Many of us are now trying to fulfill New Years resolutions to become more physically fit and healthy – and this probably involves strength training in some form. Weight training has become increasingly popular in the recreational athlete population over the past 10-15 years. Some sources claim that 4 million people participate in crossfit workouts, and many others utilize upper body weight lifting to increase strength, burn calories, and improve function. Consequently, the incidence of shoulder injuries associated with these activities has also increased. Appropriate prevention strategies, recognition, and treatment of shoulder injuries allows an athlete to maximize their performance and minimize down time when these problems occur.
The shoulder is the most flexible joint in the body in terms of planes and degree of motion. This flexibility allows complex tasks to be completed – throwing a baseball, spiking a volleyball, or performing an Olympic lift – but also subjects the supporting structures to significant stress and potential failure. Your shoulder is composed of three bones (humerus/upper arm, scapula/shoulder blade, and clavicle/collar bone) which connect at two joints (glenohumeral/main shoulder joint/ball & socket, and acromioclavicular/AC joint/point of shoulder). The most common injuries seen with weightlifting, whether Olympic or powerlifting, are labral tears, AC joint inflammation/osteolysis, and tendonopathies of the biceps, rotator cuff, or pectoralis major.
The labrum is a fibrocartilage ring that surrounds the glenoid, or socket, of the shoulder joint. It has a consistency similar to hard rubber, and acts as the attachment site for the ligaments which prevent shoulder dislocation. Labral tears can result from compression (i.e. bench press, military press), distraction (deadlift, pull ups), or a combination thereof (throwing, clean and jerk Olympic lift). These injuries are diagnosed with physical exam and imaging studies (injection MRI), combined with a history consistent with the injury. Patients often have pain reproducible with certain motions that load the injured part of the shoulder, often with catching and locking (mechanical symptoms). Labral tears are initially treated with rotator cuff rehab exercises and active rest, with return to sport determined by functional performance. If persistent pain or mechanical symptoms (catching/locking) persist, arthroscopic surgical repair/debridement is appropriate and highly successful. When repair is necessary, return to sport is a minimum of 3 months for light/controlled weights, 4-6 months for contact sports and heavy/complex lifts, 6-12 months for the dominant arm of a throwing athlete. Key points to remember here are that non-surgical treatment is generally successful, involves less down time than surgery, and MRI, while helpful, has an accuracy rate as low as 50% in some clinical studies. In other words a positive MRI does not mean surgery is necessary.
AC joint overuse injuries are one of the most common entities seen in weight training. Young athletes may develop distal clavicle osteolysis, a sort of stress fracture of the distal clavicle (collar bone), while people age 30 and older may develop AC joint arthritis. These conditions are often painful and annoying, but are not dangerous in terms of long term shoulder function. Active rest, modification of lifting technique/routine to decrease AC joint pain, anti-inflammatory medication, and occasionally a cortisone injection are standard non-surgical interventions. If the pain persists, an arthroscopic distal clavicle excision – removal of the tip of the inflamed/worn down collarbone – allows for rapid pain relief and return to activity in most cases. One study of competitive powerlifters showed that most patients returned to their maximum lifts on bench press, incline press, and military press at a mean of two weeks after surgery.
Finally, tendonopathies of the rotator cuff, long head biceps, and pec major are commonly seen in competitive weightlifters and powerlifters. The rotator cuff and biceps are responsible for maintaining the dynamic stability of the glenohumeral joint. In other words, they keep the ball in the center of the socket while the large muscles – the deltoid, latissimus dorsi, and pec major – power the arm through high demand lifts. These muscles can experience degeneration, inflammation, and partial or full thickness tearing of their tendon attachments when exposed to repetitive high level stress. Symptoms are generally pain in the lateral shoulder (rotator cuff) or anterior/front part of the shoulder (biceps) with or without weakness. Physical exam and MRI help to define the extent of the anatomic injury. When damage is incomplete (partial tears or inflammation), a rotator cuff stretching and strengthening program emphasizing external rotation resistance exercises with therabands leads to resolution of symptoms in 85% of patients with rotator cuff tendonopathies/impingement syndrome. For persistent symptoms that fail conservative treatment, arthroscopic debridement/decompression with removal of inflamed tissue and bone spurs has a 90% success rate. Full thickness tears of the rotator cuff and traumatic ruptures of the pec major require surgical repair to allow maximal function. These surgeries work very well, but recovery is a minimum of 4-6 months. Biceps tendon ruptures in the shoulder (long head biceps injuries) can be treated non-surgically with minimal risk of dysfunction and decreased down time versus surgical treatment. The biceps can be tenodesed, or repaired to the humerus, when it ruptures, but this is primarily for cosmesis, and recovery time is at minimum 3-4 months.
Most shoulder injuries are due to repetitive overuse, and can be prevented with a combination of rotator cuff strengthening exercises and attention to appropriate lifting technique, along with modification of the workout routine to de-emphasize joint pain-eliciting movements when injury occurs. I hope this information has been useful. If you have shoulder dysfunction and need help, feel free to contact me at Alabama Orthopaedic Center 205-971-1750. Have a safe and healthy 2019!
Robert S. Wolf MD
Grandview Physicians Plaza
3686 Grandview Parkway, Suite 510
Birmingham, AL 35243