Shoulder pain 1

Management of Shoulder Pain

The resolution of pain involves gradually increasing the number of repetitions or resistance of the exercises performed. However, it is important to stay within a range that allows the body to adapt to the new stresses and not increase your present level of pain. Please use the following guideline to help with that. Pain is generally rated on a scale of 0 (no pain/normal) to 10 (worst pain). At no point should exercise create more than a pain level of 1-4 or cause a steady rise in pain. Any increase in pain should be temporary and return to baseline with rest or modalities mentioned below. You should notice an overall decrease in your pain after a few sessions. Should pain increase: 1. Stay at the same number of repetitions and resistance until your soreness decreases 2. Decrease the number of repetitions, staying at the same intensity, progressing more slowly the

number of repetitions 3. Decrease both intensity and repetitions, progressing more slowly the number of repetitions It is also important to make note of your function, as this may be your first indication of improvement. Guidelines for Using Cold or Heat Cold: • Use bagged frozen vegetables (peas and corn conform best) or bag of ice about one inch thick with a

small amount of water in the bottom. Get as much air out of the bag as possible. In the winter you can use snow. Apply for 20 minutes, leaving at least one hour between applications. You can secure the ice with a compression wrap if desired.

• Ice massage- make a small block of ice in a paper cup or mold and rub the affected area 5-10 minutes until the skin turns red. This technique can be used once an hour.

Heat: Place several layers of damp cloth between the skin and the heat source. It is left in place for no more than 30 minutes with two hours between applications. Do not secure heat in place with a compression wrap or weight. Improving Torso and Head Posture- The scapula and shoulder need a stable base in order to function properly. To help restore their base and re-activate the scapular muscles, you want to restore as close to a normal torso posture and head position as possible. While this is not always possible, the closer you can get too normal, the better your chances of reactivating your muscles and creating a stable base.

In most cases, a posture similar to the one seen here is associated with shoulder pain. The back is rounded or shifted to one side and the head is “looking down”, with the ear in front of the shoulder. One shoulder may be draped lower than the other.

Shoulder pain 2 As seen here, the first step in correcting this posture is to sit up as straight as possible, level the chin and attempt to pull the ear back in line with the shoulder.

Once the torso is elevated as far as possible, you want to relearn how to engage the torso muscles by feeling for their contraction (“abdominal hollowing”). This is similar to “sucking in your gut”. Place one hand in the small of the back, the other over the belly button (Pictures’ 1-4). You then want to hollow your belly as shown in Pictures’ 2 and 4. When hollowing: 1. Use the hand in the small of the back to make sure you do not feel your back start to round. 2. The hand over the belly must move backwards towards your insides. Your technique is incorrect if your hand does not move or you feel your muscles tighten but your hand does not move. 3. The natural reaction when first attempting this technique is to hold your breath. Holding your breath is not proper technique. As you practice this exercise, you may notice an increase in your back and possibly neck soreness as the muscles strengthen. This should pass quickly as you continue exercising. Picture 1 Picture 2

Picture 3 Picture 4

The last technique point is to make sure the small muscles involved with stabilizing each vertebra are working. This involves putting the fingers in the area as shown or using a small rolled towel or round object about 1” in diameter to provide sensory feedback (Picture 5). This is a difficult muscle to find and learn how to contract. It is important to do so as these muscles balance the forces created by abdominal hollowing.

Shoulder pain 3 Picture 5

Stretching Internal Rotation- You will need a rope or strap. Monitor your torso posture by standing in front of a mirror. Make sure your shoulders stay level, torso does not twist and upper arm stays parallel to the body. Place the hand to be stretched in the position shown in Picture 6. It is normal to feel a pull around the shoulder joint and possibly down into the upper arm. If pain prevents you from getting your hand into the position shown, simply let the arm hang at your side and turn your palm so it faces backward. Throw the strap over your shoulder and grasp it with the hand in the position that it is in. You want to feel a moderate pulling sensation (1-2 on the pain scale) in the shoulder when performing this stretch. Ultimately, you want to be able to elevate your hand up your back (Picture 7) equal to the opposite side. Perform 2-60 second stretches, 2-3 times a day, resting 15 seconds between each. Picture 6 Picture 7

Strengthening In/External Rotation– You will need a resistance band of some type. Imagine 12:00 is straight out in front of you. When your right shoulder is being exercised, elevate the arm toward 2:30. On the left side 9:30. Grasp the resistance band and rotate the hand in the direction shown. Internal Rotation Start Finish

Shoulder pain 4 External Rotation Start Finish

***Due to pain/weakness, you may need to initially perform this exercise with the elbow at your side. If that is the case, position your elbow one hand space from your body and slightly forward of center. The elbow must stay stationary (imagine a rod running through the upper arm) to counter the tendency to flex the elbow and shoulder as the forearm and hand rotates about it. The motion for each exercise is the same, just in opposite directions*** Scaption- From a standing position, place the hands over the front pockets. Imagine the twelve o’clock reference point is in front of you. With the palms open, point your right hand toward two-thirty and your left hand toward nine-thirty. Elevate the hands toward these locations. Do not shrug the shoulder. Keep the point of the elbow facing backward (if the arm runs 12:00 to 6:00, the back of the elbow points toward 3:00). The hands should be visible out of the corner of the eyes at the top of the movement. It is not unusual to feel a pulling sensation through the upper part of the shoulder when performing this exercise; this is the muscle being strengthened.

Shoulder pain 5 Seated Mini-dip- Sit down on the floor and place two small objects, no taller than 4-6 inches, under the hands. Place the hands on the objects and straighten the arms (Pictures’ 8 & 9). The shoulders will elevate toward the ears. Keep the torso straight, head upright and in line with the arms, shoulders back and elbows straight. Push the hands down into the objects in an attempt to raise the body off the surface (Pictures’ 10 & 11). Picture 8 Picture 9

Picture 10 Picture 11

***If performing the exercise from the floor with your body weight is difficult: A. Sit in an arm-chair and use the legs to assist B. Drape a resistance band across your shoulders and grasp it with your hands. When straightening your elbows, the shoulders should be supported in an upward direction. From there, simply push the hands down toward the hip pockets. Occasionally pain and weakness prevent traditional strengthening. Two alternate exercises are provided if the Scaption exercise is too difficult or painful. 1. As shown in Picture 12, stand approximately 4 inches from a wall. Grasp a towel in your hand and hold that towel against the wall. To raise the arm, imagine you are sweeping the hand up the wall. Keep the shoulder back, point of the elbow facing backward and elevate the hand to the position shown in picture 13.

Shoulder pain 6 Picture 12 Picture 13

2. As shown in Picture 14, hold a towel against the wall with the arm in position shown. Keep a 90-degree angle between the arm and torso. If you lean into the wall too much, the side of the shoulder blade closest to the spine will stick out. Keeping the elbow straight, begin with small clock and counter clock circles (arrow). Again you will need to keep the point of the elbow facing the outside. Increase the size of the circles as your strength improves. Picture 14

For each of the strengthening exercises, start with 10 reps and add 2-5 reps per day as pain allows; the goal being 40 reps in a row for each exercise. Perform each exercise 2-3 times daily.

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