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Musculoskeletal Disorders of the shoulder (tendonitis)

Ice application – A demonstration

This leaflet focuses on rotator cuff tendinopathy, the musculoskeletal disorder that most commonly affects the shoulder joint.

This condition occurs when a shoulder tendon has been overloaded. Tendons are fibrous tissues that connect muscles to bones. When the same movements are repeated or improperly forced, small injuries occur in the tendons. These microtrauma cause pain and also cause a decrease in tendon elasticity. Indeed, the collagen fibers produced to repair the tendons are not as good quality as the original tendon.

Swimmers, baseball pitchers, carpenters and plasterers are the most at risk because they are required to lift their arms frequently by exerting strong forward pressure. Preventive measures generally prevent this.

Tendonitis, tendinosis or tendinopathy?

In common parlance, the affection referred to here is often called tendinitis of the rotator cuff. However, the suffix “ite” indicates the presence of inflammation. Since we now know that the majority of tendon injuries are not accompanied by inflammation, the correct word is rather tendinosis or tendinopathy – the latter term covers all tendon injuries, therefore tendinosis and tendonitis. Tendonitis should be reserved for the rare cases of acute shoulder trauma that cause inflammation of the tendon.

Causes of Musculoskeletal Disorders

 

  • An overuse of the tendon by the frequent repetition of gestures performed incorrectly;
  • A too fast variation of the intensity of an effort imposed on a poorly prepared articulation (for lack of strength or endurance). Very often, there is an imbalance between the muscles that “pull” the shoulder forward – which are usually strong – and the muscles in the back – weaker. This imbalance brings the shoulder into an inadequate position and causes additional stress on the tendons, making them more fragile. The imbalance is often accentuated by poor posture.

Sometimes we hear about calcific tendinitis or calcification in the shoulder. Calcium deposits in the tendons are part of natural aging. They are rarely the cause of pain, unless they are particularly bulky.

A bit of anatomy

The shoulder joint consists of four muscles that constitute what is called the rotator cuff: the subscapularis, the supraspinatus, the sub-spinous and the small round (see diagram). It is most often the supraspinous tendon which is at the origin of tendinopathy of the shoulder.

The tendon is an extension of the muscle that attaches it to the bone. It is powerful, flexible and not elastic. It consists largely of collagen fibers and contains some blood vessels.

See also our article entitled Anatomy of the joints: basic notions.

 Possible complication

Although it is not a serious condition in itself, tendinopathy should be treated quickly; otherwise it may develop retractable capsulitis. It is the inflammation of the joint capsule, the fibrous and elastic envelope that surrounds the joint. The capsulitis retractile occurs especially when one avoids too much to move the arm. It results in an increased stiffness of the shoulder, which causes a loss of range of motion of the arm. This problem is treated, but much more difficult than tendinosis. It also takes a lot longer to heal.

Do not wait until you reach this stage to consult. The more the tendon injury is treated quickly, the better the results.

Symptoms of Musculoskeletal Disorders

  •  A dull and diffuse pain in the shoulder, which often radiates to the arm. The pain is especially felt during the movement of raising the arm;
  • Very often, the pain intensifies during the night , sometimes to the point of impairing sleep;
  • loss of shoulder mobility.

People at risk

  • People who are required to lift their arms frequently by exerting a certain force forward: carpenters, welders, plasterers, painters, swimmers, tennis players, baseball throwers, etc. ;
  • Workers and athletes over 40 years old. With age, tissue wear and decreased blood supply to the tendons increase the risk of tendinosis and its complications.

Risk factors

At work

  • Excessive pace;
  • Extended shifts;
  • The use of an inappropriate tool or the misuse of a tool;
  • A poorly designed workstation
  • Incorrect working positions;
  • Musculature insufficiently developed for the effort required.

In sports activities

  • Insufficient or no heating
  • Activity too intense or too frequent;
  • Bad game technique;
  • Musculature insufficiently developed for the effort required.

 

Basic preventive measures

General recommendations

  • Before engaging in a high-shoulder activity, provide warm-up exercises to increase overall body temperature. For example, hopping, brisk walking, etc.
  • Take breaks frequently.

Prevention in the workplace

  • Use the services of an ergonomist or occupational therapist to implement a prevention program. In Quebec, experts from the Commission for Occupational Health and Safety (CSST) can guide employees and employers in this process (see Sites of Interest).
  • Vary work positions and take breaks.

Prevention among athletes

  • Use the services of a coach (kinesiologist or physical educator) who knows the sports discipline that one practices in order to learn the appropriate and safe techniques. For tennis players, for example, it may be sufficient to use a lighter racket or change the playing technique.
  • An athlete who wants to increase the intensity of his training should do so gradually.
  • To reduce the risk of tendinopathy, it may be necessary to strengthen the shoulder muscles (including the rotator cuff muscles, especially external rotators), which has the effect of reducing stress on the ligaments, joint capsule and bone structures.
  • Develop and maintain good muscle strength in the trunklegs and arms. These muscles are essential for producing strength in an arm raised above the head. Good musculature throughout the body will reduce stress on the shoulder.

 

It is important to consult a doctor if you have shoulder pain, especially if the pain suddenly appears after a fall, a false movement, etc. The practitioner will be able to determine if it is a simple tendinopathy, if the tendon is torn or if there is a fracture. Tendons can suffer irreversible damage if they continue to be used, despite taking medication. In addition, because of the sometimes diffuse nature of this type of pain, the symptoms felt in the shoulder could be related to a problem of cervical vertebrae or, more importantly, to pulmonary or cardiac disorders.

Acute phase

The duration of the acute phase of the injury is about 7 to 10 days. During the first 48 to 72 hours, it is essential to immediately relieve the pain and inflammation that may be present. The injury remains fragile and the tissues are more easily irritable than usual.

Here are a few tips.

  • Put the shoulder at rest avoiding the actions that led to the injury. However, it is necessary to avoid the complete stop of the movements. Indeed, if rest is an essential component of treatment, even inactivity of only a few days can stiffen the joint (ankylosis). Thus, you should never immobilize your arm with a sling or splint. The adhesive capsulitis is the most common complication of immobilizing the shoulder.
  • Apply ice on the shoulder 3 or 4 times a day for 10 to 12 minutes. There is no need to apply cold compresses or magic bags (they are not cold enough and heat up in minutes). Continue applying ice as long as symptoms persist.
    Note. Although inflammation is not the main source of the problem, it is good to use ice because there are often transient inflammatory attacks that can be easily controlled in this way.
Warning for the application of cold

Ice cubes contained in a plastic bag or in a thin, wet towel can be applied directly to the skin. There are also cool gel packs sold in pharmacies, which may be practical. However, when using these products, do not place them directly on the skin because there is a risk of frostbite. A bag of frozen green peas (or corn kernels) is a practical and economical solution, as it molds well to body shapes and can be applied directly to the skin.

Drugs. During the acute phase, the doctor may suggest taking an analgesic medication (Tylenol, Atasol or others) and referring you to a physiotherapist. The anti-inflammatory nonsteroidal available over the counter (eg Ibuprofen: Advil, Motrin, etc.,or naproxen: Aleve) or obtained on prescription can be useful in the short term, for 2 or 3 no more days. They rarely have a place in the treatment of long-term tendinopathy.

Rehabilitation phase

Physiotherapy treatments should begin as soon as the diagnosis of shoulder tendinopathy is known. Physical therapy can reduce inflammation (if any), guide new collagen fibers, prevent ankylosis, or recover lost mobility. This can be done using massage, friction, mobilizations, ultrasound, electric currents or laser.

Thereafter, the focus will be on muscle building while continuing to work on the mobility of the joint. For an optimal result, the person must participate actively in his treatment by reproducing at home the exercises taught.

When physiotherapy and home exercises do not solve the problem, the doctor sometimes uses a cortisone injection into the joint. Cortisone has a powerful anti-inflammatory effect. However, it should not be thought that cortisone alone will solve the problem in the long run. It can sometimes be used to reduce pain when it is important. This improves the effectiveness of physiotherapy treatments by allowing the person to perform his exercises more easily.

In case of retractable capsulitis

The mobilization and stretching exercises remain the main treatment to follow. The earlier we start, the better the result. Physiotherapy can help regain amplitude. If mobility is really limited and physiotherapy cannot solve the problem, one or a few cortisone infiltrations will help relax the tissues, which will facilitate the practice of exercises, essential to treatment.

Phase back to normal activities

Normal activity, which includes the motions that cause tendinopathy, is progressively regained when the full range of motion is restored and the pain is stopped.

follow-up physiotherapy and continued strengthening and stretching exercises after the resumption of normal activities help prevent relapse.

Surgery

When tendinopathy appears gradually, surgery is rarely necessary. It is only used when the usual treatments have not given the desired results after several months of treatment.

On the other hand, if the injury results from an acute trauma that has caused a tear in the tendon, surgery must be done in the days following the accident.

Warning. Incomplete rehabilitation or rapid return to normal activities slows the healing process and increases the risk of recurrence. The adherence to treatment – rest, ice, painkillers, physiotherapy – allows full return to previous capacity for the majority of people.

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