-year period (from 2002-2006), there were almost 9,000 cases of traumatic shoulder dislocations reported. This doesn’t include the number that occurred without trauma.

The total number of shoulder dislocations reported is probably under estimated for several reasons. Many people manage to put the shoulder joint back in place and don’t report it at all. Others see their primary care physician or go to an orthopedic surgeon (perhaps someone who has treated them in the past for other things or even for a previous shoulder dislocation). Cases like that don’t get reported through the hospital emergency department database.

In the CPSC-NEISS report, major risk factors for shoulder dislocations included age (young and old), sex (males), and activity (sports or recreation). Football and basketball seemed to top the list of sports that lead to shoulder dislocations.

Taking a sample of shoulder dislocations from across the country doesn’t include everyone but it does give us a peek inside the window. This kind of data can help identify trends of risk and maybe help us develop future prevention strategies. For now it looks like the group to start with are active young men and older adults. Strategies that work best to prevent shoulder dislocations may be the next step in this discovery process.

Your own local study could be very useful as well. There must be a reason for the rise in shoulder dislocations. Studies like this might be able to pinpoint what some of those risk factors may be. If possible, once those risk factors are identified, a prevention program might help. Decreasing the incidence of shoulder dislocations would reduce pain, suffering, cost, and loss of income and productivity.

It might help to consider that the rehab program didn’t fail you. In fact, you probably got benefits from it that you aren’t aware of — benefits that will make the second surgery go better for you than if you had not been so faithful.

There are many reasons why repaired rotator cuffs aren’t always successful. It’s not usually because the patient followed a rehab program for weeks to months. If anything, poor patient compliance may be a contributing factor to a failed response.

Most of the time, the absence of tendon healing or a retear occur because of the size of the tear (massive, full rupture affecting more than one tendon) and/or the age of the patient (older adults don’t do as well as younger adults). Degenerative changes in the damaged tendons and surrounding joint and soft tissues are also important risk factors for delayed or nonexistent healing. The longer the time between injury and repair, the more the body tries to heal itself by filling in with fatty tissue instead of strong tendon cells.

The rehab program following a second (revision) rotator cuff surgery will probably be less aggressive than your previous program. The first six weeks after surgery are in a shoulder sling with an abduction pillow. The pillow abducts the arm or in other words, keeps it a little bit away from the body. This position reduces the tension placed on the healing tendon tissue. You’ll be able to take the arm out of the sling to keep the elbow, forearm, wrist, and hand moving. But no formal exercise program just yet.

After six weeks in a sling and pillow a physical therapist will move the shoulder joint through its motions passively (without your assistance). You probably won’t be allowed to help move the arm for a full 12 weeks after surgery. By the end of four months, a strengthening program is started. The therapist will help you prepare to return to work and create a rehab program that will enable you to meet your work demands.

Hopefully, all will go well for you. You’ll get a break and you’ll have someone to guide and encourage you. With good results, you will see progress that will encourage you to reach your goal of full return-to-activities, including work.

Believe it or not, many people face this same decision. Tendons fail to heal after rotator cuff repair more often than anyone would like. So your question is very relevant — if you’ve had a rotator cuff tear repaired but it didn’t heal and/or it tore again, should you go for a second (revision) surgery to repair the recurrent tear?

What are the chances the second surgery will work? There aren’t very many reports out there to help guide patients and surgeons with this difficult decision. The results of a recent study from the Shoulder and Elbow Department of Orthopaedic Surgery at Washington University in St. Louis provide some very helpful information.

In that study, 21 patients with failed rotator cuff surgery (either because of failure of tendon healing or due to a retear of the previously repaired tendon) had a second operation to try and correct the problem. No one rushed into the second surgery. They all tried at least six-months of rehab after the first repair. But persistent pain and loss of motion and function sent them back to the surgeon for help.

The exact revision surgery varied from patient-to-patient depending on what the surgeon found when looking inside the shoulder. And there was a wide range of problems present: biceps tendons torn fully and retracted too far to repair, cartilage holes and tears, complete tears of one or more tendons, degenerative changes in other tendons, irregular bone edges. Everything was carefully repaired or reconstructed and the patients all went back to rehab once again.

And the results? Well, almost everyone did get pain relief and improved motion and function. Most of the patients improved enough to be able to return to work, play a sport if so desired, and resume daily activities. But less than half (48 per cent) had an intact repair as seen on ultrasound. Five of the 21 patients (about 25 per cent of the group) considered themselves disabled. With ongoing pain, they just weren’t able to even do their daily activities.

The surgeons found that single-tendon repairs were more likely to be successful than multiple-tendon repairs. In fact, statistical analysis showed that 70 per cent of the single-tendon repairs were in good shape. Only 27 per cent of the multiple tendon repairs made it. Intact tendons did improve shoulder strength. The older the patient, the greater the chance of a poor outcome.

So, the final decision in your case will be made based on what the surgeon finds during a diagnostic arthroscopic exam. Your age, the size of the tear, and extent of overall damage or degeneration of the shoulder and surrounding soft tissues will all factor into what can be done.

Just as you noticed, overhead throwing athletes move the throwing arm through a wide range of motion over and over and over. And they do that everyday whether in practice or in competition and sometimes both on the same day.

Like most things in sports activities, practice makes perfect. Their training goes year-round now and includes stretching and flexibility exercises along with strengthening and endurance training. Using the throwing action 100s and 1000s of time eventually stretches some of the soft tissues around the shoulder while strengthening others. In fact, most pitchers don’t really have more motion than you do. It’s just the location of that motion that changes.

The normal range-of-motion in degrees for shoulder rotation (full external rotation to full internal rotation) is about 180 degrees. The throwing athlete, especially baseball pitchers, can be anywhere from 160 to 180 degrees. They end up with more external rotation of the shoulder joint (pulling the arm way back to throw the pitch) but sometimes less internal rotation.

As you might imagine the excessive motion or extreme range-of-motion that comes with repetitive throwing motions can also result in microtrauma of the soft tissues in and around the shoulder. This type of physical action tests the tensile and physiologic limits of the shoulder structures. Injuries such as tears of the labrum/i> (rim of fibrous cartilage around the shoulder socket), impingement (pinching of soft tissues inside the joint), and tendinitis are common in pitchers.

Most sports have become year-round — if not in terms of competition and play, then certainly in training. As you pointed out there are only two seasons: off-season (or preseason) and in-season. Each athlete should participate in a training program that includes a general overall body conditioning program as well as a sports-specific training program. This is the ideal way to prepare for competition while preventing injuries.

The first order of business on the prevention side is to make sure you have the right kind of shoulder and arm motion needed for throwing. Gentle stretching exercises are needed to keep the arm limber throughout the season. You won’t be surprised to know that strengthening the muscles of the entire upper extremity (arm) including muscles surrounding the scapula, shoulder joint, upper arm, elbow, forearm, wrist, and hand is the second order of the day.

What you probably don’t realize is how complex the muscle activity is when throwing a ball. Besides contracting and releasing, these muscles must also help the arm decelerate (slow down) at just the right moment. Each muscle has its own unique jobs that require different types of exercises to strengthen and train them.

On the prevention side of the equation, core training and lower body strengthening are keys to off-season training and in-season maintenance. Anything that happens in the lower body is going to affect the upper body and especially that important throwing arm. The entire body must be tuned, strong, flexible, stable, and hold up under strenuous conditions (a sign of endurance). There isn’t one exercise that addresses all of these functions. That’s why many athletes and teams rely on sports physical therapists, exercise physiologists, and athletic trainers to design the right program for them.

Other off-season activities should include rest for sure — usually right after the season. This is followed by a full-body conditioning program. Your goal is to build up your strength, power, and endurance. The idea is that with this type of approach, you will be able to compete during the season in top form while recovering quickly after the season. Stay active in other recreational and sports activities but take time off from the lacrosse and tennis.

Your son may be experiencing some tightness or restriction in what is commonly referred to as the posterior shoulder capsule. The posterior capsule is a band of fibrous tissue that interconnects with tendons of the rotator cuff of the shoulder. The rotator cuff is made up of four muscles and their tendons. They cover the outside of the shoulder and form part of the posterior capsule to hold, protect, and move the joint.

Athletes who are involved in overhead throwing sports tend to develop too much motion in the anterior (front of the shoulder) capsule while compensating by tightening up in the back. There are several different ways to stretch the posterior capsule. There’s the towel stretch, the sleeper stretch, and the cross-body stretch.

Even though experts in sports rehab recommend some type of stretching for a tight posterior shoulder capsule, there aren’t very many studies comparing these various techniques to find out which one works best. Based on the results of one study so far, there’s some evidence that the cross-body stretch works best.

The exercise is done sitting or standing. Reach the involved arm across the body. Keep the elbow straight and the hand out as if reaching to shake someone’s hand. Use the other hand to hold the elbow and gently pull the arm across. Hold for 30 seconds. Repeat several times. Perform stretches three to five times each week.

Whether these work better by doing them before sports activity, after practice or play, or both remains a topic for further research and discovery. It probably won’t hurt to do both.

The cross-body stretch you are using is commonly used to help stretch the posterior capsule of the shoulder. The posterior capsule is a band of fibrous tissue that interconnects with tendons of the rotator cuff of the shoulder. The rotator cuff is made up of four muscles and their tendons. They cover the outside of the shoulder and form part of the posterior capsule to hold, protect, and move the joint.

If the posterior capsule is too tight, internal rotation motion of the shoulder can be limited. That type of shoulder tightness can lead to shoulder problems such as impingement, rotator cuff tears, and damage to the labrum. The labrum is an extra rim of fibrous cartilage around the otherwise shallow shoulder socket. It helps keep the shoulder in the joint and prevent dislocations.

Check to see if your shoulder internal rotation is limited by reaching behind you with one arm and touch your spine. Reach up as high as you can. Do the same thing with the other side — can you reach to about the same point with either hand? Can you reach back there at all? If you have trouble with this motion, you may have a tight posterior capsule.

What you are doing with the cross-body stretch is what would be recommended for anyone with tightness of this type. Since you may have some limitations, go slowly and don’t overstretch. Hold the stretch for a slow but steady count of 30. Keep breathing while stretching. You should see a difference after applying this stretching technique three to four times each week for a month but you’ll probably have to keep it up on a regular basis to maintain the increased motion.

Yes, the two injuries are different and require specific management, depending on which it is.

A separated shoulder is an injury to the joint where three bones meet: the clavicle (collarbone), the scapula (shoulder blade), and the humerus (the upper arm bone). In the natural position, the humerus fits into the socket made by the scapula and clavicle. The separation occurs when the clavicle and the scapula come together, usually as the result of a fall and a direct blow to the shoulder, or by landing on an outstretched hand. There are different levels of separation, according to the severity of the injury. Usual treatment for minor to moderate separations are ice to the joint, rest, and anti-inflammatory medications to help relieve the pain. Surgery may be considered if the patient has a very physical occupation.

When a shoulder is dislocated, rather than separated, the humerus comes out of the socket because there is an injury to the joint. These occur most often after a fall or through a sports-related accident. Dislocations must be treated immediately to limit the amount of damage done to the shoulder. To do this, a doctor must manually put the shoulder back into place. Because of the very painful nature of the procedure, most patients are given a sedative by intravenous so they are not awake for the procedure. A sling is then used for a while after, followed by careful physiotherapy and resumption of activities. In some cases, surgery may be required.