Keep shoulders flexible, don’t overload them

THE other day, I found myself pondering the phrase to have a “chip on one’s shoulder”. A quick Google search revealed its origin.

Apparently, in the US during the 19th century, it was understood that if one placed a wood chip on one’s shoulder it would stand as a challenge to a competitor. Should that competitor knock the chip off the shoulder, it would be seen as an acceptance to fight, at which point fisticuffs would ensue.

This got me thinking. Much of the time, shoulders are used in our language to denote support of some kind. Whether it be shouldering responsibility or a scholar standing on the shoulders of his or her predecessors, the word always seems to suggest a degree of foundation.

Certainly shoulders can physically hold up a lot of weight if they absolutely have to. The world record for the heaviest weight supported on the shoulders goes to a chap called Franz Mullner, who held up 560kg for 30 seconds on his no doubt rather large shoulders.

With all of that said, the shoulder is actually rather fragile, especially when you consider all of the different ways in which it can move and exert force.

Whereas some joints are made of strong bony structures, the shoulder is actually a complex of two main joints (the glenohumeral and acromioclavicular joints). You could add in a third if you include the joint between the sternum and the clavicle (sternoclavicular joint).

The main joint is the glenohumeral joint — a ball and socket in which the cup (glenoid process) is quite shallow. This leaves it prone to dislocations far more than, say, the hip joint. On the upside, it does mean the shoulder is incredibly flexible.

You may have seen videos on the internet of people trying to draw perfect circles. Most of those who are successful tend to stand side on to a blackboard with chalk in hand, and whirl their arm in one big circle with their shoulder at its centre.

What the shoulder’s anatomy gives it in terms of flexibility and range of movement, it loses in terms of stability. Hence it tends to be up there on the list of musculoskeletal ailments we see most in general practice. Around one per cent of adults present with shoulder problems annually.

In the absence of a strong bony articulation, the joints of the shoulder rely on muscles and ligaments to hold it all in place. This is where the famous rotator cuff comes into play.

As a medical student, I puzzled for some time over the rotator cuff. To me, a cuff is something at the end of my sleeve. What I came to learn, however, was that it is a group of muscles and tendons acting almost like a sling, holding the joint together. There are four in total (supraspinatus, infraspinatus, teres minor and subscapularis).

While not all shoulder issues stem from an issue with the rotator cuff, the majority do. These can range from a minor strain to a full-blown tear. The tendons that attach the muscles to bone can also become inflamed from improper overuse, something we refer to as a tendinopathy or tendonitis.

Unless it’s a full-on tear, which can sometimes require surgery, a lot of rotator cuff issues build slowly, starting with a bit of an ache and gradually worsening as we almost imperceptibly begin to lose strength in the muscles affected. For this reason, these sorts of injuries are best served with physiotherapy and anti-inflammatory pain relief such as ibuprofen or something stronger like naproxen.

The trouble is, partly because we’re using our shoulders all the time, the physio requires dedication and time and all too often people either give up too soon or don’t do the exercises they’ve been given. Shoulder issues can take a long time (about a year or so) to sort themselves out fully.

What of the famous “frozen shoulder”? This is a term that tends to get used as an umbrella for any shoulder issue. In reality, it is a separate issue from rotator cuff problems. It tends to affect women more than men and hits most commonly between the ages of
40 and 60. While the exact cause is not really known, it is sometimes referred to as an adhesive capsulitis. In other words, it is an inflammation of the tissue and fluid within the glenohumeral joint itself. This causes pain and then progresses to reduced mobility.

It tends to have three phases, the first being the painful one, which can last from two to nine months. This is the phase when intervention has the greatest chance of success. This might take the form of a steroid injection (something that can be used for most shoulder issues but which needs to be done with more caution in rotator cuff issues because if done over and over again it can have a detrimental effect on tendons).

The second phase is characterised more by stiffness and this can last anywhere from four to 12 months. At this stage, you are left with little other option than to see it through and wait until it resolves which it will eventually, but only after a final third “resolution” phase that lasts for potentially up to another year or two. Pretty miserable really.

Until you have a shoulder issue, you probably don’t realise just how much it hinders your everyday life. Even lifting things as simple as a kettle can be a problem and it can really get you down.

Generally, X-rays and scans are not that helpful for the ailments already discussed aside from perhaps a bad tear. What an X-ray can reveal, however, is osteoarthritis (wear and tear) of the joints. This is quite rare in the main glenohumeral joint but is slightly more common in the acromioclavicular joint (this is a tiny joint that links the collar bone to the scapula — shoulder blade).

An injection might help in this instance but, once again, physiotherapy is the most effective, albeit labour-intensive, way to any sort of relief. By physio, I don’t mean getting on the weights.

If you pick up the dumbbells with a shoulder injury, you’re likely to make it worse. Physio works in two main ways — firstly, by getting a regular increased blood flow to the area of pain or injury so that all the good anti-inflammatory components that hang out in the blood can find their mark and get to work. Secondly, by keeping the muscles surrounding the joint working so that they don’t shrink and become more prone to injury and, even better, so that they increase in size and strength and bolster the overall stability and strength of the joint.

Flexibility has a big part to play too. Resting a damaged shoulder exclusively is not a good idea. Even if it’s just hanging it over the back of a chair and swinging it around two or three times a day, you’re helping the mobility of the shoulder.

A physiotherapist will be able to direct you to the most appropriate exercises for your specific injury (for example a tear to the subscapularis will benefit from slightly different exercises than those for a teres minor strain) but, in general, starting off with the following is a good idea:

l Arm swings while bent forwards, arm hanging. Forwards, backwards, left and right.

l Shoulder flexing — bringing you hands together and raising your arms straight above your head.

l External rotation — bringing your elbows down to your sides, bending them to 90 degrees and moving your hands outwards.

You’ll get some better, more detailed advice on the NHS, NHS Inform and chartered physiotherapy websites so take a look at those.

Even if you don’t have an injury, it’s more than a good idea to do these exercises each day anyway. Preventing injury is the preferred option. And, given time, you might just feel comfortable enough to attempt the perfect circle trick on the blackboard.