As PTs who work with shoulder injuries know, the structure of the shoulder joint allows more range of motion than any other joint in the body. This also means an increased capacity for injury, especially in a sports setting. And this means an increase in pain for patients.
To effectively relieve the pain behind sports-related shoulder injuries, PTs have more options than ever before. Options for treating the pain run the gamut from topical to penetrative, from tangible to translucent. In the sections below, we examine the root of shoulder pain, the methods PTs can use to alleviate patient pain, and the key products available.
THE SHOULDER AND INJURY
As PTs know, the shoulder is a complicated series of joints, including the clavicle, acromioclavicular joint, and glenohumeral joint, that work together to facilitate movement. This last joint is a ball-and-socket joint that enables forward, circular, and backward movement of the shoulder. When we talk about shoulder injury, we usually refer to problems at this "main" shoulder joint, where the head of the upper arm meets the shoulder blade, that sits in a very small and shallow socket. The ball of the upper arm is larger than the socket in the shoulder, and there is little bony stability. The shoulder relies on ligaments that bind the various bones and cartilage together, tendons that connect muscle to bone, and muscles that help support and rotate the shoulder.
Injury often occurs when muscles, tendons, and ligaments are torn, overused, or otherwise strained. The most common sports injury PTs see is shoulder impingement/rotator cuff tendinitis. The rotator cuff muscles that hold the shoulder bones together can weaken over time and use, and make it easy for the head of the shoulder to slide around in the joint. With activities like baseball, tennis, swimming, golf, weight training, and others, an extended arm can cause the shoulder head to slide forward, catching the tendons between the ball and socket, and causing inflammation and pain.
Shoulder impingement and other pain are frequently caused by chronic overuse of the shoulder. Repetitive lifting, pushing, pulling, and throwing are the common sports movements that cause the injury. Overhead movement can be particularly dangerous to shoulders.
Other injuries PTs might see from sports are bursitis, frozen shoulder (adhesive capsulitis), and dislocations. Bursitis is an inflammation of the sac of lubricating fluid between moving parts of the joint. With overuse, and often in concert with tendinitis, pain and inflammation occur. Frozen shoulder can result when shoulder pain causes the patient to limit shoulder movement. When the shoulder heals from injury, scar tissue and adhesions can cause the joints to freeze together.
Effectively treating shoulder injury is a matter of addressing the root cause with stretching and strengthening exercises, or occasionally more aggressive surgical methods to tighten loose ligaments, repair torn tendons, or other tactics. But with most shoulder injuries, part of treatment is also tackling the significant pain that patients experience.
ANALGESICS
In the day-to-day world of minor aches and pains, and in the realm of chronic pain, analgesics have long been a standard treatment. Oral analgesics, including simple aspirin and more complicated COX-2 inhibitors, can provide relief. When it comes to shoulder pain from sports injuries, however, topical analgesics are a preferred and potent treatment.
These topical applications utilize a variety of materials and ingredients to provide temporary relief to pain symptoms in the shoulder. Generally, these topical analgesics are absorbed deeply into the skin, blocking pain sensations, stimulating nerve endings, and distracting the brain from the pain.
One analgesic garnering much attention as of late is the BIOFREEZE product line from Performance Health Inc, based in Export, Pa. Formulated from Ilex, an herbal extract from a South American holly shrub, BIOFREEZE products help relieve shoulder pain and also can be used prior to ultrasound treatments, massage therapy, and rehabilitation exercises to help lessen pain and complete interventions/exercises. Ilex is billed as a greaseless material (an alternative to waxes, oils, aloe, or petroleum) that helps achieve full penetration of the medication. BIOFREEZE is an analgesic available to patients through the clinician in a roll-on gel tube or spray bottles.
FLEXALL® topical analgesic is another option available for temporary relief from tendinitis, bursitis, and strains. Produced by Chattem Inc, Chattanooga, Tenn, the product contains menthol, a natural ingredient known for its cooling and antibacterial properties. With topical analgesics, it allows deeper penetration through the surface of the skin and replaces the pain message with a cooling sensation. FLEXALL is available over the counter in three strengths as a pump bottle.
Another analgesic gel based on natural plant extract ingredients is Sore No More!. Providing temporary relief for sports injuries, Sore No More! blends six natural plant extracts in combination with menthol, capsaicin (intercepts the pain signals sent to the brain), and witch hazel (an astringent), eschewing waxes, oils, artificial colors, and chemicals. Sore No More!, Moab, Utah, is also available in pump bottles or roll-on formulations.
THERAPEUTIC TAPING
Moving beyond simple pain relief, therapeutic taping can provide relief and a direct attack on the cause of the pain. Several taping methods exist and are accepted by PTs and other clinicians. Traditional sports taping is wrapped around a joint strictly for stabilization and support during an athletic event. But therapeutic taping goes much further.
When shoulder pain is due to inflamed, swollen, or stiff muscles, the space between the skin and muscle is compressed. This results in constricted flow of lymphatic fluid and pressure applied to the pain receptors beneath the skin. The Kinesio Taping® method was developed with this issue in mind by Kenzo Kase, DC, in Japan in the 1980s. The method involves taping over and around muscles in order to give support and prevent overcontraction. It also microscopically lifts the skin, facilitating lymphatic draining and relieving pressure, irritation, and pain.
Two techniques exist, one that allows patients to participate in normal physical activity with functional assistance, and another used in acute rehabilitation, with mechanical, lymphatic, ligament/tendon/fascia, space, and functional correction. This latter method, utilized by PTs in cases of shoulder injuries from sports, can be used in conjunction with cryotherapy, hydrotherapy, massage therapy, and electrical stimulation.
The Kinesio method involves special tape, the Tex Platinum and Tex Gold tape produced by the Kinesio Taping® Association, based in Albuquerque, NM. The tape has elasticity of 130% to 140% of its original lengths, and is made of cotton for comfort and air-permeability combined with a heat-activated adhesive. The tape can be worn for several days per application, and can be applied with little to no stretch.
DIATHERMY
PTs and their patients often need pain management and relief beyond analgesics and taping. Some turn to diathermy. This technique is a deep-tissue heat treatment, often for large areas, in which the temperature of the injured tissues is raised via high-frequency current, ultrasonic waves, or microwave radiation. The deep heat is thought to reduce pain, relieve muscle spasm, and promote healing.
Mettler Electronics Corp, Anaheim, Calif, first produced a shortwave diathermy unit for clinicians and patients in 1972. Shortwave diathermy avoids touching the skin and the potential for burns, and instead radiates an energy field through the tissue to cause electromagnetic heat. The Auto*Therm 390 and 390X feature continuous and pulsed shortwave diathermy in a portable machine. It features eight different treatment applicators for high-performance and safer use.
ULTRASOUND
For deeper penetration and more flexible usage, the use of ultrasound as therapy for shoulder pain management and musculoskeletal injuries is on the rise.
Therapeutic ultrasound delivers sound waves to tissue at frequencies of 0.75 MHz to 3 MHz (both above the range of human hearing), either in thermal (continuous) or nonthermal (pulsed) applications. The sound waves vibrate the tissue deep inside the injured area, creating heat that draws more blood into the tissues, sparking the healing process. The specific techniques and duration of therapy depend on equipment used and type of injury.
The benefits of therapeutic ultrasound are significant. Within tendons and joint capsules, elasticity of collagen is increased. Motor and sensory nerve conduction increases, muscle spindle activity decreases, and muscle contractile activity decreases. Taken together, pain is reduced, muscle spasms are diminished, and healing is promoted.
Mettler developed a therapeutic ultrasound machine back in 1957 and has provided innovative solutions ever since. The Sonicator® is a portable and lightweight ultrasound tool featuring unique crystal-to-patient technology that delivers ultrasound directly to the patient without a metal interface. The various models provide relative depth of ultrasound penetration between 1-MHz and 3.3-MHz frequencies for the different pain locations. For deep-tissue pain, like that with injured shoulders, a 1-MHz application is typically the best.
Specific Sonicator models include the 740, 740x, 730, and 716, all offering different applicators that change out quickly and easily. The 716 is specifically geared toward shoulders and other large, muscular areas. All devices come with detachable applicator cables, continuous and pulsed modes, and watertight characteristics to enable simultaneous underwater therapy.
Amrex Electrotherapy Equipment, Carson, Calif, is another company that offers versatile therapeutic ultrasound options. Machines come with 1-MHz and 3.3-MHz generators with standard or small soundheads. The ultrasound beam is continuous, but also the devices offer a unique modulated beam, where peak power is generated for only a portion of the pulse. The momentary burst of ultrasonic energy improves penetration of the sound waves. The U/20 and U/50 Portable Ultrasounds are Amrex's flagship therapeutic ultrasound models, and they feature lightweight transducers sealed for underwater therapy.
ELECTRIC STIMULATION
Building on the penetrative but noninvasive powers of ultrasound therapy, many PTs and patients are turning to transcutaneous electrical nerve stimulation (TENS), which delivers a low-voltage electrical current to zap pain. Conventional TENS treatment delivers the current from a small power unit to electrodes on the skin of the affected areas. The mechanism of pain relief using TENS is still under discussion, but theories suggest that the electric stimulation interferes with sensory pathways and/or the way pain is perceived and transmitted, or alternatively, increases blood flow to the affected areas to alleviate pain.
TENS is delivered through electrodes placed on the shoulder with paste in various patterns, depending on treatment goals. Sessions may last from minutes to hours, and can involve stimulation in a wide range of frequencies and intensities. Successful integration of TENS into therapy for shoulder injuries and rehab can include decreased pain, increased activity and function, reduced need for medication, and patient-controlled pain management.
Through Empi, St Paul, Minn, PTs and their patients have a TENS option that moves deeper. After traumatic injuries or major surgery, some patients experience pain significant enough to preclude active rehabilitation. To prevent loss of muscle strength and function, the neuromuscular electrotherapy stimulation (NMES) machines offer pain control and muscle stimulation. The electrical stimulation targets the nerve corresponding to specific muscles and causes it to contract, keeping the muscles firing to prevent loss of muscle mass and function. The result is speeded recovery, maintained muscle, increased range of motion, and increased local blood flow.
The 300 PV NMES Device is a compact, portable system that can function as a NMES, TENS, or high-volt device. The Infinity Plus is a multiple waveform electrotherapy device that also functions along all three parameters.
From Amrex comes several TENS devices to manage chronic and acute pain. The SpectrumMicro-1000 is a portable machine with varying outputs. The Z-Stim 100 and AdvantTeq2000 are personal TENS devices that can fit in a pocket or clip to a belt or waistband.
Mettler has a long history of stimulation devices under the Sys*Stim® brand. Each model is a TENS and neuromuscular stimulator featuring different waveforms. One-channel options are the Sys*Stim 206 and 208; two-channel options are the 208A and 210. Additional models (including the Trio, 216, 226, and 294) offer additional channels and therapeutic modes.
OTHER PRODUCTS
Some companies, recognizing the dual power of ultrasound and electric stimulation for pain management, offer combination units. Amrex offers the SynchroSonic US/50, US/54, U/HVG50, and US/752, which offer muscle/nerve stimulation and ultrasound. Mettler offers Sonicator Plus combination therapy units that combine ultrasound and electrical stimulation. The 940, 992, 994, and 930 models combine 1- and 3-MHz ultrasound with up to eight treatment waveforms.
CONCLUSION
The pain of sports-related shoulder injuries may be alleviated with an increasing array of tools available to PTs and patients. PTs can use techniques and products like those described here to bring much-needed relief and function back to comforted patients.
SOURCES
Amy Lillard is a contributing writer for Physical Therapy Products. For more information, contact .
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