Shoulder injuries are a common reason for visiting the doctor. Some data suggest that more than half of the population experiences a shoulder injury at least once during their lifetime (6). The shoulder joint is particularly prone to injury due to its anatomical structure, in which reduced stability is compensated with a wide range of motion.
It is interesting to note that the risk for such an injury is the highest among adolescent males and elderly people. The former are at higher risk due to higher physical activity that includes sports, whereas the latter are more prone to falls and pathological fractures.
The incidence of shoulder injuries among older individuals is more common in females (1). Many types of shoulder injuries exist along with various kinds of treatment approaches. Tissue damage and its healing are two factors they all have in common.
This article provides some basic information regarding the healing process, as well as ways in which this process can be accelerated and thus the injury rehabilitated. But first, let us examine the structure of the shoulder joint.
Shoulder joint anatomy and biomechanics
The shoulder is commonly regarded as a multi-joint system, which requires normal functioning of the musculoligamentous apparatus, including the normal flexibility of the cervical, thoracic and lumbar spine in order to facilitate its comprehensive function and flexibility (2).
The bone structure of the shoulder is composed of the scapula, humerus, sternum and the clavicle. The sternum is anteriorly connected to the clavicle and together they form the sternoclavicular joint. On the other end, the clavicle articulates with the acromial process of the scapula, forming the acromioclavicular joint. The connection between the humeral head and the scapula is called the glenohumeral joint, whereas the scapula and the posterior part of the thoracic cage together make up the scapulothoracic joint (2).
The physiological function of the shoulder can be achieved only with the coordinated movement of all four individual shoulder joints. The physiological movement pattern, in which simultaneous movement of the scapula and the humeral head is present, is referred to as scapulohumeral kinematics (4). It is common for it to become impaired in the early stages of disease or injury to the shoulder joint, and is known to additionally contribute to overstrain of the soft tissues of the shoulder (4).
Soft tissue structures of the shoulder include the static and dynamic stabilizers of the shoulder joint. One of these static stabilizers includes the labrum, which increases the cartilage articular surface of the scapula, referred to as the glenoid, and thus allows for better contact between the joint surface and the humeral head. Other structures that support the connective tissue are together referred to as the capsuloligamentous complex. It is composed of the joint capsule along with several ligaments that encircle the whole shoulder joint complex and ensure joint stability (6).
The dynamic stabilizers of the shoulder joint include the rotator cuff muscles (m. supraspinatus, m. infraspinatus, m. subscapularis and m. teres minor) as well as several other muscles which are activated in order to enable the execution of a movement in all directions.
Basic principles of tissue healing and the elimination of shoulder problems
The healing of bone and soft-tissue structures is possible only under favorable circumstances. A good rehabilitation process ensures such favorable conditions and can, to a certain extent, even accelerate the healing process.
Various types of shoulder injuries exist and correspondingly also numerous treatment approaches along with many exercise and therapy protocols.
The principles of the healing process can be generalized and are divided into three phases that dictate the choice of individual as well as the combination of various types of physical therapy (3). The phases often overlap and vary in duration.
First phase
The first phase of the healing of the damaged tissue is referred to as inflammation and lasts between 1 – 6 days. It typically includes swelling, redness, the presence of pain, increased heat and loss of function within the affected area. Inflammation is a natural, physiological and transient characteristic of tissue reparation and does not pose a problem as long it does not evolve into its chronical form (3). Immediately following the injury, principles of the POLICE protocol (protection, optimal load, ice, compression and elevation) should be applied (5).
Activities that stress the injured area should be avoided (relative rest) and the injured shoulder should be protected in order to prevent further injury. Within the first 48 hours cooling of the affected area can be performed in order to reduce swelling and relieve pain, however you should not apply heat to the injured area (5).
Second phase
The second phase of the healing process is called the proliferation phase and can be observed between the 3rd and 20th day after injury. During this phase the formation of scar tissue begins. The tensile strength of the newly formed connective tissue increases.
This is a period during which instrumental therapy can be more intensively incorporated and exercises targeted at increasing the range of motion of the shoulder joint can be included in order to reduce and prevent joint sclerosis, manage pain and promote blood circulation (3). Effective treatment methods include electrostimulation, the use of therapeutic laser, application of heat to the affected area and performing of special therapeutic exercises.
Third phase
The third phase of the healing process is called maturation and begins on the 9. day following the injury and can last up to two years. This phase includes the remodelling of the affected area and involves changes in the shape and structure as well as increased firmness of the tissue.
It is very important to remain physically active and to start with increasing muscle strength and range of motion in a planned and controlled manner, beginning with isometric exercises, followed by isotonic exercises and resistance training. Open and closed kinetic chain exercises should be mentioned as well.
Importance of kinesthetic exercising
Closed kinetic chain exercises define movements in which the distal aspect of the extremity is fixed to the ground, whereas open chain exercises allow the distal aspect of the extremity to move freely (3). Both have certain advantages and characteristics which we should fully comprehend before the beginning of the rehabilitation program.
The rehabilitation program should also incorporate exercises aimed at improving coordination and neuromuscular control, which is based on the brain’s ability to interpret and integrate proprioceptive and kinesthetic information, thus contributing to coordinated movement (3).
As we can see, the recovery after a shoulder injury is a complex process that requires a broad range of professional knowledge and experience. The professionals responsible for your rehabilitation have to possess a wide range of knowledge regarding the anatomical structure and biomechanics of the shoulder joint. They also have to be familiar with the mechanism of injury, understand the healing process and be able to correctly adjust different techniques and exercises to your individual condition.
A team of qualified professionals is a must
The rehabilitation process should not be carried out on your own, but rather under the close watch of a team of qualified professionals, who will track your progress, and your body’s reaction in response to therapy and regularly adjust the exercises and physiotherapy protocols.
It is very important not to follow unreliable advice that can be found on various online platforms, as you can cause irreversible tissue damage, which could permanently impede the success of your recovery.
With shoulder injuries, many individuals claim that their arm is perfectly fine, but only hurts a little when they reach for their head. Such a form of reasoning can lead to chronic issues, which can later trigger a cascade of health issues, which require orthopaedic surgical intervention. Pain syndrome must be treated accordingly.
