“Character cannot be developed in ease and quiet. Only through experience of trial and suffering can the soul be strengthened, ambition inspired, and success achieved.” — Helen Keller
Injuries happen to everyone, but some may happen earlier in life. For athletes, injuries can be both a physical and psychological barrier to competition
Today, we are looking at the prevalence of shoulder injuries in athletes and how physical therapists are the key to a healthy recovery, efficiency of form to prevent re-injury, pushing through the mind-body barriers, and return to sports training.
Research shows a prevalence of shoulder pain up to 43.5% in athletes aged 15-19 years old1 and up to 60% of senior-aged athletes have partial or full-thickness Rotator Cuff tears. We can likely all agree that injuries such as these can lead to compensation, increased strain, and poor biomechanics when athletes are attempting to train through an injury in their sport.
As physical therapists, we follow the evidence to help support how we intervene with patients and their rehab. Evidence-based practice, as we call it, allows us to follow the science of histology (study of the microscopic structure of tissue) to drive rehabilitation. We are also able to see which functional movement patterns can engage different musculature and structures depending on target tissue healing. Our body is fluid and responds to the stimulus we provide.
At Primal Physical Therapy, our therapists are trained to analyze specific patterns of movement, and in doing so, we are able to engage systems affected by injury. The result? We can influence our hidden potential in the healing process.
Common Shoulder Injuries Requiring Surgical Intervention in Athletes
Rotator Cuff Tears
The rotator cuff is composed of four muscles—Supraspinatus, Infraspinatus, Subscapularis, and the Teres Minor. The primary role of the rotator cuff is to stabilize our humerus into the socket known as the glenoid fossa. Injury to the rotator cuff will significantly affect how stable our arm is through a large degree of motion.
Any damage or injury to one of the rotator cuff muscles or its respective tendons can affect the stability of the shoulder joint as a whole. Athletes that require a lot of overhead motion, like throwing and powerlifting, or athletes that find themselves in precarious positions that stress the rotator cuff, like wrestling, all can have a depletion in performance without the stabilizing requirements of the rotator cuff muscles.
Labral Tears
The labrum is a fibrocartilage structure that deepens the shoulder joint to provide more surface area. Much like the rotator cuff, the labrum is designed biomechanically for stability. By design, the labrum is responsible for the intra-articular pressure (pressure inside the joint) that allows the surrounding structures to enhance stability.
Common injuries that require surgery to the labrum include SLAP tears and Bankart lesions. A SLAP tear stands for Superior Labrum from Anterior to Posterior. This type of tear has a classic pattern in the region of the labrum that has been torn. A Bankart lesion involves the anterior and inferior portion of a labrum. As mentioned earlier, the complex of the labrum deepens the socket, allowing for increased pressure inside the joint that allows biomechanical stability in combination with the rotator cuff musculature. Any disruption to the labrum will inherently disrupt our pressure system which cascades into a loss of stability, speed, and control – which every athlete requires to perform at the highest level.
In data collected from the NCAA’s Injury Surveillance Program (ISP), only 185 athletes out of 3.7 Million required surgery on the shoulder between the years 2009-2013. Of the injuries that required surgical treatment, superior labrum from anterior to posterior (SLAP) tears (46.4%), anterior shoulder dislocations (33.3%), and posterior shoulder dislocations (30.0%) were seen most often3. Labrum pathology is more likely in throwing athletes—particularly pitchers in baseball and contact sports like wrestling, football, and hockey.
Dislocations and Instability
Dislocations and gross instability of the glenohumeral joint can be multifactorial in nature. One reason can be due to either of the above diagnoses (labrum pathology or injury to rotator cuff) reducing the stability of the shoulder joint. The secondary component is the human physiology of our connective tissues. Everyone has a varying degree of elasticity and mobility in their ligamentous system, and this can be primarily genetic. We, as physical therapists, have the tools and the hands-on experience to help decipher between biomechanical and genetic components of gross instability and ligamentous laxity.
Post-dislocation, whether surgically repaired or not, will benefit greatly from physical therapy rehabilitation to facilitate the reintegration of the pressure system and weight-bearing stability of the glenohumeral joint.
Fractures or Severe Tendinopathies
Some injuries to the athlete’s shoulder are from chronic overuse, compensatory strategies from previous injuries, or due to high-velocity trauma. High-velocity traumas leading to fractures may need surgical intervention depending on the severity of the fracture. Surgically, realignment allows for the optimal position of structure to heal, but it is up to the physical therapist to allow for optimal force distribution of that structure to heal to its potential.
Tendon injuries also occur commonly from overuse and repetitive strain on a musculotendinous junction. As physical therapists, we provide appropriate input and energy to facilitate tendon strengthening and tendon healing through various techniques. Without a stable and strong tendon, a muscle is not able to perform high velocity, high power output.
The Role of Evidence-Based Rehabilitation Protocols
We use the terminology “evidence-based” as a reference to how physical therapists pull information from research and science and apply it to the function of healing. Evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence when making decisions about the care of individual patients. The practice of “evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”4
A very important piece of evidence-based medicine is the judicious use of clinical experience in combination with incorporating research-based decisions to create the best treatment plan and intervention for each individual.
By using research and tools available, rehabilitation is directed specifically to each individual. Every athlete has different healing chemistry, different genetics of elasticity to their ligamentous system, different morphology of joints, and different movement strategies.
While the research bundles individuals into categories, our role as physical therapists is to optimize movement strategies and facilitate tissue healing meaningful toward athletic goals. By individualizing rehabilitation, we are able to see faster recovery, reduce the risk of re-injury, and enhance return to sport performance.
Phased Approach to Shoulder Rehabilitation
This is a brief preview of the process of recovery and healing; depending on the extent of damage, surgeon preferences and overall health play a factor in protocols and recovery. It will not be the same for any two individuals but will follow evidence-based timelines of healing.
Phase 1: Immediate Post-Surgical Goals
Pain and Inflammatory management
Pain Management plays a key role in the psychological connection to our physical rehabilitation. Medications are generally prescribed postoperatively to help reduce pain intensity, but depending on the surgery and the individual’s needs, it may not be absolutely necessary to every individual’s rehab plan. There is a plethora of evidence in the area of Pain Neuroscience that shows that educating our patients on the phases of healing and helping them understand the process of Acute inflammation will help them manage their pain during these first few weeks. Additionally, we find that managing the swelling through immediate post-operative therapy sessions (1-day post-op) helps to decrease the pain response rapidly.
Typically, the greatest swelling will last hours after surgery to about 2-4 days post-op, depending on the individual. Inflammation is a normal part of the healing process and should not be feared, but facilitating the process of healing through inflammatory management modalities and hands-on physical therapy can be very helpful.
Restoring passive range of motion (ROM)
Research shows the importance of early ROM and how it correlates to improved quality of life and functional outcome scores.6 Our bodies are designed to move; with advancements in medicine and surgery, it has been found that immobilization after surgery is more harmful to outcomes than early physical therapy interventions, including mobilization and passive movement of the arm.
Phase 2: Controlled Motion and Strength Building
As tissues continue to heal, pain reduces, and tolerance to motion improves, we introduce active range of motion exercises. This now allows more cortical (sensory) input into our system and how we move following an event like surgery. It is common at this stage for compensations to occur and is recommended to be performed in front of a mirror or with some other feedback mechanism, allowing the brain to reconnect with our bodies while we reform our movement patterns and strategies.
Under the guidance of a physical therapist, it is also recommended to prevent any excess strain or poor movement patterns from being integrated.
Isometric training allows for sensory input and blood flow to facilitate any tissues damaged/repaired during injury or surgical intervention. We have a common saying in physical therapy: “Proximal stability allows for distal mobility,” implying that we must have our stabilizing system engaged and primed before our large mover muscles take us where we need to go.
Phase 3: Advanced Strengthening and Sport-Specific Movements
After we develop a strong foundation of scapular and structural stability with freedom of range of motion, we begin functional training. Functional training means any return to sport or activity required by an individual. This is the art of crafting programs specific to our client needs and providing training to achieve those needs.
Plyometric exercises have been shown to increase power and output. Plyometrics are able to target both slow twitch and fast twitch fibers needed by any athlete. Plyometrics need to be performed with high-intensity efforts, above 80 percent, to recruit the fast twitch fibers that are crucial to power development. Fast twitch muscle fibers respond better to high‐speed small amplitude pre‐stretch; therefore, specificity of rehabilitation and performance enhancement via specific exercises, intensity, sets, and reps are important in the design and execution of specific exercises.8 This is where your physical therapist comes in to make sure we are targeting appropriate tissue recruitment and facilitation of both fast twitch and slow twitch fibers.
Tools and Techniques Backed by Research
Manual Therapy and Mobilization Techniques
Manual Therapy has always been shown as an effective tool for improving tissue healing, facilitating appropriate nutrition of cartilage and soft tissue mobility, and pain reduction following surgery.
Therapeutic Modalities
Certain modalities can be very helpful for facilitating post-operative rehabilitation and return to sport after shoulder surgery.
Class 4 laser therapy is used as early as two days postoperatively to help increase blood flow, decrease inflammation, and accelerate cellular healing.
Blood flow restriction (BFR) is another great early post-operative rehabilitation tool that allows us to train our muscles as if they were under load, without the actual load. This not only preserves the tendons and joints and protects the surgical repair, but it also prevents atrophy that typically occurs postoperatively with immobilization, and it gives athletes a jump on strengthening in a way that is safe for them at early phases of rehabilitation.
TECAR therapy is another great tool post operatively. We use high-frequency electro-current to decrease inflammation, stimulate lymphatic and blood flow, and facilitate healing.
Sport-Specific Rehab Equipment
Every PT has their favorite toys and tools to use with their patients for rehabilitation and recovery. Some of our favorites are: 1. The Keiser system: great for being able to create responsive, multidimensional force in many capacities, this system allows us to create unique exercises for all of our athletes’ specific needs. The EXXENTRIC flywheel units. These units emphasize the eccentric contractions in the movements we design. Most sports demand eccentric control to withstand high-velocity forces and loads, so this is a perfect tool for meeting the needs of our patients. But maybe the most important piece of equipment is the therapist’s knowledge and creativity. Being able to craft a well-rounded, versatile, appropriately challenging, yet safe program for our athletes’ needs is the most valuable tool at any phase of post-operative care.
Modifying Protocols for Specific Sports
The demand on any part of our musculoskeletal system depends on the forces we apply to it. Part of the fun of physical therapy is tailoring sport-specific interventions and protocols.
Overhead athletes like baseball and volleyball will require excess demand on the intra-articular pressure and stability components while applying high-velocity motions. Interventions including plyometrics in the open-chain with varying degrees of speed and weight and how they integrate from the core foundation will greatly impact sports performance.
Contact sports like wrestling, rugby, and football require enhanced weight-bearing resistance training and plyometrics for power for wrestling, awareness, and training of safety positions prior to contact for rugby and football, and integration from the big toe all the way up to shoulder positioning.
Aquatic sports have a combination of all systems and need to learn to manage strength and power with resistance while underwater and speed and control while out of the water. Training in combination of resistance and speed are required to facilitate proper function when returning to sport.
Real World Success-Story
One success story was Jay, our work with a wrestler who recruiting for colleges, and during his junior year, he suffered a torn UCL on his right arm and a torn labrum on his left arm.
The UCL needed to be surgically repaired, so we treated him with one post-operatively using all of the modalities we mentioned above to get a jump on his recovery. In the meantime, we also used BFR for the right shoulder to treat the labral tear conservatively by focusing on building the muscles of the Rotator Cuff to support the shoulder.
Jay quickly and successfully recovered from both injuries and wrestled his senior year, where he was a National Preparatory Champion, and went on to commit to and wrestle for Binghamton University.
From Surgery to Success: Crafting the Perfect Playbook for Shoulder Rehabilitation in Athletes
Any injury always feels like a setback. Allowing the experience to strengthen your soul, inspire your ambition, and achieve success is a challenge to meet head-on. No one does it alone, which is why we, as physical therapists, can be right by your side.
There are a lot of variables in any injury; our physical therapists see each individual with untapped potential. It is our role to create the perfect playbook for every person to reach their goals. No matter the sport, we can help you reach your potential.
References:
- Oliveira VMA de, Pitangui ACR, Gomes MRA, Silva HA da, Passos MHP dos, Araújo RC de. Shoulder pain in adolescent athletes: prevalence, associated factors and its influence on upper limb function. Brazilian Journal of Physical Therapy. 2017;21(2):107-113. doi:https://doi.org/10.1016/j.bjpt.2017.03.005
- Almajed YA, Hall AC, Gillingwater TH, Alashkham A. Anatomical, functional and biomechanical review of the glenoid labrum. J Anat. 2022 Apr;240(4):761-771. doi: 10.1111/joa.13582. Epub 2021 Nov 1. PMID: 34725812; PMCID: PMC8930820.
- Gil JA, Goodman AD, DeFroda SF, Owens BD. Characteristics of Operative Shoulder Injuries in the National Collegiate Athletic Association, 2009-2010 Through 2013-2014. Orthopaedic Journal of Sports Medicine. 2018;6(8). doi:10.1177/2325967118790764
- Dijkers MP, Murphy SL, Krellman J. Evidence-Based Practice for Rehabilitation Professionals: Concepts and Controversies. Archives of Physical Medicine and Rehabilitation. 2012;93(8):S164-S176. doi:https://doi.org/10.1016/j.apmr.2011.12.014
- Fedoriw WW, Ramkumar P, McCulloch PC, Lintner DM. Return to play after treatment of superior labral tears in professional baseball players. Am J Sports Med. 2014 May;42(5):1155-60. doi: 10.1177/0363546514528096. Epub 2014 Mar 27. Erratum in: Am J Sports Med. 2015 Dec;43(12):NP46. doi: 10.1177/0363546515620790. PMID: 24674945.
- Misir A, Oguzkaya S, Kizkapan TB, Eken G, Sayer G. The effect of postoperative sling immobilization and early mobilization on clinical and functional outcomes after arthroscopic rotator cuff repair: A propensity score-matched analysis. Journal of Back and Musculoskeletal Rehabilitation. Published online June 20, 2022:1-8. doi:https://doi.org/10.3233/bmr-210358
- Speer KP, Warren RF, Horowitz L. The efficacy of cryotherapy in the postoperative shoulder. Journal of Shoulder and Elbow Surgery. 1996;5(1):62-68. doi:https://doi.org/10.1016/s1058-2746(96)80032-2
- Davies G, Riemann BL, Manske R. CURRENT CONCEPTS OF PLYOMETRIC EXERCISE. Int J Sports Phys Ther. 2015 Nov;10(6):760-86. PMID: 26618058; PMCID: PMC4637913.
- Manske RC. Postsurgical Orthopedic Sports Rehabilitation : Knee & Shoulder. Mosby; 2006.
